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Mining EHR data for quality improvement KEN TERRY | STAFF CORRESPONDENT
M a n y p h y s ic ia n s doubt that electronic health records (EHRs) improve quality of care. But relatively few practices are m ining their EHR data to see how well they’re doing or to update their care de livery processes. Most are collecting data mainly for external reporting purposes, usually with the help of automated EHR features.
According to a recent study in Health Affairs, between 2007 and 2013 the per centage of large practices that collected data on quality m easures nearly dou bled; that activity increased even more in small andmedium-sized practices be tween 2009 and 2013. But the use of elec tronic registries to identify patient care gaps and the feedback of performance data to physicians remained confined to a small percentage of practices.
There are several possible reasons for the low interest in m ining data for qual ity improvement. Most physicians be lieve they’re already doing a good job, and they may feel they’re too busy to de vote tim e to running reports and look ing at data. Especially if they’re work ing in sm all practices, they m ay feel intim idated by the technical require ments of data mining. It’s also difficult for providers to enter data consistently in the right EHR fields so that they have enough data to yield solid information on individual patients or populations.
With the growing use of value-based reimbursement, however, practices find them selves under increased pressure to prove that they are providing high- quality care to patients. At the sam e time, payers’ are em phasizing popu lation health m anagem ent, which re quires practices to identify care gaps and reach out to those who need care, regardless of whether they’ve been seen recently.
Experts and doctors interviewed by Medical Economics say data m ining is vital to helping practices m eet those objectives. Each practice must find an approach that fits its needs and goals; but whatever that is, the sooner you get started, the better off you’ll be in the long run.
DATA M INING OPTIONS
Health IT experts advise practices to take a close look at their EHR’s capabilities before thinking about using outside so lutions or outsourcing. In m any prod ucts, these capabilities include health m aintenance alerts and report writers.
H ealth m aintenance alerts, which are rem in d ers abou t preven tive or chronic care services th a t are recom m ended for a particular patient, pop up whenever an electronic chart is opened. While their use may not be considered data m ining, w hen you create a new health m aintenance alert, you are m in ing your EHR data for a purpose.
It’s difficult to program new health m aintenance alerts in most EHRs, says Ernie Hood, senior director, research and insights, for the Advisory Board Co. But Jen Brull, M.D., says that her nine- provider family practice in Plainville, Kan., custom ized several alerts w ith out any trouble. The real problem with prompts, she says, is that they can be overwhelming. “If you tu rn on every thing all at once, you don’t pay atten tion to anything.”
Another m ethod of data m ining is to run the reports available in the EHR or to write the reports you want and then run them. This is an area where EHRs differ widely. Dr. Brull, for example,
“But there’s still a lot of setup that you have to do, and many people never get to it. So even though a lot of EHRs offer this functionality, it’s underutilized.” Michelle Holmes, M.B.A. ECG Management Consultants, Seattle
says that her EHR includes prebuilt re ports for all of the quality measures in the Meaningful Use incentive program and the Physician Quality Reporting System (PQRS). However, her practice cannot modify these reports because they’re w ritten to m eet EHR certifica tion requirements. To produce custom reports, the practice’s IT staff devel oped a special web-based application that queries the EHR database.
In contrast, Michelle Holmes, M.B.A., a Seattle-based p rincipa l w ith ECG M anagem ent C onsultan ts, says the problem w ith m any EHRs is that they don’t offer enough prebuilt reports. In stead, they supply a “sandbox” and ava- riety of tools that practices can use to write their own reports.
The vendors do this, she notes, so ev eryone can create the reports they want. “But there’s still a lot of setup that you have to do, and many people never get to it. So even though a lot of EHRs offer this functionality, it’s underutilized.”
DRAWBACKS OF EHR REPORTS Ifyour EHR provides prebuilt reports re lated to M eaningful Use and/or PQRS measures, they might be programmed for a particular reporting period. When you run those reports, they will omit data on patients who have not sought care or have missed appointments during that period. You can lengthen the period for which the report searches the EHR data base to a year or two, Dr. Brull notes. But some patients on your panel will still be left out—a significant challenge ifyou’re trying to manage the health of your en tire patient population.
A nother problem is th a t som eone has to run EHR reports—whether pre built or customized—to extract the lat est data from them. They’re not running in the background and updated every tim e you see a patient or w ant to see how you’re doing on a particular qual ity measure. Consequently, they’re not integrated into the workflow at the point of care, notes Bruce Bagley, M.D., presi dent and CEO of TransforMED, the pa tient-centered m edical home subsid iary of the American Academy of Fam-
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ily Physicians (AAFP). He sees this as a serious deficiency of EHR-based re ports, because the reports can’t be used to inform medical decisions.
The current way of gathering infor m ation for medical decision-making, he says, is to scroll through the chart until you have what you need. “The new way would be to have it all presented on a single screen that shows you the care gaps you can focus on,” he says. “That can make the visit more efficient and ef fective.”
STANDALONE REGISTRIES T hird p arty registry softw are in ter faced withEHRs can provide automated reports that are available to physicians when they’re providing care. In addition, a good registry can give you up-to-date in formation on all ofyour patients, whether or not you’ve seen them recently.
The purpose of registries is to m an age chronic and preventive care and keep track of h igh-risk patients, Dr. Bagley says. The m ore sophisticated registries are designed to: > provide lists of subpopulations, such
as patients with hypertension and di abetes,
> identify p a tien ts w ith care gaps, based on evidence-based guidelines,
I support outreach to patien ts who have care gaps,
> provide feedback on how each phy sician is doing on particular types of care, such as the percentage of their d iabetic p a tien ts who have th e ir Hbalc levels or blood pressure under control, and
I generate q u a lity rep o rts for the practice Dr. Brull’s practice uses outside regis
try software with its EHR. The program includes a dashboard that she looks at when she sees patients. This dashboard shows data from six chronic care suites and 11 preventive care suites that are applied to each patient for whom they are appropriate.
REGISTRIES IN ACTION Dr. Brull and her colleagues look at the registry data for the whole group and use itto design quality improvement ini tiatives. Recently, they examined their data on patients with hypertension and metabolic syndrome. After comparing
the data with past information on these patients, they decided to focus on pa tients who had hypertension and m od erate renal insufficiency and were not taking an ACE inhibitor. Lists of patients in that category were provided to physi cians, who could decide if this medica tion was appropriate.
Yul Ejnes, M.D., MACP, a form er American College of Physicians board chairm an who practices in Providence, RI, says his practice uses th ird-party software attached to its EHR. The group has an IT departm ent that m ines and analyzes the data and sends reports on patient care gaps to physicians.
While Dr. Ejnes finds this information helpful, he notes that he receives the re ports only once a m onth or quarterly. That can make them less useful when he sees patients toward the end of a re porting period. But the data is far more timely than health plan claims data.
HIGH COST FOR SMALL PRACTICES Experts agree that sophisticated regis try software can be cost-prohibitive, es pecially for smaller practices. An insur ance company paid for the application that Dr. Brull’s group uses as part of a statewide patient-centered medical home program. Otherwise, it would have cost her practice a lot, she says. But she adds that it’s so valuable to the group that they probably would have bought it anyway.
Very basic registry applications, which are available online, can be fairly inex pensive and easy to implement, says Ms. Holmes. But Mr. Hood notes that these program s require some technical ex pertise to generate useful reports. The less costly the tool, the more technical knowledge needed to make it work.
Small practices can consider out sourcing data m ining and analysis to their EHR vendor or one of its technol ogy partners. Some vendors, such as Epic, Cerner, M editech, and athena- health, are incorporating analytics into their EHRs and will do the work for you in the cloud, Mr. Hood says.
Rosemarie Nelson, a Syracuse, New York-based consultant with the Med ical Group M anagem ent Association (MGMA), says this can be affordable for practices of any size, depending on the cost-benefit ratio. If a group consid ers buying a less costly product, its lead
ers should ask themselves whether the practice has the technical expertise to bu ild it out. “You’re going to pay one way or the other,” she says.
You should also look at how data m ining fits into your business plan. If you’re creating a patient-centered m ed ical home or are participating in an ac countable care organization, it m ight make sense to invest in registry soft ware or outsourcing, because you have financial incentives that could recoup your investment in time. Dr. Bagley be lieves that the use of registries to col lect and analyze data can help practices reap care m anagem ent fees and other incentives. Even a simple do-it-your self reg istry based on a spreadsheet can spur a practice “to build the work- flows that are required to ensure that data is used at the point of care. Even tually, you’ll have it integrated into the EHR. But you’ll have the workflow in place already.”
GETTING THE DATA YOU NEED Good data gets you actionable results. To start with, lab results may not be avail able in structured form, depending on whether the EHR interfaces with a par ticular lab. Dr. Ejnes’ practice, for ex ample, doesn’t have interfaces with all of the labs it uses, so employees m ust enter some faxed lab results manually into the EHR.
Dr. Ejnes also underlines the prob lem of getting all of the group’s physi cians and nurse practitioners to enter data in structured fields, rather th an as free text. The group has medical assis tants inputting some of this data so m in ers have something to mine, he says.
Even when providers enter the data in structured fields, Dr. Ejnes notes, the EHR allows them to put it in any of sev eral places—a feature that m any ven dors have built into their products, says Nelson.
Ms. Nelson says the solution is to tra in staff m em bers to en ter data in agreed-upon fields. But that’s difficult if a practice tackles 15 or 20 quality im provement areas all at once. Ms. Holmes suggests focusing on ju st one area, such as breast cancer screening. This ensures the organization receives accu rate data to change provider and patient behavior. D T
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