Graetz I, Huang J, Brand R, Shortell S, Rundall T, Bellows ... · Real-world evidence about EHRs and diabetes outcomes: the good, bad, and ugly Mary Reed, DrPH, Kaiser Permanente

Real-world evidence about EHRs and diabetes outcomes: the good, bad, and ugly

Mary Reed, DrPH, Kaiser Permanente Division of Research

Electronic Health Records (EHR), used in clinical care for patients with diabetes, form the information

backbone for diabetes care delivery, and offer the ability to extend data access to patients to interact

with their own EHR for self-management. In this session we will examine research evidence from an

integrated delivery system about the impacts of EHR use, both clinician-facing and patient-facing, on

diabetes care and outcomes, and use of the EHR in telemedicine delivery. We will discuss implications of

the EHR as a large data source for real-world research on diabetes care and outcomes, including

strengths and potential weaknesses of various EHR data sources.

References

Reed M, Huang J, Graetz I, Brand R, Hsu J, Fireman B, Jaffe M. Outpatient Electronic Health Records and the Clinical Care and Outcomes of Patients with Diabetes Mellitus. Annals of Internal Medicine 2012 October;157(7):482-489.

Reed M, Huang J, Brand R, Graetz I, Fireman B, Neugebauer R, Ballard D, Hsu J. Association between implementation of an outpatient electronic health record and emergency department visits, hospitalizations and office visits among patients with diabetes. JAMA 2013, Sep 11;310(10):1060-5.

Graetz I, Huang J, Brand R, Shortell S, Rundall T, Bellows J, Hsu J, Jaffe M, Reed M. “The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality” American Journal of Managed care. 2015 Dec;21(12):878-84.

Otte-Trojel T, Rundall T, De Bont A, Van de Klundert J, Reed M. The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente. BMC Health Serv Res. 2015 Dec 16;15(1):559.

Graetz I, Gordon N, Fung V, Reed M. The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income. Medical Care. 2016 Aug;54(8):772-9.

Reed M, Huang J, Brand R, Ballard DB, Yamin C, Hsu J, Grant R. Communicating through a patient portal: conveniently engaging family care partners. JAMA Internal Medicine, 2018 Jan 1;178(1):142-144.

Graetz I, Huang J, Brand R, Hsu J, Reed M. Bridging the Digital Divide: Mobile Access to Personal Health Records among Patients with Diabetes. American Journal of Managed Care. 2018 Jan;24(1):43-48.

Reed M, Huang J, Parikh R, Barr I, Ballard D, Wargon C. Real-Time Patient-Provider Video Telemedicine Integrated with Clinical Care. New England Journal of Medicine, 2018 Oct;379:1478-1479.

Graetz I, Huang J, Brand R, Hsu J, Reed M. Mobile-Accessible Personal Health Records Increases the Frequency and Timeliness of PHR Use for Patients with Diabetes. Journal of the American Medical Informatics Associations, in press.

Real-world evidence about EHRs and diabetes

outcomes

Mary Reed, DrPH

Research Scientist

Kaiser Permanente Division of Research, Oakland, CA

No conflicts of interest to declare – Research supported by NIDDK (R01DK085070) and PCORI (IH-12-11-4925)

American Diabetes Association Research Symposium November 2018

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Kaiser Permanente Research

HITECH act kickstarted US EHR adoption

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Source: Health IT.gov


Nearly all hospitals allow patients to view their health information electronically – healthit.gov

Look for better figure? Switch to bullets

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Health Information Exchange (HIE) &

interoperability – data to user & in time

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Source: Health IT.gov

What is HIE?

Health Information Exchange allows health care professionals and patients to appropriately access and securely share a patient’s medical information electronically


Broadening definition of Electronic Health Records (EHRs): building blocks of real-world diabetes health care data

• Clinician EHR Use: federal incentive programs kickstarted uptake

• Patient EHR Access: federal measures incentivize basic portal tools

• Secure messaging

• Lab results

• Appointment scheduling

• Medication refill orders

• EHR Health information exchange (HIE) : growing but uncertain

• Telemedicine: Using integrated EHR to support video visits

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Clinician-facing Outpatient EHRImpacts on Diabetes care and Outcomes


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EHR &Quality - Implementing an EHR:

• Increased treatment intensification for patients with high HbA1c values

• Improved monitoring

• Increased yearly retesting for all patients

• 90 day retesting decreased if patient already at goal

• Improved HbA1c and LDL values

• Greater reductions if patient is farther from control

• Greater patient improvements in cohesive clinical teams

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EHR & Utilization/Events – Implementing an EHR:

• No change in office visit rate

• Reduced ED visits

• Reduced preventive hospitalizations

• Modest savings: EHR could reduce costs for patients with diabetes by $158,478 annually per 1,000 patients

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What in the EHR produced these outcomes?

• Increased information availability

• Increased visibility of the information

• Increased speed when information was available to teams

• Increased electronic clinical decision support

• When patients’ diabetes is not well controlled

• When patients overdue for testing

• When patients needed drug initiation

• Increases in order-entry functionality

• Easier for clinicians to order appropriate tests or treatment using

streamlined prompts and short cuts

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Patient-facing Portal to EHRPatient experiences and impacts on health care use

Kaiser Permanente Research13

• 90% reported that it was convenient• 81% that it helps get faster answers• 81% that it helps to prepare for visits• 92% that the info integrated with other care• 31% of patients reported that portal use improved their

health• 35% still prefer in-person care• 17% have concerns about privacy online

Patient-reported impacts of portal use:


Patient portal impacts on Utilization/Events –When patients with diabetes use the portal:

• Higher office visit rate

• Lower ED visit rate

• Reduced preventive hospitalizations

• Greater impact in patients with diabetes + other complex

conditions

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Mobile patient portalImpacts on reach and access


Frequency of portal use increases after adding mobile use

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Graetz I, Huang J, Brand R, Hsu J, Reed M. Mobile-Accessible Personal Health Records Increases the Frequency and Timeliness of PHR Use

for Patients with Diabetes. Journal of the American Medical Informatics Associations [epub ahead of print].


Mobile patient portal access expands reach

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Graetz I, Huang J, Brand R, Hsu J, Reed M. Bridging the Digital Divide: Mobile Access to Personal Health Records among Patients with Diabetes. American Journal of Managed Care. 2018 Jan;24(1):43-48


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Video TelemedicineIntegrating EHR access to expand patient health care access


Video visits: Patient device used and visit

length (minutes): Connected video visits

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Reed M, Huang J, Parikh R, Barr I, Ballard D, Wargon C. Real-Time Patient-Provider

Video Telemedicine Integrated with Clinical Care. New England Journal of Medicine,

2018 Oct;379:1478-1479.

Smartphone74%

7.6 min

Tablet6%

10.0 min

Desktop20%

10.2 min


Evidence on EHR impacts: diabetes care

• Promising direct improvements in diabetes management and health care delivery

• Improvements in quality and control

• Decreases in over-testing

• Reduction in health events

• EHRs offer direct patient engagement for self-management – can mobile overcome ‘digital divide’?

• EHR-integrated telemedicine can expand access and support patient-physician relationship

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Generating real-world evidence from EHR data

• The Good: Abundant data

• Provider-facing & patient facing

• Impacts on clinical care and support learning health systems

• The Bad: Design limitations still remain

• Observational studies – challenges to causal inference

• Intervention studies – site-specific limits translation

• The Ugly: Unintended consequences

• Unstructured data

• Un-captured/missing data

• User-experience and workflow challenges

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Emerging opportunities to harness real-time EHR data in clinical care:

• mHealth/Telemedicine

• Remote monitoring

• Personalized clinical decision support

• Advanced analytics & machine-learning

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Thank you!

[email protected]

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Documents

Graetz I, Huang J, Brand R, Shortell S, Rundall T, Bellows ... · Real-world evidence about EHRs and diabetes outcomes: the good, bad, and ugly Mary Reed, DrPH, Kaiser Permanente