The Promise of Improved Quality: Can EMRs Deliver

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The Promise of Improved QualityCan EMRs Deliver?

• Denise Bonds, MD, MPH
• University of Virginia

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IOM

• The Institute of Medicine in their 2001 report on
  improving the quality of healthcare in the US
  stated
• The committee believes information technology
  must play a central role in the redesign of the
  health care system if a substantial improvement
  in quality is to be achieved over the coming
  decade.
• Can Information Technology deliver on this
  promise?

Crossing the Quality Chasm A New Health System
for the 21st Century (2001)
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Objective of this talk

• This talk will focus on the results of two
  projects conducted at Wake Forest University
• Carilion ACE
• Logicians Users Group

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Impact of CHF

• Congestive Heart Failure is a major public health
  threat
• Incidence is high1
• 383 men and 315 women per 100,000
• Survival is low2
• At the time of this project, 65 at 1 year and
  31 at 5 years
• Survival is improved with appropriate medication
  therapy including beta blockers and Ace
  inhibitors
• These medications are underused

• Roger VL et al. JAMA. 2004292344
• Wolinsky FD et al. Med Care. 1997351031

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Carilion ACE Project

• In conjunction with Carilion Health System, Wake
  Forest University tested the effect of an
  integrated, electronic reminder system
• Enhanced heart failure care encounter
  documentation plus/minus a heart failure
  medication prescribing tool

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Project Goals

• To improve the quality of care of patients with
  heart failure
• To increase use of ACEI, BB
• To test the use of an electronic reminder system
  and medication tool

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Setting

• Integrated healthcare system
• All outpatient clinics and medical practices use
  a single, commercially available EMR
• Central data storage and management, allowing
  central retrieval of information and development
  and implementation of software
• Prior to the CHF project, other reminder systems
  had been incorporated into system

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Design

• Randomized, controlled practice-based trial in
  primary care setting
• Thirty-six practices randomized
• All received
• Formatted progress note for HF patients in EMR
• Randomized to receive
• Patient specific EMR reminders
• Heart failure medication prescribing tool

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Carilion ACE Results
AHx sheet only BHx Med reminder
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Summary

• Results
• No effect on ACEI/ARB
• Some increase in use of BB
• Why such limited results?
• Anecdotal evidence Providers felt they were too
  busy to use the tools

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Dissemination

• Based on early trend toward improvement, a test
  of dissemination was conducted
• Three different health systems participated
• All used same EMR as Carilion in the outpatient
  setting
• All agreed to implement the EMR reminder in at
  least one outpatient primary care clinic

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Implementation issues

• Although all sites were using same EMR
  considerable variation in the availability of
  programmers and expertise at sites

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Evaluation

• Guided interview of the key personnel responsible
  for installation process
• Pre/post survey of providers and data query of
  the EMR to examine quality of care
• Patient information retrieved from the EMR using
  a standardized data pull mechanism

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Results Patient Chart Review
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Results Provider Survey
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Summary

• Despite existing software code and identical
  EMRs, incorporation into practices took
  considerable time and modification
• 80 hours of programmer time, depending on the
  site
• To obtain buy in from healthcare providers,
  modifications of the reminder system were needed
  at each site
• Self-reported use was modest
• In multi-specialty practices, who is responsible?
• Overall effect was small
• Practice with the largest increase was
  simultaneously changing from paper records to EMR
  

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EMRs- can they deliver?

• Projects to date have shown only modest
  improvements
• Dissemination can be challenging
• Why?
• Time pressure on providers
• Disagreement with recommendations
• Lack of complete integration of all patient data
• Ex LVEF not always available in EMR so required
  data entry by provider
• not my job

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GLAD Heart

• Guideline Adherence for a Healthy Heart
• Randomized, practice-based trial testing the
  effects of a palm-based decision support tool on
  adherence to ATPIII.
• An active control arm addressed adherence to JNC
  7.

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Intervention Groups
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PDA Tool Screen Shots
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Study Eligibility Criteria

• Primary Care Practices
• Internal Medicine
• Family Medicine
• Within 3-hour driving radius of WFUMS
• At least 50 of practices providers willing to
  participate in study
• Willingness to accept randomization assignment
• Willingness to participate in chart audit
• Exclusion Academic practices

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61 Participating Practices Demographics

• Specialty
• 72 Family Practice
• 23 Internal Medicine
• 5 Both specialties
• 23 solo practices
• 28 gt5 providers
• 51 gt 50 female providers
• 33 had at least 1 minority provider

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Chart Abstraction Methods

• Random sample
• Goal of 30 patients per practice
• Baseline window 6/1/2001 5/31/2003
• Follow-up window 5/1/2004 4/31/2006
• Data on demographics, CVD risk, lipid-lowering
  therapy and hypertension management
• Lipid-lowering therapy decisions assessed to
  9/30/2003 for BL and 8/31/2006 for FU
• Collaboration with CCME (QIO for NC)

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GLAD Heart Results ATP III
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GLAD Heart Results ATP III
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GLAD Heart Results ATP III
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GLAD Heart Results ATP III
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GLAD Heart Summary

• Modest but statistically significant benefit of
  the Palm tool on lipid management
• Primarily related to reduction in inappropriate
  use of LLT in low-risk individuals
• Use of LLT declined in both groups (appropriate
  use)

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Can EMRs Deliver?

• Qualified maybe
• No improvement with CHF reminder system
• Small improvement in management of cholesterol
• Perhaps greatest gain in improved quality will be
  through improved access to patient data and
  linkage to knowledge sources within the
  electronic medical record