EHRs & CVD: The Good, the Bad & the Future

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Early EHR adopters are showing how they can use health IT to improve the outcomes of patients with or at risk for cardiovascular disease (CVD). There is potential for big savings and improved health, but interoperability issues and payment structures currently hold them back.

The good

While conducting a phased EHR implementation between 2005 and 2008, Kaiser Permanente Northern California (KPNC) wanted to ascertain whether digitization was having a neutral, positive or negative impact on patients’ health outcomes. Researchers examined blood glucose and cholesterol levels of approximately 170,000 patients listed in the health system’s diabetes clinical registry by the end of 2003. They chose those two measures because high levels of glycated hemoglobin (HbA1C) and low-density lipoprotein cholesterol (LDL-C) are risk factors for CVD.

“There have been a lot of questions about whether an EHR would make a difference in patients’ lives and, if it did, whether it would be helpful, harmful or neutral,” says study co-author Marc Jaffe, MD, clinical leader of the CV risk reduction program at KPNC in San Francisco. “Our study demonstrates that it is useful.”

Among KPNC diabetics, a group that already demonstrated strong baseline performance against CV care quality measures, patients with EHRs were more likely to see greater reductions in HbA1C and LDL-C than those without (Ann Intern Med 2012;157[7]:482-489). On average, EHRs were associated with a 0.14 percent greater reduction in HbA1C values among patients with a baseline value higher than 9 percent and a 0.06 mmol/L greater reduction in LDL-C levels among patients with a baseline value higher than 3.4 mmol/L.

Patients also were more likely to return to KPNC for retesting in a shorter time frame after EHR implementation. For instance, 83.5 percent of patients with LDL-C levels greater than 3.4 mmol/L returned for testing within one year pre-implementation, and 86.7 returned within one year post-implementation.

EHRs also helped patients with HbA1C and LDL-C levels below 9 percent and 3.4 mmol/L perform better against the selected outcomes. But the most significant impact was among the group with levels above those thresholds, which Jaffe and his colleagues considered indicators of especially high-risk CVD. EHRs “focused the organizational energy on those farthest from meeting their goals,” Jaffe says.

He attributes the increased rates of retesting and medication adjustments to EHRs, which allowed clinicians to better identify patients overdue for retesting and to track the efficacy of medications. This, in turn, led to better patient performance against established quality measures.

The reductions in HbA1C and LDL-C blood glucose and cholesterol levels are modest, “but when you magnify this over a population of 170,000 patients, it’s going to translate into a meaningful reduction in cardiovascular disease,” Jaffe says.

Similar results have been achieved elsewhere. Patients of 204 physicians using EHRs from the Fishkill, N.Y.-based Taconic Independent Practice Association (TIPA) met a Healthcare Effectiveness Data and Information Set measure for HbA1C testing 90 percent of the time compared with patients of 262 physicians without EHRs who met the measure 84 percent of the time (J Gen Intern Med online Oct. 3, 2012).

“If you have an EHR, you have an opportunity to hit some of the screening recommendations that your practice has decided are key to improving outcomes,” says Susan Stuard, MBA, executive director of the Taconic Health Information Network and Community (THINC), a Fishkill nonprofit organization that sponsors regional health information exchange (HIE) and promotes EHR adoption.

The bad

While some organizations have utilized EHRs to improve patient outcomes on intermediate measures, one criticism often aimed at the costly systems is that they should be capable of more than automated reminders.

In a 2012 working paper, “Using EHRs to Monitor and Improve Adherence to Medication,” researchers from the Mayo Clinic in Rochester, Minn., and North Carolina State University in Raleigh estimated that a nationwide system of fully integrated EHRs with real-time medication monitoring capabilities would each year save $1.41 billion while adding 131,000 quality-adjusted life years (QALY) to patients recently diagnosed with diabetes.

There are barriers to achieving these kinds of results. It would require provider access to uninterrupted, longitudinal streams of patient data from