“e-indicators” of Ambulatory Care Quality: New Paradigms for
Measuring Clinical Performance Using Electronic Health Records
Presented at the Academy Health, Washington DC June 10 2008
Jonathan P. Weiner, DrPHDepartment of Health Policy & ManagementJohns Hopkins Bloomberg School of Public [email protected]
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Topics to be discussed:
• Ideas and paradigms regarding health IT (HIT) as applied to ambulatory / population based quality performance measurement and reporting.
• Findings from a multi-faceted collaborative project to develop electronic health record (EHR) based “e-indicators.”
• Future challenges and opportunities of EHR based quality measurement.
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Embracing new HIT capabilities to measure quality in the ambulatory care sector: The “e-indicator” project
Goal: To develop innovative measures of quality that take advantage of new HIT capabilities and data sources.
Development effort based at Johns Hopkins and Park Nicollet Institute: – Collaboration involving leading edge “wired” integrated delivery
systems: Park Nicollet (MN), Kaiser Permanente (OR), Geisinger (PA), Health Partners (MN) Billings (MT), Dupont/Nemours (DE), Boston CHC network (MA).
– Involves both an “adult” project focusing on chronic illness and a “child project” focusing on screening and development
– Advisors include key quality groups, NCQA, NQF, AMA, Medicare, VA, ONCHIT, AHRQ, medical specialty societies
– Funded by Commonwealth Fund, Robert Wood Johnson, US AHRQ, Nemours
– Methods include lit review, survey of experts & early adopters, case study, development of starter-set of “e-indicators”.
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Applications of HIT-based performance measures
• Quality improvement for organizations
– Real time (safety / care management)
– Retrospective evaluation
• “Pay for Performance” (P4P) incentives
• Community / regional reporting and strategic planning
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HIT will transform performance measurement
• e-Indicators will be essential tool for:
– Provider / clinician teams /organizations
– Health plan / sponsors
– Government / communities / public health
– Outcomes researchers / scientists
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Data sources and types of quality / performance measures
Type of Measure
Data Source: Denominator Process Outcome Pt-Cent. Cost
Electronic / HIT
PH records / registry X
Insurance files X X X X
EHR X X X X
CPOE (order entry) X
PHR / Pt. “web portal” X X X
CDSS (clinical support) X X
Non-electronic
Paper medical record X X
Surveys X X
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A proposed typology for HIT based “e-indicators” of quality
1) Translational: Traditional (e.g., paper record and claims) measures translated for use on HIT platforms
2) HIT-facilitated: Measures that while not conceptually limited to HIT, would not otherwise be feasible.
3) HIT-enabled: Measures that generally would not be possible outside of EMR/EHR context.
4) HIT system management: Measures needed to implement, manage and evaluate HIT systems
5) “e-iatrogenesis”: Measures of patient harm caused at least in part by application of HIT.
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Examples of each type of e-indicator
1) Translational:- Computerization of existing HEDIS measures
2) HIT-facilitated: - % of children > BMI of x receiving intervention
- % of patients with e-prescriptions who did not pick up their Rx within x days
- % of clinicians reviewing and responding to abnormal lab value with x hours
3) HIT-enabled:- % of consumer generated web-based shared care plans accessed
by both generalist & specialists within 6 months
- % of in scope care that is routed through CDSS supported workflow algorithm
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Examples of each type of e-indicator - cont.
4) HIT system management:
- Attainment of EHR interoperability targets
- % of CDSS alerts ignored by clinicians
- % of allergy lists updated by patient annually
5) e-iatrogenesis:
- % of e-prescriptions that result in wrong drug
- % of patients needlessly exposed to imaging radiation due to inappropriate use of CDSS module
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Broad observations re EHRs and quality
• The needs of quality measurement have not been adequately addressed by most current EHR / HIT systems.
• The most useful quality measures will be hard-wired into HIT “workflow” or “streamed” automatically.
• Integration of real-time clinical decision support and provider order entry (e.g., e-prescribing) represent a major paradigm shift for quality measurement.
• To date, wired organizations have replicated paper records and claims data methods and approaches.
• Outside of IDSs, e-indicators at person and population level are not feasible without EHRs “interoperability.”
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Advantages of EHR based measures
• Data elements that are “streamed” or part of structured e-workflows are likely to be most accurate.
• 100% electronic census will reduce bias associated with sampled chart reviews and surveys.
• Abstraction errors due to poor handwriting will be eliminated.
• There are rich new sources of information in the domains of time and information flow.
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Challenges of EHR based measures
• The process of entering, transferring, archiving, and analyzing EHR data introduce numerous opportunities for inaccuracy.
• There are new types of errors associated with provider behaviors (e.g., cut and paste “plagiarizing.”)
• CDSS or workflow algorithms can introduce and perpetuate measurement errors by systematizing them.
• For foreseeable future, analysis of free-text section of EHR will be fraught with difficulty.
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Some recommendations moving forward• Quality measurement must be part of workflow and HIT system design from the start.
• We need to develop a better understanding of how new paradigms and data sources affect reliability and validity.
• For foreseeable future HIT “systems management” indicators should be central part of IT CQI process.
• EHR / HIT systems offer great opportunities for population and person based measures (moving beyond those that are provider or patient based).
• Although there will likely be considerable positive benefit, we must learn how to measure and monitor “e-iatrogenesis”
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Further information / Acknowledgements
If you wish to receive copies of our project manuscripts please give me your card or send me an e-mail at [email protected]
I would like to acknowledge co-authors of this paper:
– Jinnet Fowles
– Kitty Chan
– Betsy Kind