Dr. Linda Groene is a solo practitioner in Fort Lauderdale, Florida. She practices internal medicine and geriatrics and serves a patient panel of about 340. In addition to being part of MDVIP, a concierge physician group network, her practice is also a National Committee for Quality Assurance Level III Certified Patient Centered Medical Home. This designation emphasizes the importance that Dr. Groene’s practice has placed on facilitating partnerships and communication between practice and patients/caregivers. Dr. Groene began using her current electronic health record (EHR), e-MDs, in 2003 and is currently using Version 7.2. She attested to Meaningful Use in October, 2011.
Dr. Groene’s use of EHRs is a model for making the link between health IT and quality improvement. She utilizes her EHR to generate quality measures for her patient panel and is then able to use these reports to participate in quality improvement projects.
Workflow to support Clinical Quality Measures (CQM) reporting and other Meaningful Use objectives
- Implementation. Implementing an EHR in Dr. Groene’s practice prompted a number of workflow changes that contributed to improved planning for and follow-up after patient visits. e-MDs has a feature that generates diagnosis codes based on the diagnoses Dr. Groene selects from a drop-down menu during a patient visit. This automated process allows her to more easily check whether there are any decision support rules or alerts that she needs to address by the end of the visit.
- Flow Sheets. Dr. Groene and her staff have created flow sheets within the EHR system to track performance on some of their clinical quality measures (CQMs). These flow sheets are essentially spreadsheets that Dr. Groene uses that allow her to enter new data and view past data during the patient visits. For instance, if she pulls up the preventive care flow sheet, she can see the date of the patient’s last mammogram and if the patient received the influenza vaccine this season. If all patient information is entered in fully and accurately, these flow sheets help identify gaps in patients’ care before or during the visit.
- Up to date information. Sharon notes that the EHR makes it easier to ensure that all of Dr. Groene’s patients are up to date with their visits, tests, and procedures. In particular, in preparation for a patient visit, Sharon uses the EHR to quickly identify what blood work or tests will need to be completed for that patient. Sharon also documents in the EHR when she has spoken to patients, which helps ensure that necessary follow ups have been completed.
- Education Materials. Having an EHR also allows Dr. Groene and her practice staff to distribute educational materials to patients, because it facilitates identifying patients who should receive disease- or condition-specific education materials, as well as producing graphs of patient data, flowsheets, and to-do lists to help patients understand what they need to do between visits to maintain or improve their health. Dr. Groene pays for an additional subscription to these robust materials. Older patients in particular have given Dr. Groene feedback that they appreciate this type of information.
- Patient Portal. Dr. Groene has also established a patient portal as part of e-MDs, which she believes will make her staff’s job easier in the long-run. Sharon encourages patients to register on the patient portal and enter their demographic information there so that she or other staff at the practice do not have to collect this information during the visit. The patient portal also allows members of Dr. Groene’s staff to communicate with patients or their caregivers via the portal. Though most of her patients are fairly advanced in age, some are computer literate and those who are not may have caretakers who are.
EHR Meaningful Use Objective Addressed: Reporting Clinical Quality Measures
Dr. Groene used her EHR to report on the three core CQMs for Meaningful Use Stage 1:
- Adult Weight Screening and Follow Up (NQF 0421)
- Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention (NQF 0028)
- Hypertension: Blood Pressure Measurement (NQF 0013).
She also selected the following three “menu set” CQMs to report from her EHR:
- Pneumonia Vaccination Status for Older Adults (NQF 0043)
- Breast Cancer Screening (NQF 0031)
- Diabetes: Blood Pressure Management (NQF 0061).
To ensure that these measures accurately represented the care being provided in her practice, Dr. Groene took the time to understand the numbers behind the CQM reports produced by her EHR. For example, with regard to the first measure on adult weight screening and follow up, she found that follow up was only “counted” for the CQM if a diagnostic code was recorded. While this created extra work for the practice, this is a necessary step in using CQMs to accurately capture care provided in a systematic way. For one of the “menu set” measures, blood pressure management for patients with diabetes, Dr. Groene discovered that the CQM reported by the EHRwas only capturing patients in the denominator whose primary diagnostic code was diabetes.
Examining and understanding CQM data is critical for taking the next steps in improving on CQMs. Dr. Groene learned this even before she began working toward Meaningful Use, when working with the Florida Quality Improvement Organization (QIO) on quality measurement and improvement efforts. Specifically, the QIO brought in application tailored to e-MDs that helped her run reports and query data on her patients for certain CQMs. Although e-MDs has improved their queries to be certified for Meaningful Use, and she no longer uses the third-party applications, this early experience helped her verify that the results of her selected Meaningful Use clinical quality measures were indeed accurate.
Dr. Groene found that examining performance data on quality measures for her entire patient population was an eye-opening and worthwhile experience early in her time using an EHR. Although she at first believed that she was providing recommended care for all of her patients all the time, having access to EHR data allowed her to check that assumption and make corrections where necessary.
In addition to providing a real-time check on key quality measures for her patients, the EHR is also a tool that can facilitate more targeted quality improvement projects. Dr. Groene has undertaken several quality improvement efforts over the past few years. In renewing her geriatric certification, Dr. Groene completed the ACP’s web-based Adult Body Mass Index practice improvement module. This module required that she survey 35 patient charts at two different times, a process which the EHR made much easier than before, when she used paper charts. Upon reviewing her results, Dr. Groene met with her staff and developed a plan to improve the practice’s rates of performance on the topic. Dr. Groene notes that she plans to use the ACP modules for other quality improvement purposes going forward.
- Capturing Data. An EHR might have unanticipated “quirks” in how it uses clinical information to calculate clinical quality measures. For example, the CQM may not pull from new versions of existing EHR templates or may only use the first diagnosis code in the list of diagnoses when including or excluding patients from the denominator. Dr. Groene recommends taking the time to investigate how the EHR vendor is capturing EHR data, especially if the data doesn’t match predictions about the frequency with which certain services are provided or certain outcomes are met. In doing so, practices will be able to make corrections and have greater confidence in its CQM data.
- Templates. EHR templates are a great way to ensure that clinicians are aware of all of the data elements that must be collected during a patient visit. However, it is important to continuously edit the templates to suit the practice’s changing needs. It is also important to confirm that when revising templates, the fields are correctly “mapped” to the fields that the EHR system uses to calculate CQMs.
- Documentation. Keeping your EHR documentation up to date maximizes the usefulness of reminder systems and other clinical decision support notifications.
“It’s a lot of work, but it’s worth it.” -Dr. Groene
- Lab results Tracking. In the future, Dr. Groene would like to work on improving laboratory result tracking so that her staff can more efficiently follow up with patients whose lab results have not been sent to the practice (perhaps indicating that the tests Dr. Groene may have prescribed were never done by the patient after a visit).
- Consider all the opportunities to leverage quality measurement for the practice. Will it help in a professional re-certification process? Will it provide access to additional incentive funds through pay for performance programs? Will it help in meeting patient- centered medical home criteria?
- Even after the EHR is installed and fully implemented, consider ongoing training via user conferences and online opportunities to learn about additional EHR features and more efficient processes.
- Entering laboratory data and other clinical information into the EHR in a timely manner will help maximize the value that the EHR can provide, by providing rules, reminders, and other tips before or during patient visits. This type of clinical decision support can also help improve clinical quality measure performance rates.