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Association Between Meaningful Use of Electronic Health Records and Patient Health Outcomes in Schizophrenia: A Retrospective Database Analysis
Daisy Ng-Mak, PhD; and Charles Ruetsch, PhD

Association Between Meaningful Use of Electronic Health Records and Patient Health Outcomes in Schizophrenia: A Retrospective Database Analysis

Daisy Ng-Mak, PhD; and Charles Ruetsch, PhD
Improvements in patient outcomes from the meaningful use of electronic health records (EHRs) have not been extensively studied among patients with schizophrenia. This study assessed the association between EHR use, provision of quality care, and patient outcomes. Providers who were at least 50% compliant with current requirements for the CMS Electronic Health Records Incentive Program were classified as EHR providers. Quality of mental health care was assessed using 4 Healthcare Effectiveness Data and Information Set indicators. Patient outcomes included inpatient admissions and emergency department visits. A total of 18,305 providers (EHR: 16.6%; non-EHR: 83.3%) treated 27,153 patients with schizophrenia. EHR use was associated with improved rates of diabetes screening (77.9% vs 72.4%; P <.001), diabetes monitoring (72.1% vs 61.4%; P <.001), and better antipsychotic adherence (54.7% vs 36.6%; P <.001). EHR use was also associated with fewer inpatient admissions (15.9% vs 25.2%; P <.001) and emergency department visits (32.2% vs 49.3%; <.001). These data suggest that EHR use may have a positive influence on the process and outcomes of psychiatric care when treating patients with schizophrenia. More research is needed to identify the drivers of the influence of EHRs and to develop programs that ensure all EHR users enjoy the same potential benefits as demonstrated here.
Am J Manag Care. 2019;25:-S0
Improving healthcare quality is a top priority for CMS, which is consistent with the Triple Aim of optimizing patients’ quality of care and improving population health, while maintaining the affordability of healthcare.1,2 The use of electronic health records (EHRs) to appropriately diagnose, treat, and manage patient care through meaningful tracking and monitoring systems is an approach that is being widely adopted in the United States and elsewhere.

In the United States, the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized the use of healthcare technologies by providers to improve coordination of care.3 Meaningful use of EHRs, as defined in the HITECH Act, set the minimum standard for the incentives. Implementation of meaningful use occurred in 3 sequential stages with the objectives of each stage overlapping and building on those prior in a cumulative manner. Stage 1, which began in 2011, focused on capturing and sharing basic patient information through 15 core objectives.4 Stage 2, which began in 2014, focused on advanced clinical processes through 17 core objectives (eg, identifying patients who should receive preventative/follow-up care, identifying patient-specific education resources, using secure electronic messaging to communicate with patients).5 Stage 3, which began in 2017, focused on improving patient outcomes.6 The specific requirements and timelines for stages 2 and 3 have since been modified by newer legislation.6,7

The majority of providers utilize some form of EHR, and most believe EHR use improves quality of care.8 A review of the literature identified increased productivity, better quality, and improved data management as the most frequently reasons for adoption of EHR, while the most commonly reported barriers to adoption of EHR were data errors, a lack of standards, and productivity loss.9  At one academic healthcare center, EHRs were found to be a substantial burden on primary care physicians’ time (5.9 hours per day),10 although the time to complete the same clinical process using paper charts was not estimated. Critics have argued that there is no consistent evidence that EHR use leads to improved patient outcomes.11,12 Although the meaningful use of EHRs has been correlated with enhanced healthcare quality and processes,13-17 the impact of the meaningful use of EHRs on patient outcomes, especially in treating serious mental illness such as schizophrenia, has not yet been determined.

Schizophrenia is uncommon, affecting only 0.5% to 1% of the population in the United States18,19; however, it is one of the most expensive and disabling mental illnesses.20 In 2013, the total cost—including direct healthcare costs, direct nonhealthcare costs (eg, law enforcement, homeless shelters, and research and training), and indirect costs (eg, unemployment, productivity loss, premature mortality, and caregiving)—of schizophrenia in the United States was estimated at $155.7 billion, with $37.7 billion reflecting the direct healthcare costs.21 Schizophrenia ranks as the sixth most disabling disease worldwide, due in part to severe psychiatric symptoms such as delusions, hallucinations, and social withdrawal.20 In addition, patients with schizophrenia also tend to have higher rates of diabetes and cardiovascular disease compared with the general population.22 Many of the atypical antipsychotics that are the first-line treatment for schizophrenia19,23 cause weight gain, which in turn can exacerbate these comorbid conditions.24,25

Recognizing these issues, the National Committee for Quality Assurance added Healthcare Effectiveness Data and Information Set (HEDIS) measures to specifically address metabolic care for patients with mental illness. These 4 measures include diabetes screening, diabetes monitoring, cardiovascular monitoring, as well as the assessment of antipsychotic medication adherence.26 The results of a recent retrospective insurance claims database study indicated that over 80% of patients with schizophrenia who were taking antipsychotics received the recommended HEDIS metabolic monitoring.27 However, it remains unclear if meeting these specific quality-of-care metrics actually leads to improved patient outcomes. Thus, the current study assessed the association between the meaningful use of EHRs, the quality of patient care, and patient outcomes in schizophrenia.


Study Design and Data Source

This retrospective database analysis examined the meaningful use of EHRs and patient outcomes in schizophrenia utilizing 3 large datasets, which were linked through physicians’ National Provider Identifier (NPI) numbers. The Inovalon “More2 Registry”—a multipayer medical and pharmacy claims database from private and public (Medicare Advantage or Managed Medicaid) sector health plans in all 50 US states that contains information on 252 million unique patients—contained all of the data with the exception of providers’ EHR use.28 All patient health data in the Inovalon More2 Registry were de-identified in compliance with the Health Insurance Portability and Accountability Act.

Meaningful use of EHR information came from 2 separate CMS datasets. Providers in the Inovalon More2 Registry were grouped into either the EHR providers group or the non-EHR providers group. Those who were listed in the CMS Electronic Health Records Incentive Program dataset as at least 50% compliant with current requirements were identified as having meaningful use of EHR. Those who were not identified in this dataset were either not participating in meaningful use of EHR or simply not seeing Medicare or Medicaid patients. Therefore, all non-EHR providers were also required to be in CMS’s “Medicare Provider Utilization and Payment Data: Physician and Other Supplier” dataset. Less than 0.5% of providers were excluded because they were not identified in either of these 2 datasets.

Because these data were analyzed at the provider rather than patient level, the claims of all patients who met the study inclusion or exclusion criteria were linked with their providers. Based on the patient–provider linkages, the group of patients under the care of a provider during the study period was labeled the patient panel for that provider. If a single patient saw multiple providers, the patient was included on the patient-panels for each of the providers that saw the patient.

Patient Inclusion/Exclusion Criteria

Patients were included if they were 18 years or older and diagnosed with schizophrenia (International Classification of Diseases (ICD)-9-Clinical Modification (CM) 295.xx). Schizophrenia diagnosis was determined by either a single inpatient admission or ED claim with a primary diagnosis of schizophrenia, or 2 outpatient claims with a primary diagnosis of schizophrenia within a 1-year period. Patients were required to have continuous enrollment with medical and pharmacy eligibility from January 1, 2014, through December 31, 2014. Patients also needed to qualify for at least 1 of the 4 HEDIS mental health quality measures (ie, diabetes screening, diabetes monitoring, cardiovascular monitoring, assessment of antipsychotic medication adherence) assessed in 2014 as part of the primary analysis. See the eAppendix for detailed definitions.

Provider Inclusion/Exclusion Criteria

Providers were included if they met all of the following criteria: accepted commercially insured and Medicare or Medicaid members, had at least 1 patient qualifying for 1 of 4 HEDIS mental health quality measures, and were not part of a group practice. Providers with an NPI number associated with a group practice were excluded if there was no other NPI number that identified him or her as an individual provider because the care could not be attributed to a single physician.

High- vs General-Quality Provider Definition

Providers were categorized as delivering either high- or general-quality care using CMS’ “Guide to Quality Performance Scoring Methods for Accountable Care Organizations,” which outlined

33 measures of quality care in 4 domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population.29 Providers were defined as high-quality providers if at least 90% of their patients achieved all measures for which they were eligible; otherwise, the providers were classified as general-quality providers.

Outcome Measures

The quality of care provided in mental health was evaluated using the proportion of 4 HEDIS quality measures met by the provider’s patient panel. The specific HEDIS measures were defined based on the National Committee for Quality Assurance definitions for diabetes screening (for those treated with antipsychotics), diabetes monitoring (for those with diabetes), cardiovascular monitoring (for those with cardiovascular disease), and antipsychotic medication adherence (for those treated with antipsychotics).26

In addition, patient outcome proxy variables were computed and aggregated at the provider level. Two relapse-related proxies based on healthcare service utilization included: (1) at least 1 ED visit with a primary diagnosis of a relevant mental health condition (ICD-9-CM 295.xx–305.xx); and (2) at least 1 inpatient admission with a primary diagnosis for schizophrenia (ICD-9-CM 295.xx).

Among the subset of patients who had relevant lab values, mean values of glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C), as well as the proportion of patients with elevated A1C of at least 7% and patients with LDL-C of at least 160 mg/dL, were examined.

Statistical Analysis

Means and standard deviations were computed for continuous variables, and frequencies and proportions were computed for discrete or event-related variables. All indicators were computed at the provider level. A patient’s data could contribute to multiple providers’ patient-panels. Patients who saw more than 1 provider—both those who engaged in meaningful use of EHR and non-EHR—were only included in patient-panels of the most common provider type (see eAppendix for details). The grand mean across providers in meaningful use of EHR and non-EHR groups, as wells as the CMS high- and general-quality groups, were computed and weighted by the providers’ patient-panel sizes. Outcome measures were compared between meaningful use of EHR and non-EHR providers using t tests for continuous variables and Chi-square tests for categorical variables with a 2-tailed alpha of 0.05. All analyses were completed using SPSS Statistics for Windows (IBM Corporation; Armonk, NY).


Provider Characteristics

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