Better Health Greater Cleveland: The EHR Effect

Better Health Greater Cleveland, a nonprofit program established in 2007 under Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, is making strides with adoption of electronic health records (EHRs) and creating accountable care communities.

Better Health is a regional health improvement collaborative that includes 569 doctors in 10 healthcare systems, which take care of 27,000 diabetics. As a part of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, Better Health is supported through 2015 by a $300 million commitment to improve healthcare in 16 communities, which together cover 12 percent of the U.S. population. The program first targeted diabetes patients, but has now widened to include hypertension and heart failure patients.

Evidence-Based Medicine and EHRs
According to a January 2011 Better Health study, EHRs led to a dramatic improvement in physician adherence to evidence-based medicine and that patients with diabetes who are cared for by doctors who use EHRs received all the recommended care for their condition 51 percent of the time, compared with just seven percent of the time for those with paper records. Randall Cebul, M.D., Better Health’s director, says EHRs have improved care decisions, not neccesarily outcomes of care, as the EHR helps providers to make the right decisions at the right time.

When it comes to outcomes, he says, more factors need to taken into account. Across Better Health practices in 2009-10, just more than four out of 10 patients met overall outcomes standards, which require that a patient be in good control of at least four out of five health indicators: blood sugar, blood pressure, cholesterol, weight, and not smoking. “I think public reporting is a big piece of this,” says Cebul. “The transparency component of this has motivated people. And it’s celebrating successes, in that public reporting has kept people, even those that have achieved less, in the game.”

Cebul says the success of his “accountable care community” is in part due to using the same locally-vetted measures and standards for care across competing organizations and sharing best practices for EHR clinical decision support at semiannual learning collaborative meetings. “We share with other systems and doctors from other organizations what we’re doing in regards to prompts and automated order sets, registries, and population management, so we grow that capacity and relate them specifically to the conditions like diabetes that we have focused our attention on,” says Cebul.

Challenges: Sustainability, Provider Limitations
On the journey to sustainability, as other Aligning Forces for Quality communities have, Better Health became a nonprofit organization in December 2010 to broaden the reach of the initiative. In addition to grant funding, Better Health has sought multi-stakeholder participation and has instituted various memberships for providers, payers, and community partners. So far Better Health has five insurers as paying members, as well as business coalition support. “Commercial insurers and employers should be interested in sites and systems that use electronic health records and in supporting adoption and meaningful use,” says Cebul. “Because each one of them has a different perspective on the program and for each of them we provide value. That value then gets reflected in the membership dues and the sponsorship of various events.”

In addition to sustainability, Cebul sees challenges with engaging providers, who have limitations, sometimes proprietary, but mostly with competing factors like meaningful use requirements and other quality initiatives. Cebul’s hopes are to engage as many providers who have EHRs in the region to be part of the collaborative, agree to community-wide standards and quality measures, and finally connect everyone together to share best practices.

Greater Health is now beginning to screen chronic patients for depression and also adding metrics, including data on ER visits and hospitalizations to be exchanged across the region. On September 23, Better Health will sponsor a summit focusing on patient-centered healthcare and health IT. Topics to be discussed will be what important metrics will be analyzed regarding the patient care experience, and what is needed to further reduce readmissions. Much of the patient measures will be adopted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) measure set from the Agency for Healthcare Research and Quality.