Improvement in Hypertension Control Among Adults Seen in Federally Qualified Health Center Clinics in the Stroke Belt: Implementing a Program with a Dashboard and Process Metrics.

Objective: Attain 75% hypertension (HTN) control and improve racial equity in control with the American Medical Association Measure accurately, Act rapidly, Partner with patients blood pressure (AMA MAP BP™) quality improvement program, including a monthly dashboard and practice facilitation. Methods: Eight federally qualified health center clinics from the HopeHealth network in South Carolina participated. Clinic staff received monthly practice facilitation guided by a dashboard with process metrics (measure [repeat BP when initial systolic ≥140 or diastolic ≥90 mmHg; Act [number antihypertensive medication classes prescribed at standard dose or greater to adults with uncontrolled BP]; Partner [follow-up within 30 days of uncontrolled BP; systolic BP fall after medication added]) and outcome metric (BP <140/<90). Electronic health record data were obtained on adults ≥18 years at baseline and monthly during MAP BP. Patients with diagnosed HTN, ≥1 encounter at baseline, and ≥2 encounters during 6 months of MAP BP were included in this evaluation. Results: Among 45,498 adults with encounters during the 1-year baseline, 20,963 (46.1%) had diagnosed HTN; 12,370 (59%) met the inclusion criteria (67% black, 29% white; mean (standard deviation) age 59.5 (12.8) years; 16.3% uninsured. HTN control improved (63.6% vs. 75.1%, p<0.0001), reflecting positive changes in Measure, Act, and Partner metrics (all p<0.001), although control remained lower in non-Hispanic black than in non-Hispanic white adults (73.8% vs. 78.4%, p<0.001). Conclusions: With MAP BP, the HTN control goal was attained among adults eligible for analysis. Ongoing efforts aim to improve program access and racial equity in control.

Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

BACKGROUND: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN: Cross-sectional observational study. SETTING: 5 internal medicine or cardiology practices. PARTICIPANTS: 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Using electronic health records to measure physician performance for acute conditions in primary care: empirical evaluation of the community-acquired pneumonia clinical quality measure set.

BACKGROUND: Electronic health records (EHRs) have the potential to facilitate performance measurement for acute conditions. OBJECTIVE: To evaluate the reliability and feasibility-of-use of a performance measure set for community-acquired pneumonia in an ambulatory EHR. DESIGN: Retrospective, cross-sectional electronic chart review. SETTING: Primary Care Clinics. PATIENTS: Adults with an administrative claims diagnosis of pneumonia during a 14-month period. MEASUREMENTS: Two reviewers independently examined data in the EHR to determine if (1) the encounter was a visit for acute pneumonia; (2) there was documentation for each of 12 performance measures; and (3) such information was in coded form. RESULTS: Of 688 encounters with a claim diagnosis of pneumonia, 210 (31%) were identified by either reviewer as a primary care acute pneumonia visit. The 2 reviewers agreed that 198 encounters to 71 different clinicians were visits for acute pneumonia [kappa, 0.96; 95% confidence interval (CI), 0.93-0.98]. Measure performance ranged from 10% for providing location of care rationale to 91% for documenting blood pressure, averaging 52% across all 12 measures. Inter-rater reliability ranged from 0.66 (95% CI, 0.47-0.84) for providing a location of care rationale to 0.97 (95% CI, 0.91-1.0) for vital sign assessment. The proportion of data that was in coded form ranged from 0% for mental status, hydration status, chest x-ray performance, and location of care to 100% for medications and immunizations. CONCLUSIONS: Although EHRs offer potential advantages for performance measurement for acute conditions, accurate identification of pneumonia visits was challenging, performance generally appeared poor, and much of the data were not in coded form.

Using health information technology-related performance measures and tools to improve chronic care.

BACKGROUND: The American Medical Association led a collaborative initiative to explore opportunities for improving the quality of outpatient chronic care through the use of nationally endorsed clinical performance measures and tools. The measures and tools focused on adult diabetes, major depressive disorder, chronic stable coronary artery disease, heart failure, hypertension, and asthma. METHODS: The RAND Corporation conducted an independent, formative assessment of the initiative's four pilot activities using the Context-Input-Process-Product evaluation model. RESULTS: Pilots 1 and 2 demonstrated the feasibility and value of implementing performance measures and tools in practices with electronic health information systems, while highlighting the difficulty of using them in practices with paper-based systems and in community-based models, where multiple stakeholders are expected to share patient data. Pilot 3 illustrated the usefulness of validating performance measures before their use for internal quality improvement or external reporting. Pilot 4 documented the challenges involved in exporting clinical performance data from a physician practice to external entities for multiple potential uses. DISCUSSION: Improving the quality of chronic care through clinical performance measurement, data aggregation, and reporting will require expanded use of clinical performance measures for both internal quality improvement and pay-for-performance; integrating electronic health records (EHRs) or electronic-based registries into more physician offices; more accurate measurement and documentation of diagnoses and care procedures; EHR products that make it easier to capture certain types of information; and simplified, standardized processes for performance data extraction and exporting.

Automated review of electronic health records to assess quality of care for outpatients with heart failure.

BACKGROUND: Electronic health records (EHRs) may be used to assess quality of care. OBJECTIVE: To evaluate the accuracy of automated review of EHR data to measure quality of care for outpatients with heart failure. DESIGN: Observational study of quality of care for heart failure comparing automated review of EHR data with automated review followed by manual review of electronic notes for patients with apparent quality deficits (hybrid review). SETTING: An academic general internal medicine clinic with several years' experience using a commercial EHR. PATIENTS: 517 adults with a qualifying International Classification of Diseases, Ninth Revision, diagnosis of heart failure in their EHR data and 2 or more clinic visits over the past 18 months. MEASUREMENTS: Left ventricular ejection fraction (LVEF), prescription of a beta-blocker and an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF <0.40) and prescription of warfarin for patients with comorbid atrial fibrillation. RESULTS: Performance based on automated review of EHR data was similar to that based on hybrid review for assessing LVEF measurement (94.6% vs. 97.3%), prescription of beta-blockers (90.9% vs. 92.8%), and prescription of ACE inhibitors or ARBs (93.9% vs. 98.7%). However, performance based on automated review was lower than that based on hybrid review for prescription of warfarin for atrial fibrillation (70.4% vs. 93.6%), primarily because automated review did not detect documentation of accepted reasons for not prescribing warfarin. LIMITATIONS: The findings may not be applicable to other practices and other EHRs. The authors used EHR data to identify eligible patients, so the study may have excluded some patients with heart failure. Patient charts were manually reviewed only if a provider appeared to fail a quality measure on automated review and did not determine the sensitivity and specificity of automated review according to standard definitions. CONCLUSIONS: Automated review of EHR data to measure the quality of care of outpatients with heart failure missed many exclusion criteria for medications documented only in providers' notes. As a result, it sometimes underestimated performance on medication-based quality measures.

Assessing the validity of national quality measures for coronary artery disease using an electronic health record.

BACKGROUND: Nationally endorsed, clinical performance measures are available that allow for quality reporting using electronic health records (EHRs). To our knowledge, how well they reflect actual quality of care has not been studied. We sought to evaluate the validity of performance measures for coronary artery disease (CAD) using an ambulatory EHR. METHODS: We performed a retrospective electronic medical chart review comparing automated measurement with a 2-step process of automated measurement supplemented by review of free-text notes for apparent quality failures for all patients with CAD from a large internal medicine practice using a commercial EHR. The 7 performance measures included the following: antiplatelet drug, lipid-lowering drug, beta-blocker following myocardial infarction, blood pressure measurement, lipid measurement, low-density lipoprotein cholesterol control, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for patients with diabetes mellitus or left ventricular systolic dysfunction. RESULTS: Performance varied from 81.6% for lipid measurement to 97.6% for blood pressure measurement based on automated measurement. A review of free-text notes for cases failing an automated measure revealed that misclassification was common and that 15% to 81% of apparent quality failures either satisfied the performance measure or met valid exclusion criteria. After including free-text data, the adherence rate ranged from 87.5% for lipid measurement and low-density lipoprotein cholesterol control to 99.2% for blood pressure measurement. CONCLUSIONS: Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement. Validity testing in different settings is required.

Best practice implementation: lessons learned from 20 partnerships.

BACKGROUND: Partnerships can facilitate effective implementation of best practices, but literature describing effective and ineffective strategies to address barriers to implementation in partnerships is lacking. METHODS: Principal investigators (PIs) were surveyed to identify barriers to best practice implementation, rank their significance, and articulate the success and failure of solutions attempted. RESULTS: The top four categories of barriers to implementation were partnership challenges, practitioner/local organization variables, time frame challenges, and financial concerns. Ninety-eight effective and 38 ineffective solutions used to overcome these barriers were identified. The most common categories of successful solutions were flexibility of interventions to align with unique local characteristics, schedules, and budgets (36.7% of listed successful solutions); communication strategies that emphasize frequent bidirectional information exchange in person (26.5%); and thoughtful use of personnel emphasizing sites' senior leadership and centralized quality and analytic content expertise (16.3%). DISCUSSION: Despite substantial partnership diversity, consistent themes related to barriers to implementation and solutions to these barriers emerged. The successful and unsuccessful solutions provided should be proactively assessed to enhance the likelihood of future partnership success.

Secondary uses of clinical data in primary care.

This paper, presented as a panel at the American Medical Informatics Association (AMIA) Fall Symposium 2006, explores a number of secondary uses of primary care clinical data derived from point-of-care systems, and the issues arising from those uses. The authors (from the USA and the UK) describe, compare and contrast some secondary uses: pay-for-performance, public disclosure, clinical audit, health resource planning, and clinical system usage; in various environments: national health system, network of small family practice offices, and university teaching centres. In the UK, such data are now being used in pay-for-performance for GPs, and approximately 35% of their salary has been put at risk, which has resulted in close scrutiny. In the USA, pay-for-performance is at an earlier stage but is increasingly prevalent and continues to be hotly debated. Some of the issues that arise from these uses of clinical data - data quality including accuracy, comparability, perverse incentives, effect of secondary uses on care provision, and security and confidentiality among others - were discussed. Finally, options and opportunities for improving secondary uses of data in the light of the issues covered earlier were considered.

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control.

Evidence-based interventions differ for increasing hypertension awareness, treatment, and control and should be targeted for specific patient panels. This study developed a hypertension control cascade to identify patients with a usual source of care represented at each level of the cascade using the 2007-2012 National Health and Nutrition Examination Survey. Overall, 10.7 million adults in the United States were unaware of their condition, 3.8 million were aware but untreated, and 15.8 million were treated but uncontrolled. The results also suggest that failure to attain hypertension control because of lack of awareness or lack of treatment despite awareness occurs mainly among younger individuals and those with no annual healthcare visits, while the elderly and minorities are more likely to remain uncontrolled when aware and treated. Opportunities to leverage population health management functions in electronic health information systems to align the specific patient subgroups facing barriers to hypertension control at each level of the cascade with targeted hypertension management interventions are discussed.

Electronic health record systems: the vehicle for implementing performance measures.

Advances in information technology and recent national directives have the potential to support dramatic improvements in health care. Two key components are the implementation of functional electronic health record systems and widely accepted, evidence-based clinical performance measures for physicians. Midwest Heart Specialists, a 55-physician cardiovascular group at 14 locations in northern Illinois, has utilized an outpatient electronic health record system since 1997. Since 2003, the group has integrated cardiovascular measurement sets developed by the American Medical Association-convened Physician Consortium for Performance Improvement into its electronic health record system. With this integration, the group was able to capture data needed for internal quality assessment and improvement as part of routine outpatient care without the need for additional resources. Critical disease-management data for decision support are available continuously, resulting in improvements in health care. The reporting of these standardized data could be the foundation to support quality-based reimbursement strategies and physician office-based disease-management strategies.