Development and Initial Use of an Evidence-Based Home Blood Pressure Monitoring mHealth Platform.

Home blood pressure monitoring (HBPM) has been shown to provide a more reliable assessment of blood pressure (BP) than in-office measurement and may lead to improved BP control. While many mHealth apps are available to help users track their blood pressure (BP), no apps incorporate the full set of evidence-based HBPM recommendations for ensuring accurate measurement at home. Through an agile development approach employing user stories, we translated an evidence-based standardized protocol for BP measurement and monitoring over a recommended 3-7 day monitoring period into a mHealth app and corresponding clinician portal. We then pilot tested this platform to assess its feasibility for guiding users to measure BP over multiple days according to this protocol. During this pilot testing, one hundred and twenty five users created an app account; 75 (60.0%) of these users recorded at least one BP reading and 47 (37.6%) completed at least one monitoring period. Through this work, we have demonstrated how a series of guidelines can be systematically translated into a mHealth platform for HBPM. Such platforms may be accessible resources to facilitate standardized HBPM and sharing of readings with providers.

Translating CKD Research into Primary Care Practice: a Group-Randomized Study.

BACKGROUND: Chronic kidney disease (CKD) is common in the primary care setting. Early interventions may prevent progression of renal disease and reduce risk for cardiovascular complications, yet quality gaps have been documented. Successful approaches to improve identification and management of CKD in primary care are needed. OBJECTIVE: To assess whether implementation of a primary care improvement model results in improved identification and management of CKD DESIGN: 18-month group-randomized study PARTICIPANTS: 21 primary care practices in 13 US states caring for 107,094 patients INTERVENTIONS: To promote implementation of CKD improvement strategies, intervention practices received clinical quality measure (CQM) reports at least quarterly, hosted an on-site visit and 2 webinars, and sent clinician/staff representatives to a "best practice" meeting. Control practices received CQM reports at least quarterly. MAIN MEASURES: Changes in practice adherence to a set of 11 CKD CQMs KEY RESULTS: We observed significantly greater improvements among intervention practices for annual screening for albuminuria in patients with diabetes or hypertension (absolute change 22% in the intervention group vs. - 2.6% in the control group, p < 0.0001) and annual monitoring for albuminuria in patients with CKD (absolute change 21% in the intervention group vs. - 2.0% in the control group, p < 0.0001). Avoidance of NSAIDs in patients with CKD declined in both intervention and control groups, with a significantly greater decline in the control practices (absolute change - 5.0% in the intervention group vs. - 10% in the control group, p < 0.0001). There were no other significant changes found for the other CQMs. Variable implementation of CKD improvement strategies was noted across the intervention practices. CONCLUSIONS: Implementation of a primary care improvement model designed to improve CKD identification and management resulted in significantly improved care on 3 out of 11 CQMs. Incomplete adoption of improvement strategies may have limited further improvement. Improving CKD identification and management likely requires a longer and more intensive intervention.

Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study.

BACKGROUND: Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs). OBJECTIVE: To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs. DESIGN: A two-phase, 27-month demonstration project. SETTING: Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR). PARTICIPANTS: Thirty-nine providers were included in the project. INTERVENTION: A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs. MAIN OUTCOME MEASURES: 1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis. KEY RESULTS: The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57% [95% CI, -5.35%, 8.49%] in adults and -1.89% [95% CI, -9.03%, 5.26%] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, -16.30%, [95% CI, -24.81%, -7.79%] in adults and -16.30 [95%CI, -23.29%, -9.31%] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined. CONCLUSIONS: This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.

Preventive services delivery in patients with chronic illnesses: parallel opportunities rather than competing obligations.

PURPOSE: Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records. METHODS: We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient's number of chronic conditions, adjusted for patient age and encounter frequency. RESULTS: Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services. CONCLUSIONS: Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.

Colorectal cancer screening in primary care: theoretical model to improve prevalence in the practice partner research network.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Half of Americans older than age 50 are not current with recommended screening; research is needed to assess the impact of interventions designed to increase receipt of CRC screening. The Colorectal Cancer Screening in Primary Care (C-TRIP) study is a theoretically informed group randomized trial within 32 primary care practices. Baseline median proportion of active patients aged 50 years or older up-to-date with CRC screening among the 32 practices was 50.8% (N = 55,746). Men were more likely to have been screened than women (52.9% vs. 49.2%, respectively). Patients 50 to 59 years of age were less likely to be up-to-date with screening (45.4%) than those in the 60 to 69 years and 70 to 79 years groups (58.5% in both groups). Opportunities exist to increase the proportion of CRC screening received in adults aged 50 and older. C-TRIP evaluates the effectiveness of a model for improvement for increasing this proportion.

Colorectal cancer screening in primary care: translating research into practice.

BACKGROUND: Colorectal cancer (CRC) screening is recommended for all adults 50 to 75 years old, yet only slightly more than one-half of eligible people are current with screening. Because CRC screening is usually initiated upon recommendations of primary care physicians, interventions in these settings are needed to improve screening. OBJECTIVES: To assess the impact of a quality improvement intervention combining electronic medical record based audit and feedback, practice site visits for academic detailing and participatory planning, and "best-practice" dissemination on CRC screening in primary care practice. RESEARCH DESIGN: Two-year group randomized trial. SUBJECTS: Physicians, midlevel providers, and clinical staff members in 32 primary care practices in 19 States caring for 68,150 patients 50 years of age or older. MEASURES: Proportion of active patients up-to-date (UTD) with CRC screening (colonoscopy within 10 years, sigmoidoscopy within 5 years, or at home fecal occult blood testing within 1 year) and having screening recommended within past year among those not UTD. RESULTS: Patients 50 to 75 years in intervention practices exhibited significantly greater improvement (from 60.7% to 71.2%) in being UTD with CRC screening than patients in control practices (from 57.7% to 62.8%), the adjusted difference being 4.9% (95% confidence interval, 3.8%-6.1%). Recommendations for screening also increased more in intervention practices with the adjusted difference being 7.9% (95% confidence interval, 6.3%-9.5%). There was wide interpractice variation in CRC screening throughout the intervention. CONCLUSIONS: A multicomponent quality improvement intervention in practices that use electronic medical record can improve CRC screening.

Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention.

AIMS: To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care. DESIGN: Two-year randomized, controlled trial. SETTING/PARTICIPANTS: Twenty-one primary care practices across the United States with a common electronic medical record. INTERVENTION: To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies. MEASUREMENTS: Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses. FINDINGS: Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7-38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3-23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling. CONCLUSIONS: Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures.

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

BACKGROUND: The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE: This study was designed to assess the time trends in use of always inappropriate and rarely appropriate medications in primary care patients aged >or=65 years during a quality improvement project. METHODS: A 4-year, prospective demonstration project was delivered to 99 primary care practices that use a common electronic medical record and are members of the Practice Partner Research Network. Each participating practice received quarterly performance reports on the use of always inappropriate and rarely appropriate medications in the elderly. Optional interventions included biannual on-site visits and annual network meetings for performance review, academic detailing, and quality improvement planning. General linear mixed regression models were used to analyze the change in prescribing rates over time. RESULTS: Across 42 months of project exposure, 124,802 active patients (61% women, 39% men) aged >or=65 years were included in the analyses. Among the 33 practices that participated in all 42 months of the intervention, the proportion of patients with a prescription for an always inappropriate medication decreased from 0.41% to 0.33%, and the proportion of patients with a prescription for a rarely appropriate medication decreased from 1.48% to 1.30%. Across all 99 practices, the adjusted absolute annual declines for the comprehensive categories of always inappropriate medications (00.018%, P = 0.03) and rarely appropriate medications (0.113%, P = 0.001) were statistically significant. Propoxyphene was the only individual medication that decreased significantly in use over time (baseline proportion, 0.72%; adjusted absolute annual decline, 0.072% [P = 0.001]). CONCLUSIONS: Always inappropriate and rarely appropriate medication use decreased over time in this practice-based research network study. Additional studies of robust interventions for improving medication use in the elderly are warranted.

Improving the translation of research into primary care practice: results of a national quality improvement demonstration project.

BACKGROUND: There is widespread evidence of inadequate translation of research findings into primary care practice. Theoretically sound demonstrations of how health care organizations can overcomes these deficiencies are needed. A demonstration project was conducted from January 1, 2003, through June 30, 2006, to evaluate the impact of a multicomponent intervention and improvement models intended to enhance adherence to clinical practice guidelines across eight broad clinical areas. METHODS: The demonstration project involving 530 clinicians and staff members from 99 primary practices in 36 states entailed practice performance reports (audit and feedback), practice site visits for academic detailing and participatory planning, and network meetings for sharing 4 of "best practice" approaches. Data from electronic medical records (EMRs) of 847,073 patients were abstracted to identify 31 process and 5 outcome quality measures for prevention and treatment of cardiovascular disease and diabetes, cancer screening, adult immunization, respiratory and infectious disease, mental health and substance abuse, obesity and nutrition, safe medication prescribing in the elderly, and a summary measure, the Summary Quality Index (SQUID). RESULTS: The yearly adjusted absolute improvement in the SQUID was 2.43% (95% confidence interval [C.I.], 2.24%-2.63%). Clinically and statistically significant improvements occurred for 29 of the 36 quality measures, including all 5 outcome measures. DISCUSSION: The findings suggest that a multicomponent quality improvement intervention involving audit and feedback, academic detailing and participatory planning activities, and sharing of "best practice" approaches in practices with EMRs can have a robust impact in quality of care for Americans seen in primary care practices.

Achievable benchmarks of care for primary care quality indicators in a practice-based research network.

A number of sources publish health care quality reports in the United States, but there is limited information about achievable performance in primary care settings. The objective of this article is to report Achievable Benchmarks of Care (ABCs) for 54 quality indicators. Eighty-seven practices participating in a demonstration project in the Practice Partner Research Network (PPRNet), representing 35 US states and 711 969 patients, were included in the analyses. PPRNet practices use a common electronic medical record (Practice Partner, Seattle, Washington). ABCs ranged from 25% to 99%. High ABCs (> or =90%) were achieved for blood pressure screening, lipid screening, and avoiding antibiotics in upper respiratory infection. Some calculated ABCs may be lower than the actual ABCs due to incomplete data recording or abstracting. Primary care practices can achieve high performance across a number of quality indicators, and PPRNet ABCs can serve as benchmarks for primary care practitioners and payers.

Different paths to high-quality care: three archetypes of top-performing practice sites.

PURPOSE: Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes. METHODS: This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies. RESULTS: Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet's improvement model. CONCLUSIONS: Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.

Improving diabetes care through a multicomponent quality improvement model in a practice-based research network.

This article reports the impact of a multicomponent quality improvement intervention on adherence with 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID). The intervention was conducted between January 1, 2004, and July 1, 2005, within 66 primary care practices in 33 states, including 372 providers and 24 250 adult patients with diabetes. Across all practices, the average Diabetes-SQUID was 50.6% (10th percentile 36.5%, 90th percentile 63.0%) on January 1, 2004, and 58.4% (10th percentile 47.6%, 90th percentile 69.7%) on July 1, 2005, with an average absolute improvement of 7.8% (95% confidence interval, 5.9%-9.7%). Significant improvements occurred for 12 of the 13 individual measures: blood pressure and urine microalbumin monitoring; HDL cholesterol, LDL cholesterol, triglyceride, and glycosylated hemoglobin measurements; prescription of antiplatelet therapy; and blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride, and glycosylated hemoglobin control. The findings suggest that a multicomponent intervention can have a robust impact on quality of care for diabetes.

Effect of terminal digit preference on blood pressure measurement and treatment in primary care.

BACKGROUND: Terminal digit preference in blood pressure (BP) measurement has been reported in both clinical and research settings. This article examines the prevalence of terminal digit preference (TDP) in primary care practices and the effect that a practice's level of TDP influences patients' BP measurements and management. METHODS: Data were obtained in cross-sectional fashion from the electronic medical records of active patients from 85 practices around the United States. The TDP prevalence was calculated, and statistical techniques were used to examine the influence of a practice's TDP on patients' BP measurements and on the likelihood that patients had an active prescription for selected antihypertensive medications. RESULTS: The TDP was common, with zero being recorded 44.6% and 47.5% of the time for systolic BP and diastolic BP, respectively. Patients belonging to practices with higher TDP levels had significantly (P < .01) lower systolic BP measurements than patients in practices with lower TDP levels. Patients belonging to practices with higher TDP levels also had significantly lower odds (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99], P = .036) of having an active prescription for an antihypertensive medication, an association that was stronger in women (OR = 0.91, P = .023) than in men (OR = 0.95, P = .21). CONCLUSIONS: The TDP for BP measurements is common. Although TDP effects on patients' BP measurements may appear modest, treatment of patients, especially women, with antihypertensive medication may be systematically affected by this preference.

Effects of direct-to-consumer advertising of hydroxymethylglutaryl coenzyme a reductase inhibitors on attainment of LDL-C goals.

BACKGROUND: Although highly controversial, directto-consumer (DTC) television advertising for prescription drugs is an established practice in the US health care industry. While the US Food and Drug Administration is currently reexamining its regulatory stance, little evidence exists regarding the impact of DTC advertising on patient health outcomes. OBJECTIVE: The objective of this research was to study the relationship between heavy television promotion of 3 major hydroxymethylglutaryl coenzyme A reductase inhibitors ("statins") and the frequency with which patients are able to attain low-density lipoprotein cholesterol (LDL-C) blood-level goals after treatment with any statin. METHODS: We used logistic regression to determine achievement of LDL-C goals at 6 months after statin treatment, using electronic medical record extract data from patients from geographically dispersed primary care practices in the United States. We identified LDL-C blood levels as being at or less than goal, as defined by risk-adjusted guidelines published by the National Heart, Lung, and Blood Institute from the Adult Treatment Panel III (ATP III) data. A total of 50,741 patients, identified from 88 practices, were diagnosed with hyperlipidemia and had begun therapy with any statin medication during the 1998-2004 time period. In addition, total dollars spent each month on television advertising at the national and local levels for atorvastatin, pravastatin, and simvastatin were obtained. DTC advertising data were merged by local media market where the physician practice was located and by the month in which the patient was first prescribed a statin. The models were run for all patients who initiated therapy, and also on a subsample of patients who continued to receive prescriptions for the drugs for at least 6 months. Logistic regressions were used to predict the likelihood that each patient attained the ATP III LDL-C blood-level goals as a function of DTC advertising and other factors. RESULTS: High levels of national DTC advertising when therapy was initiated were found to increase the likelihood that patients attained LDL-C goals at 6 months by 6% (P < 0.001)-although the effect was concentrated among patients with the least-restrictive ATP III LDL-C goals (

Quality improvement for prevention of cardiovascular disease and stroke in an academic family medicine center: do racial differences in outcome exist?

OBJECTIVES: We evaluated whether a one-year, multifaceted quality improvement intervention improved adherence to 13 clinical guidelines for lipid screening, hypertension management, and diabetes management among White and African-American adult patients. SETTING: An academic family medicine center. PARTICIPANTS: Six faculty physicians and a clinical pharmacist participated between July 1, 2002, and June 30, 2003. Data from 2860 patients' electronic medical records were abstracted. INTERVENTIONS: Performance reports and lists of patients eligible for each guideline measure were generated. Interventions targeted patients who needed improvement. Statistical analyses used generalized estimating equations to determine the intervention effect. RESULTS: Significant improvements occurred in blood pressure control for all adults (OR= 1.44) and those with hypertension (OR=1.82), measures of total cholesterol (OR=1.10) and high-density lipoprotein cholesterol (OR= 1.27) for all patients, and measure of low-density lipoprotein cholesterol (OR=2.01) and blood pressure control (OR=1.71) for patients with diabetes mellitus. Significant decline was seen in measures of blood pressure for all patients (OR=.60). After adjusting for patient demographic factors, provider variability, and comorbidities, race was not associated with the change observed in any of the measures from baseline to follow-up. CONCLUSIONS: Even though a multifaceted intervention can improve process of care measures for Whites and African Americans, further studies are needed to improve outcome measures, especially in African Americans.

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Use of Clinical Decision Support to Improve Primary Care Identification and Management of Chronic Kidney Disease (CKD).

BACKGROUND: Early detection of chronic kidney disease (CKD) can lead to interventions to prevent renal failure and reduce risk for cardiovascular disease, yet adherence to treatment goals is suboptimal in the primary care setting. The purpose of this study was to assess whether clinical decision support (CDS) can be used to improve the identification and management of CKD. METHODS: This 2 year demonstration study was conducted in 11 primary care PPRNet practices. CDS included a risk assessment tool, health maintenance protocols, flow chart and a patient registry. Practices received performance reports and hosted annual half day on-site visits. RESULTS: There were statistically significant increases in screening for albuminuria (median 24 month change 30%, p < 0.0005) and monitoring albuminuria (median 24 month change 25%, p < 0.0005). An absolute 23.5% improvement in appropriate use of ACE-inhibitor or angiotensin receptor blocker and an absolute 7.0% improvement in hemoglobin measurement were not statistically significant. There were no clinical or statistically significant differences in other CKD CQMs. Facilitators to CDS use included practices' prioritization of improving CKD and staff use of standing orders. Barriers included incorporating use into existing workflow and variable use among providers. CONCLUSIONS: Use of CDS to improve CKD identification and management in primary care practices shows promise. However, other barriers must be addressed to effectively achieve improvements in CKD outcomes.

A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial.

BACKGROUND: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care. OBJECTIVE: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke. DESIGN: 2-year randomized, controlled clinical trial with the practice as the unit of randomization. SETTING: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record. PARTICIPANTS: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients. INTERVENTIONS: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches. MEASUREMENTS: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator. RESULTS: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]). LIMITATIONS: The study involved a small number of practices and lacked a pure control group. CONCLUSIONS: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.

"Meaningful" clinical quality measures for primary care physicians.

OBJECTIVES: To systematically solicit recommendations from Meaningful Use (MU) exemplars to inform Stage 3 MU clinical quality measure (CQM) requirements. STUDY DESIGN: The study combined an electronic health record (EHR)-based CQM performance assessment with focus groups among primary care practices with high performance (top tertile), or "exemplars." METHODS: This qualitative exploratory study was conducted in PPRNet, a national primary care practice-based research network. Focus groups among lead physicians from practices in the top tertile of performance on a CQM summary measure were held in early 2014 to learn their perspectives on questions posed by the Office of the National Coordinator related to Stage 3 MU CQMs. RESULTS: Twenty-three physicians attended the focus groups. There was consensus that CQMs should be evidence-based and focus on high-priority conditions relevant to primary care providers. Participants thought the emphasis of CQMs should largely be on outcomes and that reporting of CQMs should limit the burden on providers. Incorporating patient-generated data and accepting locally developed CQMs were viewed favorably. Participants unanimously concurred that platforms for population management were vital tools for improving health outcomes. CONCLUSIONS: Using a series of focus groups, we solicited Stage 3 MU CQM recommendations from a group of physicians who have already achieved "meaningful use" of their EHR, as demonstrated by their high performance on current MU CQMs. Adhering to the standards deemed to be important to high-performing real-world physicians could ensure that the MU Incentive Programs achieve their ultimate goal to improve outcomes.