Ilana Graetz

Outpatient Electronic Health Records and the Clinical Care and Outcomes of Patients With Diabetes Mellitus

BACKGROUND Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes. OBJECTIVE To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes. DESIGN Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering. SETTING Kaiser Permanente Northern California, an integrated delivery system. PATIENTS 169 711 patients with diabetes mellitus. INTERVENTION Use of a commercially available certified EHR. MEASUREMENTS Drug treatment intensification and hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein cholesterol (LDL-C) testing and values. RESULTS Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA(1c) values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA(1c) and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA(1c) levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA(1c) levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA(1c) and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001). LIMITATION The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures. CONCLUSION Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.

The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income.

Background:Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups. Objectives:To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences. Research Design:Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference. Subjects:One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate). Measures:Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics. Results:Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference. Conclusions:As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

In Consumer-Directed Health Plans, A Majority Of Patients Were Unaware Of Free Or Low-Cost Preventive Care

Consumer-directed health plans are plans with high deductibles that typically require patients to bear no out-of-pocket costs for preventive care, such as annual physicals or screening tests, in order to ease financial barriers and encourage patients to seek such care. We surveyed people in California who had a consumer-directed health plan and found that fewer than one in five understood that their plan exempted preventive office visits, medical tests, and screenings from their deductible, meaning that this care was free or had a modest copayment. Roughly one in five said that they had delayed or avoided a preventive office visit, test, or screening because of cost. Those who were confused about the exemption were significantly more likely to report avoiding preventive visits because of cost concerns. Special efforts to educate consumers about preventive care cost-sharing exemptions may be necessary as more health plans, including Medicare, adopt this model.

The Association between EHRs and Care Coordination Varies by Team Cohesion

OBJECTIVE To examine whether primary care team cohesion changes the association between using an integrated outpatient-inpatient electronic health record (EHR) and clinician-rated care coordination across delivery sites. STUDY DESIGN Self-administered surveys of primary care clinicians in a large integrated delivery system, collected in 2005 (N=565), 2006 (N=678), and 2008 (N=626) during the staggered implementation of an integrated EHR (2005-2010), including validated questions on team cohesion. Using multivariable regression, we examined the combined effect of EHR use and team cohesion on three dimensions of care coordination across delivery sites: access to timely and complete information, treatment agreement, and responsibility agreement. PRINCIPAL FINDINGS Among clinicians working in teams with higher cohesion, EHR use was associated with significant improvements in reported access to timely and complete information (53.5 percent with EHR vs. 37.6 percent without integrated-EHR), agreement on treatment goals (64.3 percent vs. 50.6 percent), and agreement on responsibilities (63.9 percent vs. 55.2 percent, all p<.05). We found no statistically significant association between use of the integrated-EHR and reported care coordination in less cohesive teams. CONCLUSION The association between EHR use and reported care coordination varied by level of team cohesion. EHRs may not improve care coordination in less cohesive teams.

Emergency Physicians’ Knowledge and Attitudes of Clinical Decision Support in the Electronic Health Record: A Survey‐based Study

OBJECTIVES The objective was to investigate clinician knowledge of and attitudes toward clinical decision support (CDS) and its incorporation into the electronic health record (EHR). METHODS This was an electronic survey of emergency physicians (EPs) within an integrated health care delivery system that uses a complete EHR. Randomly assigned respondents completed one of two questionnaires, both including a hypothetical vignette and self-reported knowledge of and attitudes about CDS. One vignette version included CDS, and the other did not (NCDS). The vignette described a scenario in which a cranial computed tomography (CCT) is not recommended by validated prediction rules (the Pediatric Emergency Care Applied Research Network [PECARN] rules). In both survey versions, subjects responded first with their likely approach to evaluation and then again after receiving either CDS (the PECARN prediction rules) or no additional support. Descriptive statistics were used for self-reported responses and multivariate logistic regression was used to identify predictors of self-reported knowledge and use of the PECARN rules, as well as use of vignette responses. RESULTS There were 339 respondents (68% response rate), with 172 of 339 (51%) randomized to the CDS version. Initially, 25% of respondents to each version indicated they would order CCTs. After CDS, 30 of 43 (70%) of respondents who initially would order CCTs changed their management decisions to no CCT versus two of 41 (5%) with the NCDS version (chi-square, p = 0.003). In response to self-report questions, 81 of 338 respondents (24%) reported having never heard of the PECARN prediction rules, 122 of 338 (36%) were aware of the rules but not their specifics, and 135 of 338 (40%) reported knowing the rules and their specifics. Respondents agreed with favorable statements about CDS (75% to 96% agreement across seven statements) and approaches to its implementation into the EHR (60% to 93% agreement across seven statements). In multivariable analyses, EPs with tenure of 5 to 14 years (odds ratio [AOR] = 0.51, 95% confidence interval [CI] = 0.30 to 0.86) and for 15 years or more (AOR = 0.37, 95% CI = 0.20 to 0.70) were significantly less likely to report knowing the specifics of the PECARN prediction rules compared with EPs who practiced for fewer than 5 years. In addition, in the initial vignette responses (across both versions), physicians with ≥15 years of ED tenure compared to those with fewer than 5 years of experience (AOR = 0.30, 95% CI = 0.13 to 0.69), and those reporting knowing the specifics of the PECARN prediction rules were less likely to order CCTs (AOR = 0.53, 95% CI = 0.30 to 0.92). CONCLUSIONS EPs incorporated pediatric head trauma CDS via the EHR into their clinical judgment in a hypothetical scenario and reported favorable opinions of CDS in general and their inclusion into the EHR.

Characteristics of Hospital and Emergency Care Super-utilizers with Multiple Chronic Conditions

BACKGROUND Targeted care transitions programs may improve the value of hospital-based health care. Super-utilizing patients with multiple chronic conditions (MCC) are thought to be particularly amenable to care transitions interventions. OBJECTIVES To identify characteristics, future utilization patterns, and health outcomes for super-utilizers with MCC. METHODS Retrospective cohort study of patients receiving care in an urban multi-hospital system in Tennessee over 3 years. Adult patients with Medicaid or Medicare insurance, or both, MCC, and multiple hospitalizations and emergency department (ED) visits in a 6-month period were included. The primary outcome measures were numbers of hospitalizations and ED visits in the 12 months after the 6-month period of high utilization. Secondary outcomes included 30-day readmissions and discharge disposition. RESULTS Of 1537 super-utilizing patients, 59.0% (n = 907) had at least two targeted chronic conditions. This final study cohort (n = 638) experienced a mean of 3.2 hospitalizations and 2.8 ED visits without hospitalization in the 12-month follow-up period. During follow-up, 26% experienced one or more 30-day readmission(s) within the health care system. Despite their medical complexity, 46% reported not having a regular primary care provider, and 48% had presenting pain scores ≥8/10. Only 1% of the visits to the ED were triaged as nonurgent. CONCLUSIONS Medicare and Medicaid patients with high baseline utilization and MCC experience continued high health care utilization. Patient characteristics, future utilization patterns, and health outcomes suggest the subgroup identified is an important subgroup of super-utilizers that merits attention because they may be particularly amenable to intervention.

Financial Barriers to Care Among Low-Income Children With Asthma: Health Care Reform Implications

IMPORTANCE The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts. OBJECTIVE To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma. DESIGN, SETTING, AND PARTICIPANTS A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (e.g., ≥

Community Oncology Medical Homes: Physician-Driven Change to Improve Patient Care and Reduce Costs

75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (i.e., Medicaid or Childrens Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (i.e., income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics. MAIN OUTCOMES AND MEASURES Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care. RESULTS After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physicians office visit (3.8% vs. 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs. 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their childrens care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their childrens asthma care. CONCLUSIONS AND RELEVANCE Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACAs low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites.

Although the patient-centered medical home is a well-established model of care for primary care providers, adoption by specialty providers has been relatively limited. Recently, there has been particular interest in developing specialty medical homes in medical oncology because of practice variation, care fragmentation, and high overall costs of care. In 2012, the Center for Medicare and Medicaid Innovation awarded Innovative Oncology Business Solutions a 3-year grant for their Community Oncology Medical Home (COME HOME) program to implement specialty medical homes in seven oncology practices across the country. We report our early experience and lessons learned.Through September 30, 2014, COME HOME has touched 16,353 unique patients through triage encounters, patient education visits, or application of clinical pathways. We describe the COME HOME model and implementation timeline, profile use of key services, and report patient satisfaction. Using feedback from practice sites, we highlight patient-centered innovations and overall lessons learned.COME HOME incorporates best practices care driven by triage and clinical pathways, team-based care, active disease management, enhanced access and care, as well as financial support for the medical home infrastructure. Information technology plays a central role, supporting both delivery of care and performance monitoring. Volume of service use has grown steadily over time, leveling out in second quarter 2014. The program currently averages 1,265 triage encounters, 440 extended hours visits, and 655 patient education encounters per month.COME HOME offers a patient-centered model of care to improve quality and continuity of care.

Most Exchange Plans Charge Lower Tobacco Surcharges Than Allowed, But Many Tobacco Users Lack Affordable Coverage

Background:Care for patients with chronic conditions often requires coordination between multiple physicians and delivery sites. Electronic Health Record (EHR) use could improve care quality and efficiency in part by facilitating care coordination. Objective:We examined the association between EHR use and clinician perceptions of care coordination for patients transferred across clinicians and delivery sites. Research Design:Repeated surveys of primary care clinicians during the staggered implementation of an outpatient EHR (2005–2008), followed by an integrated inpatient EHR (2006–2010). We measured the association between EHR use stages (no use, outpatient EHR only, and integrated inpatient-outpatient EHR) and care coordination using logistic regression, adjusting for clinician characteristics, study year, and medical center. Subjects:Adult primary care clinicians in a large Integrated Delivery System. Measures:Three measures of clinician-reported care coordination for patient care transferred across clinicians (eg, from specialist to primary care team) and across delivery sites (eg, from the hospital to outpatient care). Results:Outpatient EHR use was associated with higher reports of access to complete and timely clinical information and higher agreement on clinician roles and responsibilities for patients transferred across clinicians, but not for patients transferred across delivery sites. Use of the integrated outpatient-inpatient EHR was associated with higher reports of access to timely and complete clinical information, clinician agreement on the patient’s treatment plan for patients transferred across delivery sites, and with all coordination measures for patients transferred across clinicians. Conclusion:Use of an integrated EHR with health information exchange across delivery settings improved patient care coordination.