516991
research-article2013 Herrin et al
AJMXXX10.1177/1062860613516991Herrin et alAmerican Journal of Medical Quality
Article
Impact of an EHR-Based Diabetes Management Form on Quality and Outcomes of Diabetes Care in Primary Care Practices
American Journal of Medical Quality 2015, Vol. 30(1) 14–22 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613516991 ajmq.sagepub.com
Jeph Herrin, PhD,1,2 Briget da Graca, JD, MS,3 Phil Aponte, MD,4 H. Greg Stanek, MS,3 Terianne Cowling, BA,3 Cliff Fullerton, MD, MSc,4 Priscilla Hollander, MD, PhD,3 and David J. Ballard, MD, MSPH, PhD3
Abstract Health information technology shows promise for improving chronic disease care. This study assessed the impact of a diabetes management form (DMF), accessible within an electronic health record. From 2007 to 2009, 2108 diabetes patients were seen in 20 primary care practices; 1103 visits involved use of the DMF in 2008. The primary outcome was “optimal care”: HbA1c ≤8%, low-density lipoprotein (LDL) cholesterol 1 million patient encounters annually. Between May 2006 and December 2009, HTPN rolled out an EHR system (GE Centricity Physician Office—EMR 2005; GE Healthcare, Waukesha, WI) across its practices on a staggered schedule. This study included all HTPN practices that met the following criteria: the practice includes physicians specializing in internal medicine (IM) or family medicine (FM); the practice was part of HTPN on July 1, 2005; the practice had no prior experience (such as a pilot program) with the EHR; and the practice had implemented the EHR prior to January 1, 2007. Patient encounters with any physician specializing in IM or FM at these practices were included. During the period covered by this study, all HTPN primary care physicians received semiannual performance reports on the recommended diabetes-related quality and outcome measures. The reports were transparent, meaning each physician could see his/her performance in comparison to the other HTPN physicians, and how his/her practice compared with the other practices. Physician champions met with physicians showing low performance to discuss ways in which they could improve, including through use of tools such as the DMF. Additionally, there was widespread and frequent discussion about the introduction of a pay-for-performance program that would put 10% of HTPN primary care physicians’ compensation at risk based on the quality of care they provided—5% being dependent on patient satisfaction scores, and 2.5% each dependent on performance on recommended diabetes-related quality measures and clinical preventive service measures. This program was implemented in June 2009.
Data Collection As has been described previously,6 HTPN established a retrospective semiannual diabetes prevalence cohort database, covering the period January 1, 2005, to June 30, 2010, using the American Medical Association Physician Consortium Adult Diabetes Performance Measure set. Each cohort was defined by the claims-based algorithm used by the Centers for Medicare and Medicaid Services (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]: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 250.xx) during the preceding 12 months.13 Process of care and clinical outcome data were collected for overlapping 12-month periods from both paper and
Downloaded from ajm.sagepub.com at UNIV OF PITTSBURGH on March 12, 2015
16
American Journal of Medical Quality 30(1)
electronic medical records by trained nurse abstractors using a standardized data collection tool created in MS Access (Microsoft Corporation, Redmond, WA). DMF usage data were obtained directly from the EHR. The EHR was queried to determine occurrences of use of the DMF for all patients included in the study sample. Office visits within each cohort period during which the DMF was accessed were identified by performing a string search on a text field within the EHR for any of the following: “Diabetes Management Assessment/Plan:”, “Diabetes Management Exam:”, “Diabetes Management History:”. These strings are automatically inserted by the DMF in the relevant text field and are expressed/formatted in ways HTPN physicians entering data “freehand” seldom use. Thus, for any visit in which one of these strings was identified in the text field, the DMF was considered to have been used. Multiple tables were used to develop these data into a categorical DMF Use variable (yes or no), and then matched the patients back to the HTPN diabetes prevalence cohort database using a 2-step process: first by practice and medical record number and then by practice and social security number. Any remaining patients in the chart review cohort were considered not to have been exposed to the DMF.
Study Population The study team included all patients captured in the diabetes prevalence cohort database who were ≥40 years of age; had at least 2 diabetes-related visits during 2007 at a practice that had implemented the EHR prior to December 31, 2007; and had 2 additional diabetes-related visits during both 2008 and 2009, with the “optimal care” bundle (see Study Outcomes) measured at least once during each calendar year. Patients were excluded if they had any visits prior to 2007 where the DMF was accessed, or if they were seen at multiple practices during the study period (n = 106). Patients aged
research-article2013 Herrin et al
AJMXXX10.1177/1062860613516991Herrin et alAmerican Journal of Medical Quality
Article
Impact of an EHR-Based Diabetes Management Form on Quality and Outcomes of Diabetes Care in Primary Care Practices
American Journal of Medical Quality 2015, Vol. 30(1) 14–22 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613516991 ajmq.sagepub.com
Jeph Herrin, PhD,1,2 Briget da Graca, JD, MS,3 Phil Aponte, MD,4 H. Greg Stanek, MS,3 Terianne Cowling, BA,3 Cliff Fullerton, MD, MSc,4 Priscilla Hollander, MD, PhD,3 and David J. Ballard, MD, MSPH, PhD3
Abstract Health information technology shows promise for improving chronic disease care. This study assessed the impact of a diabetes management form (DMF), accessible within an electronic health record. From 2007 to 2009, 2108 diabetes patients were seen in 20 primary care practices; 1103 visits involved use of the DMF in 2008. The primary outcome was “optimal care”: HbA1c ≤8%, low-density lipoprotein (LDL) cholesterol 1 million patient encounters annually. Between May 2006 and December 2009, HTPN rolled out an EHR system (GE Centricity Physician Office—EMR 2005; GE Healthcare, Waukesha, WI) across its practices on a staggered schedule. This study included all HTPN practices that met the following criteria: the practice includes physicians specializing in internal medicine (IM) or family medicine (FM); the practice was part of HTPN on July 1, 2005; the practice had no prior experience (such as a pilot program) with the EHR; and the practice had implemented the EHR prior to January 1, 2007. Patient encounters with any physician specializing in IM or FM at these practices were included. During the period covered by this study, all HTPN primary care physicians received semiannual performance reports on the recommended diabetes-related quality and outcome measures. The reports were transparent, meaning each physician could see his/her performance in comparison to the other HTPN physicians, and how his/her practice compared with the other practices. Physician champions met with physicians showing low performance to discuss ways in which they could improve, including through use of tools such as the DMF. Additionally, there was widespread and frequent discussion about the introduction of a pay-for-performance program that would put 10% of HTPN primary care physicians’ compensation at risk based on the quality of care they provided—5% being dependent on patient satisfaction scores, and 2.5% each dependent on performance on recommended diabetes-related quality measures and clinical preventive service measures. This program was implemented in June 2009.
Data Collection As has been described previously,6 HTPN established a retrospective semiannual diabetes prevalence cohort database, covering the period January 1, 2005, to June 30, 2010, using the American Medical Association Physician Consortium Adult Diabetes Performance Measure set. Each cohort was defined by the claims-based algorithm used by the Centers for Medicare and Medicaid Services (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]: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 250.xx) during the preceding 12 months.13 Process of care and clinical outcome data were collected for overlapping 12-month periods from both paper and
Downloaded from ajm.sagepub.com at UNIV OF PITTSBURGH on March 12, 2015
16
American Journal of Medical Quality 30(1)
electronic medical records by trained nurse abstractors using a standardized data collection tool created in MS Access (Microsoft Corporation, Redmond, WA). DMF usage data were obtained directly from the EHR. The EHR was queried to determine occurrences of use of the DMF for all patients included in the study sample. Office visits within each cohort period during which the DMF was accessed were identified by performing a string search on a text field within the EHR for any of the following: “Diabetes Management Assessment/Plan:”, “Diabetes Management Exam:”, “Diabetes Management History:”. These strings are automatically inserted by the DMF in the relevant text field and are expressed/formatted in ways HTPN physicians entering data “freehand” seldom use. Thus, for any visit in which one of these strings was identified in the text field, the DMF was considered to have been used. Multiple tables were used to develop these data into a categorical DMF Use variable (yes or no), and then matched the patients back to the HTPN diabetes prevalence cohort database using a 2-step process: first by practice and medical record number and then by practice and social security number. Any remaining patients in the chart review cohort were considered not to have been exposed to the DMF.
Study Population The study team included all patients captured in the diabetes prevalence cohort database who were ≥40 years of age; had at least 2 diabetes-related visits during 2007 at a practice that had implemented the EHR prior to December 31, 2007; and had 2 additional diabetes-related visits during both 2008 and 2009, with the “optimal care” bundle (see Study Outcomes) measured at least once during each calendar year. Patients were excluded if they had any visits prior to 2007 where the DMF was accessed, or if they were seen at multiple practices during the study period (n = 106). Patients aged
