Impact of an EHR-based Diabetes Management Form on Quality and

Outcomes of Diabetes Care in Primary Care Practices

Jeph Herrin, PhD1,2

Phil Aponte, MD3

Briget da Graca, JD, MS3

Greg Stanek, MS3

Terianne Cowling, BA3

Cliff Fullerton, MD, MSc4

Priscilla Hollander, MD, PhD3

David J Ballard, MD, MSPH, PhD3

 1. Department of Medicine, Yale University, New Haven CT

2. Health Research and Educational Trust, Chicago IL

3. Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX

4. HealthTexas Provider Network, Baylor Health Care System, Dallas, TX

AHRQ grant: R21 HS20696-02

Investigators

Electronic Health Records (EHRs) may :

Improve communication between patient and physician

Provide clinical decision support

Provide registry-type functionality for tracking care

Facilitate physician performance measurement

Some or all of these may lead to improved care of patients with chronic conditions.

Bodenheimer, T. 2003. “Interventions to Improve Chronic Illness Care: Evaluating Their Effectiveness.” Disease Management 6 (2): 63–71.

Background

Evidence is limited:Evaluations of tailored EHRs

Evaluations of commercial EHRs on a small scale

And conflictingNo impact on chronic care

Some impact on chronic care

No large studies of commercially available EHRs…

Background

…until recently†.

We looked at14,501 diabetes patients at 34 practices

Our outcome was “Optimal Care” (HbA1c≤8 percent; LDL cholesterol <

100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and

documented aspirin use in patients 40 years of age)

We found a difference of 9.2% (95% CI: 6.1, 12.3) in the final year

between patients exposed to the HER (higher rate of optimal care) and

those not exposed to it.

Also improved processes of care (eye exams, foot exams, labs)†Herrin, J.,  Nicewander D, Fullerton C, Aponte P, Stanek G, Cowling T, Collinsworth A, Fleming NS, Ballard DJ. "The effectiveness of implementing an electronic health record on diabetes care and outcomes." 2012. Health Serv Res 47(4): 1522-1540.

Background

Hypothesis:

The effect of the EHR on the care and outcomes of diabetes

patients was due in part or in entirety to the incorporation

of a “Diabetes Management Form” (DMF), a component of

the EHR designed to manage the care of diabetes patients.

Objective

HealthTexas Provider Network (HTPN)

Is the ambulatory care network affiliated with the Baylor

Health Care System, a not-for-profit integrated healthcare

delivery system serving patients throughout North Texas.

Comprises >100 practices, with 450 physicians, and has >1

million patient encounters annually.

The current study incorporates all practices which include

physicians specializing in Internal Medicine (IM) or Family

Medicine (FM), with EHR implemented prior to Jan 1

2006.

Setting

CollinCollinCollinCollinCollinCollinCollinCollinCollinWiseWiseWiseWiseWiseWiseWiseWiseWise

TarrantTarrantTarrantTarrantTarrantTarrantTarrantTarrantTarrant

DentonDentonDentonDentonDentonDentonDentonDentonDenton

RockwallRockwallRockwallRockwallRockwallRockwallRockwallRockwallRockwall

DallasDallasDallasDallasDallasDallasDallasDallasDallasKaufmanKaufmanKaufmanKaufmanKaufmanKaufmanKaufmanKaufmanKaufman

ParkerParkerParkerParkerParkerParkerParkerParkerParker

JohnsonJohnsonJohnsonJohnsonJohnsonJohnsonJohnsonJohnsonJohnsonEllisEllisEllisEllisEllisEllisEllisEllisEllis

HTPN Service Areas in Texas

Setting

What made this study possible is the contemporaneous collection of

data on diabetes patients.

In 2007 HTPN established and began populating a retrospective

diabetes prevalence cohort database using the AMA Physician

Consortium Adult Diabetes Performance Measure set.

Each cohort was defined by the claims-based algorithm used by the

Centers for Medicare and Medicaid Service (CMS)

All patients with ≥2 ambulatory care visits ≥7 days apart with a

diabetes-related billing code (CMS National Measurement

Specifications Diabetes Quality of Care Measures [2002]: ICD-9-CM

Diagnosis Codes 250.xx) during the preceding 12 months were

identified from administrative data.

Data Collection

Study Population

All patients who :

Were 40 years or older Had at least 2 diabetes related visits in 2007 Had no DMF “exposure” in 2007 or prior Had at least 2 diabetes related visits in 2009

Know: age, sex, insulin usage, number of visits

Intervention

Intervention

Key element – last dialogue box

Outcomes

Primary Outcome: Optimal Care Bundle

HbA1c≤8 percent

LDL cholesterol < 100 mg/dl

blood pressure < 130/80 mmHg

not smoking; and

documented aspirin use

All criteria met = optimal care (yes/no)

Outcomes

Secondary

Clinical:

HbA1c≤8 percent

LDL < 100 mg/dl

BP < 130/80 mmHg

not smoking

documented aspirin use

Triglycerides < 150

Total cholesterol < 100

Process:

HbA1c checked

Lipids checked

Microalbumin checked

Eye exam done

Foot exam done

Flu vaccine

Smoking status assessed

Smoking cessation

Design

Design Considerations:

Not all patients have measurements in both 2007

and 2009

DMF exposure in 2009 might effect outcomes in

2009

Design

Naïve Design: Use all available data

No DMF DMF

Followup

2007

2009

2008

Followup

Baseline

Design

Naïve Analysis:

logit(Pr[Yij]) =

is time (baseline vs followup)

is the interaction effect

are random effects at patient, practice level to account for

repeated measures on patients, within practices

Patients  All Patients Never Exposed

Some Form Use  

  n(%) n(%) n(%) P-valueN 3577 (100.0) 1371 (100.0) 2206 (100.0)  Age Category       0.04541-50 679 (19.0) 256 (18.7) 423 (19.2)  51-60 1326 (37.1) 476 (34.7) 850 (38.5)  61-70 1300 (36.3) 521 (38.0) 779 (35.3)  71+ 272 ( 7.6) 118 ( 8.6) 154 ( 7.0)  

Sex       0.185Male 1776 (49.7) 700 (51.1) 1076 (48.8)  Female 1801 (50.3) 671 (48.9) 1130 (51.2)  

Insulin use       0.836No 2936 (82.1) 1123 (81.9) 1813 (82.2)  Yes 641 (17.9) 248 (18.1) 393 (17.8)  

Visits in 2007       0.8371 92 ( 2.6) 34 ( 2.5) 58 ( 2.6)  2 748 (20.9) 302 (22.0) 446 (20.2)  3 874 (24.4) 332 (24.2) 542 (24.6)  4 712 (19.9) 268 (19.5) 444 (20.1)  5 436 (12.2) 160 (11.7) 276 (12.5)  6-10 636 (17.8) 248 (18.1) 388 (17.6)  11+ 79 ( 2.2) 27 ( 2.0) 52 ( 2.4)  

HbA1c<=8       0.356No 379 (10.6) 137 (10.0) 242 (11.0)  Yes 3198 (89.4) 1234 (90.0) 1964 (89.0)

Perfect Care       0.086No 2562 (71.6) 993 (72.4) 1569 (71.1)  Yes 325 ( 9.1) 110 ( 8.0) 215 ( 9.7)  Missing 690 (19.3) 268 (19.5) 422 (19.1) 

ResultsNaïve Results: Unadjusted

  No Form Use   Form Use      Baseline Followup Change Baseline Followup Change    n/N (%) n/N (%) (% pts) n/N (%) n/N (%) (% pts) P-value*Optimal Care              

Met 110/1103 (10.0) 242/1215 (19.9) 9.9 215/1784 (12.1) 468/2017 (23.2) 11.2 <0.001Outcomes          

A1c<8 1066/1317 (80.9) 1081/1347 (80.3) -0.7 1711/2133 (80.2) 1676/2173 (77.1) -3.1 0.041

LDL good 795/1183 (67.2) 868/1226 (70.8) 3.6 1329/1906 (69.7) 1445/2033 (71.1) 1.4 0.020

BP good 455/1361 (33.4) 574/1371 (41.9) 8.4 807/2201 (36.7) 1074/2205 (48.7) 12 <0.001

TRI good 667/1232 (54.1) 758/1271 (59.6) 5.5 1047/2003 (52.3) 1158/2113 (54.8) 2.5 0.024

Cholesterol good 1003/1233 (81.3) 1058/1271 (83.2) 1.9 1622/2007 (80.8) 1780/2113 (84.2) 3.4 0.018

Smoking status 170/1284 (13.2) 174/1360 (12.8) -0.4 270/2099 (12.9) 247/2196 (11.2) -1.6 0.070Process          

Aspirin Prescribed 740/1371 (54.0) 1086/1371 (79.2) 25.2 1252/2206 (56.8) 1898/2206 (86.0) 29.3 <0.001

A1c checked 1317/1371 (96.1) 1347/1371 (98.2) 2.2 2133/2206 (96.7) 2173/2206 (98.5) 1.8 <0.001

Lipids checked 1232/1371 (89.9) 1271/1371 (92.7) 2.8 2002/2206 (90.8) 2112/2206 (95.7) 5 <0.001

Microalbumin 778/1356 (57.4) 879/1360 (64.6) 7.3 1186/2172 (54.6) 1643/2192 (75.0) 20.4 <0.001

Eye Exam 351/1371 (25.6) 538/1371 (39.2) 13.6 494/2206 (22.4) 1005/2206 (45.6) 23.2 <0.001

Foot Exam 98/1371 ( 7.1) 623/1371 (45.4) 38.3 228/2206 (10.3) 1619/2206 (73.4) 63.1 <0.001

Flu vaccine 732/1371 (53.4) 801/1371 (58.4) 5 1124/2206 (51.0) 1217/2206 (55.2) 4.2 <0.001

Smoking Assessed 1284/1371 (93.7) 1360/1371 (99.2) 5.5 2099/2206 (95.1) 2196/2206 (99.5) 4.4 <0.001

Smoking Cessation 126/170 (74.1) 143/174 (82.2) 8.1 185/270 (68.5) 215/247 (87.0) 18.5 0.002

ResultsNaïve Results: Adjusted

  No Form Form Use Difference P-value

 absolute

change (%)absolute

change (%)    Optimal Care        Met 5.92 6.38 0.46 <0.001

Outcomes        A1c<8 0.15 0.24 0.09 0.519LDL good 1.75 0.71 -1.04 <0.001BP good 5.64 6.52 0.88 <0.001TRI good 2.23 1.86 -0.37 0.007Cholesterol good 1.59 1.41 -0.17 <0.001Smoking 0.00 0.00 0.00 0.032

Process        Aspirin Prescribed 16.02 16.06 0.04 <0.001A1c checked 0.01 0.00 0.00 <0.001Lipids checked 2.48 2.09 -0.39 <0.001Microalbumin 7.63 9.93 2.30 <0.001Eye Exam 8.63 13.16 4.53 <0.001Foot Exam 24.81 30.10 5.29 <0.001Flu vaccine 3.05 1.63 -1.42 <0.001Smoking Assessed 2.15 2.85 0.69 <0.001Smoking Cessation 7.19 9.57 2.37 <0.001

Design

Improved Design: Only Patients with both 2007 & 2009 measurements!

No DMF DMF

Followup

2007

2009

2008

Followup

Baseline

Design

Main Model:

logit(Pr[Yij]) =

is time (baseline vs followup)

is the interaction effect

are random effects at patient, practice level to account for

repeated measures on patients, within practices

Patients    Primary Analysis  All Patients Control Exposed        in 2008    n(%) n(%) n(%) P-valueN 2087 (100.0) 995 (100.0) 1092 (100.0)  Age Category       0.21441-50 372 (17.8) 177 (17.8) 195 (17.9)  51-60 764 (36.6) 344 (34.6) 420 (38.5)  61-70 791 (37.9) 390 (39.2) 401 (36.7)  71+ 160 ( 7.7) 84 ( 8.4) 76 ( 7.0)  

Sex       0.135Male 1013 (48.5) 500 (50.3) 513 (47.0)  Female 1074 (51.5) 495 (49.7) 579 (53.0)  

Insulin use       0.173No 1744 (83.6) 843 (84.7) 901 (82.5)  Yes 343 (16.4) 152 (15.3) 191 (17.5)  

Visits in 2007       0.8811 32 ( 1.5) 14 ( 1.4) 18 ( 1.6)  2 381 (18.3) 191 (19.2) 190 (17.4)  3 538 (25.8) 246 (24.7) 292 (26.7)  4 450 (21.6) 211 (21.2) 239 (21.9)  5 268 (12.8) 128 (12.9) 140 (12.8)  6-10 376 (18.0) 184 (18.5) 192 (17.6)  11+ 42 ( 2.0) 21 ( 2.1) 21 ( 1.9)  

HbA1c<=8       0.321No 179 ( 8.6) 79 ( 7.9) 100 ( 9.2)  Yes 1908 (91.4) 916 (92.1) 992 (90.8)

Perfect Care       0.320No 1828 (87.6) 879 (88.3) 949 (86.9)  Yes 259 (12.4) 116 (11.7) 143 (13.1)  Missing 0 ( 0.0) 0 ( 0.0) 0 ( 0.0) 

ResultsMain Results: Unadjusted

  No Form Use   Form Use      Baseline Followup Change Baseline Followup Change    n/N (%) n/N (%) (% pts) n/N (%) n/N (%) (% pts) P-value*Optimal Care              

Met 116/995 (11.7) 241/995 (24.2) 12.6 143/1092 (13.1) 258/1092 (23.6) 10.5 <0.001Outcomes          

A1c<8 854/995 (85.8) 845/995 (84.9) -0.9 906/1092 (83.0) 881/1092 (80.7) -2.3 0.022

LDL good 687/995 (69.0) 718/995 (72.2) 3.1 783/1092 (71.7) 796/1092 (72.9) 1.2 0.056

BP good 353/995 (35.5) 486/995 (48.8) 13.4 387/1092 (35.4) 501/1092 (45.9) 10.4 <0.001

TRI good 580/994 (58.4) 620/994 (62.4) 4 628/1091 (57.6) 652/1092 (59.7) 2.1 0.243

Cholesterol good 835/995 (83.9) 860/995 (86.4) 2.5 934/1092 (85.5) 957/1092 (87.6) 2.1 0.025

Smoking status 121/995 (12.2) 124/995 (12.5) 0.3 128/1092 (11.7) 112/1092 (10.3) -1.5 0.206Process          

Aspirin Prescribed 563/995 (56.6) 815/995 (81.9) 25.3 644/1092 (59.0) 950/1092 (87.0) 28 <0.001

A1c checked 995/995 (100.0) 995/995 (100.0) 0 1092/1092 (100.0) 1092/1092 (100.0) 0 NA

Lipids checked 994/995 (99.9) 994/995 (99.9) 0 1091/1092 (99.9) 1092/1092 (100.0) 0.1 NA

Microalbumin 636/995 (63.9) 720/995 (72.4) 8.4 626/1092 (57.3) 824/1092 (75.5) 18.1 <0.001

Eye Exam 309/995 (31.1) 452/995 (45.4) 14.4 274/1092 (25.1) 538/1092 (49.3) 24.2 <0.001

Foot Exam 87/995 ( 8.7) 562/995 (56.5) 47.7 143/1092 (13.1) 788/1092 (72.2) 59.1 <0.001

Flu vaccine 562/995 (56.5) 618/995 (62.1) 5.6 634/1092 (58.1) 645/1092 (59.1) 1 0.006

Smoking Assessed 995/995 (100.0) 995/995 (100.0) 0 1092/1092 (100.0) 1092/1092 (100.0) 0 NA

Smoking Cessation 92/121 (76.0) 111/124 (89.5) 13.5 91/128 (71.1) 94/112 (83.9) 12.8 0.091

ResultsMain Results: Adjusted

  No Form Form Use Difference P-value

 absolute

change (%)absolute

change (%)    Optimal Care        Met 7.15 6.00 -1.15 <0.001

Outcomes        

A1c<8 0.57 -0.07 -0.64 0.134

LDL good 1.80 0.68 -1.12 0.027

BP good 7.53 5.84 -1.69 <0.001

TRI good 2.27 1.16 -1.11 0.309

Cholesterol good 1.31 1.03 -0.28 0.004

Smoking 0.00 0.00 0.00 0.213

Process        

Aspirin Prescribed 14.85 15.85 1.00 <0.001

A1c checked       NA

Lipids checked       NA

Microalbumin 4.96 9.83 4.88 <0.001

Eye Exam 7.93 13.15 5.22 <0.001

Foot Exam 25.61 30.27 4.66 <0.001

Flu vaccine 3.21 0.53 -2.68 0.007

Smoking Assessed       NA

Smoking Cessation 8.07 7.16 -0.90 0.057

Limitations

Observational trial

Difficult to disentangle exposure and measurement

sicker patients may be more likely to be measured

sicker patients may be more likely to be “exposed”

DMF “exposure” includes no measure of fidelity

DMF may merely be opened and closed

DMF may be used incorrectly

Incremental effect on top of EHR effect may be difficult to

detect

Conclusion

While EHR improved care and outcomes of diabetes patients

(prior study), evidence here is that the incremental effect of a

Diabetes Management Form is negative or mixed.

Definitive inferences may require randomized trial