Use of Commercial EMRs for Quality Reporting

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Use of Commercial EMRs for Quality Reporting
Improvement The Experience of Physician Practices

• Joy M. Grossman, PhD and
• Hoangmai Pham, MD, MPH

AcademyHealth Annual Research Meeting, June 10,
2008
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Study Motivation

• EMRs have potential to improve quality
  measurement and reporting
• Base measures on clinical rather than claims data
  
• Reduce administrative burden
• Provide better, more timely feedback to
  physicians
• Policymakers are promoting EMR adoption to
  support quality reporting
• Little research on how commercial EMRs are being
  used for quality initiatives

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Research Questions

• How are physician practices using commercial EMRs
  to generate quality reports for internal and
  external purposes?
• What are the facilitators and barriers that
  physicians face in using EMRs for these purposes?
  
• What are the implications for efforts to promote
  quality improvement via performance measurement?

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Qualitative Research Design

• 27 telephone interviews conducted 5/07 -8/07
• 8 leading edge physician practices and CHCs w/
  commercial EMRs and quality reporting
• Average of 2 respondents per practice (clinical
  and IT)
• 11 expert respondents including clinical
  informaticists, quality measure developers, EMR
  vendors, policymakers

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Participating Physician Practices/CHCs

• Selected purposively from three Community
  Tracking Study sites with most quality reporting
  activity (Boston, Seattle, Orange County, CA)
• Most large (gt100 physicians), multispecialty
  practices
• All using mainstream EMR products
• All participating in multiple quality reporting
  programs and internal quality improvement
  initiatives
• Health plans, MHQP, IHA, NCQA/BTE, and HRSA
  Health Disparities Collaboratives

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EMRs Used For Internal Rather Than External
Quality Reporting

• Limited use of EMRs to produce reports for
  external quality programs
• Many programs rely on claims data
• Active use of EMRs for internal quality reporting
  and improvement activities
• EMRs provide opportunities for quality
  improvement but must be supplemented with other
  IT tools and dedicated staff

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Substantial Barriers to Using EMRs to Automate
Quality Activities

• Difficulty capturing needed data in structured
  and coded fields
• Limited ability to query system, extract patient
  lists, generate reports
• Automated quality improvement tools have limited
  application

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Barriers to Data Capture

• Missing or multiple fields
• Data from external providers doesnt autopopulate
  EMR
• Lack of standardized clinical terminology
• Inaccuracy of diagnosis coding
• Physician resistance to capturing data if
  workflow impeded

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Barriers to Data Extraction and Reporting

• Difficult to generate lists of patients that meet
  multiple criteria
• Reports require additional programming
• Difficult to automate certain aspects of measure
  specification, e.g. exclusions
• Lack of consistent measure specification across
  quality reporting programs and over time

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Barriers to Automating Quality Improvement Tools

• Limited capability to refine quality improvement
  parameters, e.g. account for exclusions
• Practices may want to specify different
  guidelines for clinical targets than what is
  programmed in EMR or used in performance
  measurement
• Depending on EMR design and practice workflow,
  physician may not see reminders/alerts

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Practice Responses to Barriers

• EMR customization
• Use of additional IT tools
• Data warehouses, chronic disease registries,
  reporting tools and spreadsheets
• Dedicated analyst and technical staff, over and
  above clinical quality and IT staffs
• Changes in work flow processes for clinical and
  administrative staff
• Physician and staff education

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Conclusions

• EMR viewed as valuable tool for quality
  activities
• Numerous barriers exist to using EMR to automate
  process
• Leading practices invest substantial resources to
  automate quality activities
• Smaller practices face even more difficulty since
  they do not have the financial or staff resources

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Policy Implications

• Gap between reality today and assumption behind
  policy proposals that EMRs can support quality
  activities
• Reducing gap will require moving from ad-hoc
  fixes within practices and by EMR vendors to
  more systematic solutions
• Recent efforts by AHIC Quality Workgroup, NQF HIT
  Expert Panel, and AMA-CMS-NCQA Working Group to
  develop feedback loops between quality measure
  and guideline developers and EMR vendors and
  other IT organizations can help address barriers

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Policy Implications (2)

• Quality measure and guideline developers
• Standardize measures, linking them to guidelines
• Consider data requirements and ease of automating
  specifications
• Provide guidelines for developing standards
• IT and standards organizations (e.g. CCHIT/HITSP)
• Develop standards for clinical terminology, data
  exchange and quality reporting
• Develop certification criteria
• EMR vendors
• Develop more user-friendly reporting tools
• Create canned reports for reporting programs

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Acknowledgement

• Project was funded by the Robert Wood Johnson
  Foundation