Typical electronic health record use in primary care practices and the quality of diabetes care

PURPOSE

Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.

METHODS

We analyzed data from 16 EHR-using and 26 non–EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.

RESULTS

EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A_1c, low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12–2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.

CONCLUSIONS

Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.     

Small, nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems

To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all.     

Technological trends in health care: electronic health record

The most relevant technological trend affecting health care organizations and physician services is the electronic health record (EHR). Billions of dollars from the federal government stimulus bill are available for investment toward EHR. Based on the government directives, it is evident EHR has to be a high-priority technological intervention in health care organizations. Addressed in the following pages are the effects of the EHR trend on financial and human resources; analysis of advantages and disadvantages of EHR; action steps involved in implementing EHR, and a timeline for implementation. Medical facilities that do not meet the timetable for using EHR will likely experience reduction of Medicare payments. This article also identifies the strengths, weaknesses, opportunities, and threats of the EHR and steps to be taken by hospitals and physician medical groups to receive stimulus payment.     

Standards and the integrated electronic health care record

The goal of creating an integrated electronic health care record is within our reach. It will depend chiefly on the creation and adoption of standards for health care data. This article explains why standards development is important, gives examples of the different types of standards relevant to health care, offers examples of data sets used in health care, and, finally, presents examples of standards development organizations that health care supervisors should be familiar with.     

Implementing a strategy for improving care: lessons from studying those age 80 and older in a health system

This article describes some potential solutions to the many practical barriers that arise when trying to improve clinical care in everyday practice. A useful mnemonic for incorporating measurement into daily work is called GAPS--setting Goals, Assessing the current processes, Planning a new approach, and Starting it. The 80+ Project represents a foundation of information and offers promise to create durable, productive interactions for elderly individuals and their health care providers.     

Disseminating public health practice guidelines in electronic medical record systems.

An evaluation of public health practice guidelines published by CDC was conducted to determine the feasibility of disseminating them through electronic medical record (EMR) systems. Of 1,069 guidelines evaluated, 360 contained at least one recommendation that could be presented as an alert or reminder to the clinician during the patient encounter. These guidelines were in the areas of: HIV (59), sexually transmitted diseases (8), health care associated infections (14), tuberculosis (TB) (25), immunizations/vaccine-preventable diseases (80), other infectious diseases (134), reproductive health diseases (8), cancers (9), diabetes (5), and other chronic diseases (18). Further efforts to disseminate CDC guidelines through EMR systems are in progress.     

The value of electronic health records in solo or small group practices

We conducted case studies of fourteen solo or small-group primary care practices using electronic health record (EHR) software from two vendors. Initial EHR costs averaged $44,000 per full-time-equivalent (FTE) provider, and ongoing costs averaged $8,500 per provider per year. The average practice paid for its EHR costs in 2.5 years and profited handsomely after that; however, some practices could not cover costs quickly, most providers spent more time at work initially, and some practices experienced substantial financial risks. Policies should be designed to provide incentives and support services to help practices improve the quality of their care by using EHRs.     

The financial and nonfinancial costs of implementing electronic health records in primary care practices

The incentives in the American Recovery and Reinvestment Act to expand the "meaningful use" of electronic health record systems have many health care professionals searching for information about the cost and staff resources that such systems require. We report the cost of implementing an electronic health record system in twenty-six primary care practices in a physician network in north Texas, taking into account hardware and software costs, as well as the time and effort invested in implementation. For an average five-physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. We also estimate that the HealthTexas network implementation team and the practice implementation team needed 611 hours, on average, to prepare for and implement the electronic health record system, and that "end users"-physicians, other clinical staff, and nonclinical staff-needed 134 hours per physician, on average, to prepare for use of the record system in clinical encounters.     

A new age for older people? Policy shifts in health and social care

This paper considers health and social policies for older persons from a cross-national perspective and attempts to uncover some of the factors influencing policy formulation and implementation. The focus is on community care, its meanings and practical implementation. Examples are drawn from Western Europe and the U.S.A. to illustrate and explain differences and similarities. Two sets of explanatory factors are considered crucial. First, the structure of health and social care systems create incentives for clients, care providers and planners in certain directions. The degree of organisational fragmentation and of public control are seen to be the most important structural factors. Second, it is argued that the political and ideological context within which health and social systems operate must be understood if one is to assess the likely directions of future policies.     

A blockchain based patient centric electronic health record storage and integrity management for e-Health systems

ObjectivesIn the digitization of health records, patients and doctors find difficulty in accessing their health records, especially when the health records are fragmented with different health service providers. In this paper, Patient Centric blockchain smart contracts are designed to provide a regulated solution to the requirements of patients, doctors and health service providers with integrity management.MethodsThe proposed system launches smart contracts namely i) Registration contract for immutable patient log creation. ii) Health Record Creation Contact to generate digital health records. iii) Health Record Storage Contract for secure storage and rapid access with a new Modified Merkle Tree data structure. iv) Update permission Contract that can provide access at emergency situations. v) Data sharing Permission Contract for exchange of health records between different stakeholders and vi) Viewership Permission Contract for viewing the health information by the patients for home care and future care.ResultsThe work has been carried out on a number of trials to check the effectiveness of the proposed system. The qualitative and quantitative metrics of the proposed system have been measured to evaluate the performance of resources, transactions per second, and the latency of transaction.ConclusionThe proposed system provides high security and integrity through cryptographic hash functions. The results are encouraging. The designed system is implemented and found to outperform the existing systems.     

Migration and health at older age in rural Malawi

The connection between migration and health has long been established, but relatively little is known about this relationship for older persons, particularly in sub-Saharan Africa (SSA). In this paper, we examine migration selection with regards to health status among older individuals in Malawi, by testing whether older migrants differ from non-migrants in health status before migration. To do so, we use data from the Malawi Longitudinal Study of Families and Health, a longitudinal panel dataset that includes a relatively large number of individuals at older ages. We focus on three measures: mental health, physical health, and HIV status. We find that the relationship between migration and health selection differs by gender. Older women who are HIV-positive are nearly 10 times more likely to migrate compared to their HIV-negative counterparts. For men, those with better mental health are less likely to migrate in the future. These results suggest that, although research in some settings shows that migrants have better health before moving, some older migrants have worse health than their non-migrant peers, and may, therefore, add to the already-heavy burden on rural health centres in Africa.