Electronic health records, clinical decision support, and blood pressure control

ArticleinThe American Journal of Managed Care 17(9):626-32 · September 2011with12 Reads
Source: PubMed
Abstract
Adding clinical decision support (CDS) to electronic health records (EHRs) is required under meaningful use legislation, but there has been little national data on effectiveness in improving clinical outcomes. We sought to determine whether EHRs with CDS improved blood pressure control in US primary care visits. Study Design: We used a cross-sectional, nationally representative survey. We examined adult visits to primary care physicians using the 2007 and 2008 National Ambulatory Medical Care Survey (NAMCS). We found that patients had a mean age of 52 years, 34% were male, 15% had diabetes, and 70% were white. Rates of blood pressure control were significantly higher in visits where both an EHR and CDS (79%) were used, compared with visits where physicians used neither tool (74%; P = .004). Blood pressure control rates remained higher after adjusting for potential confounders. In unadjusted analyses, mean systolic blood pressure was 2 mm Hg lower in visits with the use of both an EHR and CDS, compared with visits where physicians used neither tool (P = .03), and this difference remained significant after adjustment. The NAMCS shows that physician use of an EHR with CDS is associated with improved blood pressure control. These findings are important because small improvements in blood pressure control are associated with reductions in cardiovascular morbidity and mortality.
    • "PCPs and nephrologists working together should be able to control patients' blood pressure, yet we saw no difference in this measure between solo managed and co-managed patients. Both EHR alerts and population management are likely to be part of the answer [26, 28], but to date, there have been no successful systems-level interventions for uncontrolled blood pressure in a CKD population. Ideally, we will develop EHR alerts that are sophisticated enough to track management over time and to consider previous medication regimens and drug allergies [29, 30]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients. Methods We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (eGFR) between 15–59 mL/min/1.73 m2 separated by 90 days. We assessed process measures (serum eGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage. Results Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum eGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26). Conclusion For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
    Full-text · Article · Dec 2015
    • "Studying CDSS and patient outcomes in inpatient as opposed to outpatient settings, Sintchenko et al. [15] remarked that only 31% of the studies in the latter group had a positive change after implementation, as opposed to 100% of the inpatient studies. Overall, looking at the original studies reported in systematic reviews and studies published since then, it appears that between 2005 and 2011, 5 out of 10 studies testing various systems have failed to demonstrate improved patient outcomes in outpatient populations22232425262728293031, while 6 out of 7 studies in the inpatient setting report improvements in diverse areas such as thromboembolism, adverse drug events, and mortality rates32333435363738 (Table 1 ). In conclusion, the positive impact of HIT on patient safety and health outcomes in primary care has not clearly been demonstrated as it has in acute care settings. "
    [Show abstract] [Hide abstract] ABSTRACT: Health information technology represents a promising avenue to improve health care delivery. How can we use lessons learnt from existing health information technologies in primary care to inform the optimal design of newer developments such as personal health records? The results of systematic literature reviews about the impact of different information systems on health outcomes in primary care are critically discussed in a narrative synthesis, with a focus on their implications for the development of personal health records. Given the proliferation of systematic reviews and randomized controlled trials, high quality evidence for health information technology in primary care is accumulating with mixed results. The heterogeneity of systems being compared and the quality of research can no longer account for these findings. One potential explanation may be that systems originally designed for acute care settings are being implemented in primary care. Early studies evaluating personal health records suggest that targeting patient outcomes directly and adapting systems to patients' needs may be part of the solution. In order to develop personal health records for primary care, studies are needed that involve the users, namely patients and primary care health professionals, in the design and evaluation of these systems from their inception. Participatory research is a recommended methodological approach.
    Full-text · Article · Aug 2012
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