Physician frustration over the functionality of electronic health record (EHR) systems has been escalating. While the source of physician unhappiness stems from the belief that expensive technology should make their work life easier, the reality is that this technology requires greater physician involvement at a time when many practices struggle to maintain adequate patient volumes and remain financially solvent.
The disquiet over the current state of technology was well documented in a recent Medical Economics survey of nearly 1,000 physicians in which 45% of responding physicians said patient care had grown worse since they implemented an EHR system. Nearly a quarter of internists said the quality of care was significantly worse.
While the message came through loud and clear in this survey, what can we learn from the silent minority about using data in their EHRs—including their Meaningful Use quality reports—to improve the quality of care they deliver?
Jennifer Brull, MD, a solo family practitioner (FP) in Plainville, Kansas, shares office space, staff and services with four other FPs, four midlevel practitioners, and a nurse midwife. When she and her colleagues first implemented an EHR in 2007, she screened only 43% of her eligible patients for colorectal cancer; in the next few years, with the help of EHR reminders, she raised that rate to 90%. She also used the EHR to increase her patients’ recommended mammography rate from 65% to 99%.
Chronic care also benefited from her practices’ EHR use. In 2012, Brull and her colleagues were regularly testing only 14% of their patients with diabetes for microalbumin. After educating their staff in the process and turning on an alert in their EHR, they raised that number to 95% within nine months. In 2012, only 11% of their heart failure patients had received a recommended echocardiogram within the previous two years; by the end of 2013, the network had increased that to 68%.
Most of the data you need to improve the quality of care is in your EHR, says Rosemarie Nelson, a Medical Group Management Association consultant based in Syracuse, New York. “But in some cases, the tools to make the data useful are not there,” she notes. Even when those functions are present, she adds, clinicians don’t necessarily use them.
If you find EHR documentation a bit overwhelming and resent the time it takes away from patient care, you might view the idea of using your EHR for quality improvement as a non sequitur. But some studies show that EHRs also do improve patient care and safety. Moreover, we’re entering a new era of value-based reimbursement, in which part of your income will be based on your quality scores. So it’s worth considering how your EHR can help you raise those scores.
EHR Challenges
EHRs were not originally designed for quality improvement, but rather for improving efficiency and documentation so that doctors could get a return on their investment. But with the advent of Meaningful Use, vendors had to rewrite their software to produce quality reports in order to get certified for Meaningful Use. At the same time, physicians started to pay more attention to quality improvement.
The Breakaway Group, a health information technology consulting firm owned by Xerox, surveyed physician practices with EHRs in 2009 and found that fewer than 20% of them were trying to understand how EHRs affected quality of care. Today, partly because of Meaningful Use, “people are being forced to answer some of those questions,” says Heather Haugen, PhD, managing director of the Breakaway Group.
EHR vendors are offering better tools for quality reporting than they did a few years ago, Nelson notes. But the quality of these tools varies considerably, and some of them must be purchased as add-ons, she says.
The leading EHRs include health maintenance alerts that remind physicians about some of their patients’ preventive and chronic care gaps when they see them. In some systems, however, users have to build their own alerts, Nelson says.
If an EHR includes prebuilt alerts, you may be able to customize or add to them. Brull says this is not a big chore in her EHR. She has customized about 25% of the health maintenance alerts—most of them in less than five minutes each.
Certified EHRs must be able to extract quality data for Meaningful Use. While the clinical quality measures are very limited, they can be used in quality improvement, Nelson says. In some EHRs, for example, you can get a list of diabetic patients with an HbA1c >8 by clicking on the percentage of patients in that category.
Unfortunately, Brull says, “That’s where it stops in our EHR software. You can’t click on the patient’s name and go to their chart, which is the most actionable next step.”
The other problem with the reports in Brull’s EHR, she says, is that they can’t be customized. That is one reason why her group has acquired web-based registry software that interfaces with its EHR. This application, which also has population health management features, can generate a wide range of custom reports.
“The ability to customize reports is something the EHR vendors are working on,” Haugen says. “But it’s definitely not there. What most practices do, if they want to get this information, is hire people who can write those custom reports.”
Of course, many practices can’t afford to pay a technical expert to program these reports, so it doesn’t get done, she adds.
Registry functions
Registries, which track the services provided to patients along with indicators of their health status and due dates for recommended care, are not yet being widely used in healthcare, Haugen says. But some vendors have begun to incorporate registry functions into their EHRs, according to Nelson.
Several vendors, for example, offer the ability to query the database for a range of dates, she says. For example, the EHR could supply a list of patients with uncontrolled hypertension who haven’t been seen in three months and don’t have an appointment in the next three months.
Brull’s EHR can’t do this, but her group can use the web-based dashboard of its outside registry for that purpose. “If I have a patient with high blood pressure (BP) who fails to come see me for a prolonged period of time, they won’t show up on my EHR report, but they will show up on my registry report as a patient with hypertension who has not had their BP checked in an interval of time,” she says.
Making the data actionable
Seeking to capitalize on the new opportunities for value-based reimbursement, a growing number of healthcare organizations are using EHRs and other kinds of health IT applications to identify patients who have care gaps. But relatively few of them are able to ensure that those gaps are filled, Haugen says.
In large part, that’s because EHRs lack the functionality to make the data actionable. For example, even if the EHR has a built-in registry, it may not be able to upload a list of patients who need a specific service to an automated messaging system or send a message to those patients through the EHR’s patient portal, Nelson says.
Brull agrees. There’s a “registry processor” function in her group’s EHR that lets the practice email a list of patients who need services, she says. But even if the network could send such emails securely, she notes, it’s not easy to construct the end-to-end process with the outside registry. “All the pieces are there, but they’re not ‘click here and do this.’ You have to know what you’re doing,” she says.
Instead, the group exports the registry report data to an Excel file that includes patient demographic information, including addresses and phone numbers. Since regular mail hasn’t proved to be effective, the staff either calls patients or contacts them via the patient portal, “but it’s not an automated process,” Brull notes.
The large group approach
In a large group practice the challenges are somewhat different. The EHR usually operates on a central server, and the quality reports are programmed by the organization’s IT department. The organization may also have a mechanism for contacting patients who are not in compliance with their providers’ care plans.
Robert Segal, MD, works for Scottsdale Healthcare in Scottsdale, Ariz. His ambulatory EHR is used by hundreds of physicians that are employed by the healthcare system. When the system decides that it wants the doctors to focus on a particular quality area, a report-writing team creates the requisite reports, and data on individual doctors’ performance is sent to them monthly.
In the near future, Segal says, the organization will begin giving the physicians comparative quality reports. He welcomes those because they will show him where he stands in relation to his peers and how he can improve his quality scores.
While some healthcare organizations use this approach, others don’t even share the quality data with their doctors, Haugen says. She cites the example of a large hospital group that was collecting quality data for Meaningful Use but was not communicating it to the physicians. They told her, “We’d like to see the data but no one is showing it to us.”
Haugen comments, “In some respects, small practices are doing this better because their ability to affect the process is sometimes much more immediate.”
Structured data is key
Although doctors don’t like to hear it, their ability to use their EHRs to improve quality depends on whether they enter key data into the system in structured form. If the data is not in codified fields, it doesn’t show up in reports or health maintenance alerts. Consequently, those reports and alerts may not be reliable.
Haugen, a strong proponent of structured data entry, acknowledges that this is a sore point for doctors. But not all data has to be structured to improve quality, she says. What practices need to do is find “a happy medium between what data must be structured and what can be unstructured,” she notes. Vendors must also do their part to make it easier for physicians and their staffs to enter the data, she adds.
Nelson suggests that practices work on improving clinical documentation if they want to improve quality. Also, she says, the physicians in a group should standardize their EHR templates and enter data the same way. If one doctor uses a template that suits him or her, but nobody else uses it, quality improvement will suffer.
In the end, you’ll get out of the EHR what you put into it. If big chunks of data are missing, you can’t use the information to deliver better care. Also, remember that the EHR is only a tool; process improvement is up to you and your staff.
“We can track the quality of care with the EHR, but the EHR doesn’t change the care we’re providing,” Haugen observes. “So we have a big step to take beyond the EHR.”
