Improving Outcomes for High-Risk Diabetics Using Information Systems
Improving Outcomes for High-Risk Diabetics Using Information Systems
Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices' use of information.
Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA1c ≤ 8, LDL ≤ 100, BP ≤ 130/85). Practices' use of information was derived from clinician responses to a survey on their use of clinical information systems for patient identification and tracking. Hierarchical linear modeling examined relationships between patient outcomes and practice use of information, controlling for patient level covariates (age, gender, hypertension, and cardiovascular comorbidities) and practice level covariates (solo/group, and electronic health record [EHR] presence).
Results: Practices' use of identification and tracking systems significantly (P < .007 and 0.002) increased odds of achieving diabetes care targets (odds ratio [OR] 1.23 95%, confidence interval [CI] 1.06 to 1.44, and OR 1.32 95% CI 1.11 to 1.59). For diabetic patients with hypertension, odds of hypertension control were higher with higher use of tracking systems (OR = 1.52, P = .0017) and reflected similar trend with higher use of identification systems (OR = 1.28, P = .1349). EHR presence was not associated with attainment of clinical targets.
Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use.
Although a gap exists between guidelines and practice in diabetic patient care, increasing evidence suggests guideline application efforts require prioritization and customization to those patients who are most at risk from complications and who would benefit most from interventions. Consequently both practitioners and researchers are challenged to apply interventions to minimize resources and maximize results.
Primary care of diabetic patients requires access to and management of complex clinical information. Primary care practices deal with multiple competing demands, and the ability to identify at risk patients and track their management and prevention parameters are important information needs. Therefore, clinical information systems should help focus scarce practice resources on patients most at risk. However, the ability to meet these information needs in primary care practices is increasingly challenged by a host of factors, including rapid scientific advances, financial pressures to increase patient throughput and limit expenditures, and discontinuity of care caused by patient mobility, insurance turnover, and the provision of care through multiple providers. Rather than being used as excuses, these challenges actually provide reasons for better information systems. Information cannot be retained in the memory of a single clinician or buried in longitudinal progress notes and at the same time be reliably available for decision making. Reconciling information needs with practice resources remains a challenge.
Recent models for improving quality advocate expanding interventions beyond clinicians and effecting change in the practice as an organization. Although some models have advocated considerable investment in infrastructure such as EHR, and personnel, a model for change and improvement developed by our research team focuses on the importance of practice work relationships and incorporates the concept of interdependent practice organizational attributes. One organizational attribute is the practice's capacity to access and use information to deliver quality care. The use of clinical information systems is one aspect of this capacity hypothesized as supporting individual and organizational decision making. Whether electronic or paper, these information systems identify at-risk patients and track relevant prevention and treatment parameters.
In this study, we empirically test 3 hypotheses, which were developed a priori: Hypothesis 1 (H1), the use of clinical information systems favorably impacts patient-level measures of diabetes assessment, treatment and achievement of targets among all diabetic patients; H2, information use favorably impacts patient level measures particularly in diabetics with comorbidities; and H3, information use favorably impacts hypertensive control in diabetics with hypertension. H2 and H3 examine practice information use for those patients with more complex decision making information needs, at greater risk and who would benefit the most from intervention.
Abstract and Introduction
Abstract
Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices' use of information.
Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA1c ≤ 8, LDL ≤ 100, BP ≤ 130/85). Practices' use of information was derived from clinician responses to a survey on their use of clinical information systems for patient identification and tracking. Hierarchical linear modeling examined relationships between patient outcomes and practice use of information, controlling for patient level covariates (age, gender, hypertension, and cardiovascular comorbidities) and practice level covariates (solo/group, and electronic health record [EHR] presence).
Results: Practices' use of identification and tracking systems significantly (P < .007 and 0.002) increased odds of achieving diabetes care targets (odds ratio [OR] 1.23 95%, confidence interval [CI] 1.06 to 1.44, and OR 1.32 95% CI 1.11 to 1.59). For diabetic patients with hypertension, odds of hypertension control were higher with higher use of tracking systems (OR = 1.52, P = .0017) and reflected similar trend with higher use of identification systems (OR = 1.28, P = .1349). EHR presence was not associated with attainment of clinical targets.
Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use.
Introduction
Although a gap exists between guidelines and practice in diabetic patient care, increasing evidence suggests guideline application efforts require prioritization and customization to those patients who are most at risk from complications and who would benefit most from interventions. Consequently both practitioners and researchers are challenged to apply interventions to minimize resources and maximize results.
Primary care of diabetic patients requires access to and management of complex clinical information. Primary care practices deal with multiple competing demands, and the ability to identify at risk patients and track their management and prevention parameters are important information needs. Therefore, clinical information systems should help focus scarce practice resources on patients most at risk. However, the ability to meet these information needs in primary care practices is increasingly challenged by a host of factors, including rapid scientific advances, financial pressures to increase patient throughput and limit expenditures, and discontinuity of care caused by patient mobility, insurance turnover, and the provision of care through multiple providers. Rather than being used as excuses, these challenges actually provide reasons for better information systems. Information cannot be retained in the memory of a single clinician or buried in longitudinal progress notes and at the same time be reliably available for decision making. Reconciling information needs with practice resources remains a challenge.
Recent models for improving quality advocate expanding interventions beyond clinicians and effecting change in the practice as an organization. Although some models have advocated considerable investment in infrastructure such as EHR, and personnel, a model for change and improvement developed by our research team focuses on the importance of practice work relationships and incorporates the concept of interdependent practice organizational attributes. One organizational attribute is the practice's capacity to access and use information to deliver quality care. The use of clinical information systems is one aspect of this capacity hypothesized as supporting individual and organizational decision making. Whether electronic or paper, these information systems identify at-risk patients and track relevant prevention and treatment parameters.
In this study, we empirically test 3 hypotheses, which were developed a priori: Hypothesis 1 (H1), the use of clinical information systems favorably impacts patient-level measures of diabetes assessment, treatment and achievement of targets among all diabetic patients; H2, information use favorably impacts patient level measures particularly in diabetics with comorbidities; and H3, information use favorably impacts hypertensive control in diabetics with hypertension. H2 and H3 examine practice information use for those patients with more complex decision making information needs, at greater risk and who would benefit the most from intervention.
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