A reminder and a measuring stick

As the nationwide campaign to improve healthcare quality gathers steam, some physician groups are starting to build performance measures into their electronic health records. By embedding the measures in their EHR templates and computer prompts, these groups are making dramatic improvements in some areas of patient care. In regions that have pay for performance, this approach could also make it easier for physician groups to garner financial rewards.

Whatever the size of your practice, it makes sense to think about customizing your EHR to incorporate widely accepted performance measures. This will become even more important as health plans and Medicare start to implement national performance standards.

Saving lives and money without increasing work

Within a year after the group added measure-based reminders to its EHR, for example, the percentage of its patients who had their LDL cholesterol at goal increased from 22 to 78 percent (the national average was 10 to 15 percent of patients with coronary artery disease).

By extrapolating from studies of CAD patients, electrophysiologist Michael F. O'Toole, the group's director of medical informatics, calculated that this one change had prevented 78 deaths, 158 heart attacks, and 38 strokes. It's also saved between $3 and $5 million in avoided hospitalizations, he says.

Real-time feedback makes the difference

While MHS physicians have received computer-based performance feedback for several years, the feedback alone wasn't nearly as effective as the group's latest approach. "Getting a report card at the end of the month isn't a bad first step," says O'Toole, but it doesn't tell the doctor how to address areas that need improvement. "The time to address it is when the patient is in front of you." Measure-based prompts-noting, for instance, that there's no documentation of ejection fraction for a heart failure patient-that pop up on the EHR during patient visits allow the doctor to do just that.

Still, the monthly report cards do serve a function. O'Toole admits that every doctor-himself included-is surprised when he discovers how far below the mark his own performance falls. "Without the data, we always think we're doing better than we are."

But in some cases, he says, poor grades are related to poor documentation. He cites the example of a patient with heart failure who isn't on an ACE inhibitor because he has an allergy to it. If the doctor fails to document that, his performance figures will suffer.

O'Toole also believes that MHS's numbers would look better still if the group could get more online data from the eight hospitals where its doctors work. If the group scans paper documents into its EHR, that doesn't automatically put the data into fields where it can be collected. "If a hospital report includes the ejection fraction," he notes, "someone in the practice has to enter that into the EHR."

Changing processes to make the grade

Cardiologist Joseph C. Marek, one of O'Toole's colleagues, says the data feedback from the EHR has helped him catch things that might otherwise have been neglected. "Sometimes the patient comes in with his chief complaint, and he's telling you about his spouse not understanding him, and you've got to check his blood pressure, check his medicines-and very often, a missing cholesterol level would fall through the cracks."