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The American Journal of Managed Care December 2015
Interest in Mental Health Care Among Patients Making eVisits
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The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality
Ilana Graetz, PhD; Jie Huang, PhD; Richard Brand, PhD; Stephen M. Shortell, PhD, MPH, MBA; Thomas G. Rundall, PhD; Jim Bellows, PhD; John Hsu, MD, MBA, MSCE; Marc Jaffe, MD; and Mary E. Reed, DrPH
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The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality

Ilana Graetz, PhD; Jie Huang, PhD; Richard Brand, PhD; Stephen M. Shortell, PhD, MPH, MBA; Thomas G. Rundall, PhD; Jim Bellows, PhD; John Hsu, MD, MBA, MSCE; Marc Jaffe, MD; and Mary E. Reed, DrPH
Patients with diabetes that are cared for by primary care teams with higher cohesion experienced greater EHR-related outcome improvements, compared with patients cared for by lower cohesion teams.
Evidence of the impact electronic health records (EHRs) have on clinical outcomes remains mixed. The impact of EHRs likely depends on the organizational context in which they are used. This study focuses on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association between EHR use and changes in clinical outcomes for patients with diabetes.

Study Design: Retrospective longitudinal study.

Methods: We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005-2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects were comprised of 80,611 patients with diabetes, in whom we measured changes in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C).

Results: For A1C, EHR use was associated with an average decrease of 0.11% for patients with higher-cohesion primary care teams compared with a decrease of 0.08% for patients with lower-cohesion teams (difference = 0.02% in A1C; 95% CI, 0.01%-0.03%). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher-cohesion primary care teams compared with a decrease of 1.42 mg/dL for patients with lower-cohesion teams (difference = 0.73 mg/dL; 95% CI, 0.41-1.11 mg/dL).

Conclusions: Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams.

Am J Manag Care. 2015;21(12):878-884
Take-Away Points
Patients with diabetes cared for by higher cohesion primary care teams experienced modest but statistically significantly greater health outcome improvements related to electronic health records (EHRs), compared with patients cared for by providers practicing in lower cohesion teams.
  • Previous studies of the effects of EHR use on diabetes clinical outcomes have been mixed, and none examined how the organizational environment may change the EHR impact on clinical care.
  • Understanding the conditions necessary to maximize the potential benefits of EHR use is important.
  • Our results suggest that team cohesion plays a critical role in fully realizing potential gains in care quality from EHR use.
Adoption of electronic health records (EHRs) has been promoted as a policy goal to improve the quality and efficiency of the American healthcare system. Starting in 2011, qualified healthcare providers in the United States began receiving federal incentive payments through the Meaningful Use program for the specified utilization of certified EHRs.1-3 Although the meaningful use criteria were developed to target improvements in the overall quality of healthcare,4 they do not address the organizational environment in which EHRs are used. The healthcare system consists of a myriad of organizational settings that affect how various technological innovations are implemented and used.5 Recent calls for the adoption of patient-centered medical homes and the increasing demand for primary care are propelling the adoption of multidisciplinary, team-based care.6-8 Therefore, it is important to understand how the team environment in particular impacts the adoption and effectiveness of new technology. Team cohesion is a measure of the constructive work relationships among primary care team members.9-12 How well teams work together may be an important factor in helping practices maximize the potential benefits of EHRs.13

The results of previous studies of the effects of health information technology on the clinical outcomes of patients with diabetes have been mixed, with some showing improvements in low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (A1C) values,14 and others reporting null or negative results.15-20 Differences in work environments, such as team cohesion, may help explain these conflicting findings. Work relationships are crucial for providing safe and reliable patient care and establishing the collective capacity for change, such as adopting new technologies, which demands considerable changes to the clinical work flow.21-28 Team cohesion may promote an atmosphere of more informal learning, in which members are more comfortable experimenting with the EHR and sharing best practices with each other. Consequently, cohesion among team members likely influences the success of teams at adopting EHRs and achieving desired improvements in patient care.

In prior work, we reported that the use of a commercially available federally certified outpatient EHR, within a large integrated delivery system, resulted in modest improvements in patient physiologic outcomes, measured by lipid and glycemic levels, and in fewer unfavorable clinical events such as hospitalizations.29,30 In this study, we explored the heterogeneity of these physiologic effects by examining how primary care team cohesion changes this EHR-associated improvement in clinical outcomes for patients with diabetes. We hypothesized that patients cared for by primary care teams with higher team cohesion would achieve greater improvements from EHR use compared with patients cared for by teams with lower team cohesion.

Study Setting
This study was conducted at Kaiser Permanente Northern California (KPNC), a large, prepaid Integrated Delivery System (IDS) providing comprehensive medical care for more than 3 million members. The system receives bundled prospective payments for all medical care. Primary care clinicians worked in 110 primary care teams, across 18 medical centers. Primary care teams were created in the 1990s in an effort to redesign primary care using multidisciplinary teams. The size and composition of teams varied, but each generally included 1 or more physicians, nurse practitioners, registered nurses, health educators, pharmacists, behavioral medicine specialists, physical therapists, etc. Teams ranged in size from 5 to 37 members (Table 1).

An individual with diabetes will often receive care from multiple members of the care team. For example, a primary care physician or nurse practitioner provides routine care (“check-ups”) and acute care, a health educator teaches diabetes self-care, a dietitian assists with dietary and nutritional needs, a pharmacist provides information regarding medications, and a behavioral medicine specialist can help address stress, depression, and other mental health issues.

Team Cohesion Measure
In 2005, before the staggered implementation of an EHR, we mailed a letter introducing the study, a survey, and a pre-paid return envelope to all primary care team members working in the IDS. Respondents who completed the survey received a $5 gift card. Nonrespondents were re-sent up to 3 follow-up surveys.

The team cohesion measure was designed to describe the quality of working relationships and communication between primary care team members and, was developed using published validated instruments.9-12 Although other instruments capture similar aspects of the team environment—such as team participation, team dynamics, and relational coordination—we chose to use this one specifically because it was the only validated instrument available at the time of the study that was created specifically for use among primary care teams.9 We asked primary care team members whether they agreed or disagreed with the following 4 items: “when there is conflict on this team, the people involved usually talk it out and resolve the problem successfully”; “team members have constructive work relationships”; “there is often tension among people on this team” (reverse scored); and “the team members operate as a real team.”

Response options included a 5-point Likert-like agreement scale (1-5) that were averaged over the 4 team cohesion items for each respondent, and then averaged across members from the same team. The overall measure demonstrated high internal consistency with a Cronbach alpha coefficient of reliability of 0.83. For ease of interpretability, we categorized team cohesion scores into quartiles and created a binary indicator variable classifying each team as having lower or higher cohesion, with the lowest quartile of scores representing lower cohesion teams. We chose to categorize lower cohesion teams as those in the lowest quartile of cohesion because the median cohesion score in the study setting was higher than those previously reported; our 25th percentile scores were similar to the median score previously published.9

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