The findings provide some perspectives on the federal government's Meaningful Use program, which requires attestation-of-quality data this year and electronic reporting in 2012. Not coincidently, the national coordinator of health IT, Farzad Mostashari, MD, who has responsibility for implementing the federal incentive program, led the team that created the New York EHR program when he was assistant commissioner of the city's department of health and mental hygiene.
Since 2007, the Primary Care Improvement Project (PCIP) has helped primary care doctors in underserved areas acquire EHRs. Quality data has been transmitted automatically from those EHRs to the department of health on a monthly basis.
The JAMIA study focused on 309 small practices that adopted EHRs under PCIP between 2007 and 2010. Most of these practices contained only one or two physicians, and 53% of their patients were on Medicaid or uninsured.
Over the course of a year, the researchers found, the rates of preventive care among the PCIP practices increased by up to 2.4% per month, depending on the indicator. The percentage of adult patients who had seen their primary care doctor in the past 12 months rose by only 0.1%, perhaps because it was already high at baseline. But the percentage of patients with diabetes who had received an HbA1c test within the past six months jumped 2.4%.
Among the other preventive care measures the PCIP practices improved were: body mass index recording (2%), smoking cessation intervention (0.9%), breast cancer screening (1.1%), influenza vaccination (0.5%), antithrombotic treatment (0.9%), and blood pressure control (0.7%).
Cholesterol and HbA1c control declined slightly among the PCIP physicians' patients. However, the researchers noted that less than half of the practices contributed data on these indicators at the beginning of the study period. Increased screening rates during the study period may have contributed to the downturn, they speculated.
Mickey Tripathi, president of the Massachusetts eHealth Collaborative (MaeHC), said the JAMIA study's findings were consistent with another recent study of data from the MaeHC's pioneering work in providing EHRs to physicians in three Massachusetts communities, starting in 2005. That study found that doctors who used EHRs were more likely to use registries, which enable them to track their patients' preventive and chronic care.
Tripathi, who was closely acquainted with PCIP in its formative stages, said that Mostashari and his team were focused on improving quality from the start. They realized that this wouldn't happen unless they required physicians to document their data in a structured way and share the information with the city.
PCIP wisely chose to require all of the participating physicians to use the same EHR, Tripathi noted. That gave PCIP considerable influence over the vendor, eClinicalWorks (ECW). PCIP persuaded ECW to build in a number of prompts and alerts that made it easy for the doctors to follow the preventive care guidelines. In addition, the vendor built a data reporting mechanism into the version of its EHR that it created for PCIP.
Transmitting the data from a single EHR to a central repository is much simpler than what the Centers for Medicare and Medicaid Services (CMS) proposes to do, which is to have users of multiple EHRs send their data to a national data warehouse. Nevertheless, Tripathi noted, the number of practices in the JAMIA study that contributed data declined from the beginning to the end, partly because of data transmission problems. "Consistent transmission of data is really hard," he said, and he questioned whether CMS could pull this off with thousands of EHRs sending in data from all over the country.
But PCIP's experience also contains a positive harbinger for Meaningful Use, he noted: Physicians were forced to enter structured data in their EHRs, which allowed the city to monitor population health.
"Meaningful Use is now a lever for that [on a national basis], and it provides a nice roadmap and framework to be able to say to physicians, 'You won't get these incentives unless you do things in this way,'" Tripathi pointed out. "These requirements are geared toward allowing EHRs to be effective, which can only happen if the data is structured in a way that it can be measured."
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