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The Use of EHR in Diabetes Patients Through Cohesive Care Teams

EHR-associated treatment in diabetes patients?

Electronic health records (EHRs) have been used to promote patient care and improve the overall quality and efficiency of the American healthcare system. The Meaningful Use program, started in 2011, provided federal incentives to healthcare providers for using certified EHRs. Although the use of EHRs has been proven to improve healthcare, the environment in which EHRs are used has not been addressed. Because the demand of providing patient-centered care is gradually increasing, the use of these innovative EHRs among various healthcare disciplines must be understood.

Team cohesion is defined as the measure of constructive work relationships among primary care team members. It promotes an atmosphere of informal learning where members are more comfortable in sharing best practices with each other and experimenting with EHRs. The extent of team cohesion might determine the benefits of maximizing the use of EHRs to improve healthcare. This study hypothesized that the patients who were cared for by a team of higher cohesion primary care providers would achieve an improvement in healthcare from EHRs when compared to patients who were cared for by a team of lower cohesion primary care providers.

This was a retrospective longitudinal study that examined whether team cohesion among primary care team members determined the beneficial clinical outcomes when using EHRs in patients with diabetes. Before the implementation of staggered EHRs, team cohesion was developed and measured to describe the work environment and communication between primary care providers. Thereafter, each team was classified as having low or high cohesion. A total of 80,611 patients from the health plan’s diabetes clinical database registry were included in the study. Inclusion criteria into the registry were patients with 1 inpatient principal diagnosis, 2 outpatient diabetes diagnoses within 5 years, 2 or more abnormal lab results within 2 years (A1C > 6.5%, fasting glucose > 162 mg/dL, random glucose > 200 mg/dL), or 1 diabetes medication prescription. Using the health plan’s automated lab data, the A1C and the LDL-C of the patients were collected. Between 2005 and 2009, Kaiser Permanente North California (KPNC) implemented outpatient EHRs to each of the primary care teams. The status of the EHR on each patient and their potential effects on treatment and follow-up were measured. Follow-up A1C and LDL-C valued were examined using linear regression models.

Baseline mean A1C’s for each patient treated by the lower and higher cohesion primary care teams were similar (7.2% and 7.1%, respectively). The baseline LDL-C’s were modestly different (96.8 mg/dL for low cohesion teams and 97.5 mg/dL for high cohesion teams; P = 0.01). At the end of the study, it was determined that for patients who were cared for by the higher cohesion primary care teams, the use of EHR-associated improvements in A1C were significantly greater compared to patients who were cared for by the lower cohesion primary care teams. There was a 0.02% point difference between the two teams (95% CI, 0.00% – 0.03%; P < 0.01). Similarly, for patients treated by primary care teams with high cohesion, the use of EHR was associated with greater reduction in LDL-C (2.15 mg/dL reduction), when compared to patients treated by primary care teams with low cohesion (1.42 mg/dL reduction). The difference in EHR-associated reduction in LDL-C was 0.73 mg/dL (95% CI, 0.41-1.11 mg/dL; P < 0.01). Additionally it was determined that the use of EHR and good physiologic control (A1C < 7% and LDL-C < 100 mg/dL) among patients treated with high cohesion primary care teams was significantly higher, compared to patients treated with low cohesion primary care teams (P <0.01).

The study determined that the use of EHR’s to treat glycemic and lipid control in patients with diabetes depended on the extent of team cohesion. Patients who were cared for by more cohesive teams using EHR showed a higher improvement on glycemic control and lipid panels. It is possible that the teams with lower cohesion had fewer agreed-upon approaches, which made communicating among multidisciplinary teams complicated and made it difficult to retrieve critical patient health information. High cohesion is an important aspect in providing patient-centered care. Although this study determined that team cohesion enhanced EHR associated short-term clinical outcomes, future studies should determine the implication of team cohesion on EHR-associated changes in the long run.

Practice Pearls:

  • Electronic Health Records (EHR) is an innovative way to provide patient-centered care among the diverse healthcare professions.
  • EHR-associated care has been shown to improve healthcare by high cohesive primary care teams.
  • High cohesive teams have been shown to significantly improve EHR-associated glycemic control and lipid panels in patients with diabetes.

Researched and prepared by Sabair Pradhan, Doctor of Pharmacy Candidate USF College of Pharmacy, reviewed by Dave Joffe, BSPharm, CDE

Graetz I, Huang J, Brand R, et al. The impact of electronic health records and teamwork on diabetes care quality. Am J Manag Care. 2015;21(12):878-84.