New paradigms for measuring clinical performance using electronic health records.

UNLABELLED: Measures of provider success are the centerpiece of quality improvement and pay-for-performance programs around the globe. In most nations, these measures are derived from administrative records, paper charts and consumer surveys; increasingly, electronic patient record systems are also being used. We use the term 'e-QMs' to describe quality measures that are based on data found within electronic health records and other related health information technology (HIT). We offer a framework or typology for e-QMs and describe opportunities and impediments associated with the transition from old to new DATA SOURCES: If public and private systems of care are to effectively use HIT to support and evaluate health-care system quality and safety, the quality measurement field must embrace new paradigms and strategically address a series of technical, conceptual and practical challenges.

No change in physician dictation patterns when visit notes are made available online for patients.

OBJECTIVE: To determine whether physicians document office visits differently when they know their patients have easy, online access to visit notes. PATIENTS AND METHODS: We conducted a natural experiment with a pre-post design and a nonrandomized control group. The setting was a multispecialty group practice in Minnesota. We reviewed a total of 400 visit notes: 100 each for patients seen in a rheumatology department (intervention group) and a pulmonary medicine department (control group) from July 1 to August 30, 2005, before online access to notes, and 100 each for patients seen in these 2 departments 1 year later, from July 1 to August 30, 2006, when only rheumatology patients had online access to visit notes. We measured changes in visit note content related to 9 hypotheses for increased patient understanding and 5 for decreased frank or judgmental language. RESULTS: Changes occurred for 2 of the 9 hypotheses related to patient understanding, both in an unpredicted direction. The proportion of acronyms or abbreviations increased more in the notes of rheumatologists than of pulmonologists (0.6% vs 0.1%; P=.01), whereas the proportion of anatomy understood decreased more in the notes of rheumatologists than of pulmonologists (-5.9% vs -0.8%; P=.02). One change (of 5 possible) occurred related to the use of frank or judgmental terms. Mentions of mental health status decreased in rheumatology notes and increased in pulmonology notes (-8% vs 7%; P=.02). CONCLUSION: Dictation patterns appear relatively stable over time with or without online patient access to visit notes.

Employee engagement factors that affect enrollment compared with retention in two coaching programs--the ACTIVATE study.

This article describes enrollment and retention results from a randomized controlled trial that tested differences between a traditional worksite health promotion program and an activated consumer program on health behaviors and health status. A control arm was included. Baseline survey and clinical data were collected from 631 of 1628 eligible employees (39% response rate) between March and June of 2005. Retention data were collected in March 2007-12 months into an 18-month program. At baseline, participants in the 6 groups (3 arms in each of 2 companies) were comparable in health status but not in patient activation status. Enrollment of high-risk employees into the 2 individualized coaching programs (one focused on traditional health promotion, the other focused on activated consumer navigation) varied significantly by industry type, smoking status, and patient activation. In contrast, retention in the coaching programs was related to sex, age, and industry type. Our findings suggest that one set of strategies may be needed to encourage program enrollment while a distinctly different set of strategies may be needed to sustain participation.

Review: electronic health records and the reliability and validity of quality measures: a review of the literature.

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

Implementing electronic health record-based quality measures for developmental screening.

OBJECTIVE: The goal was to examine the current abilities and future potential of electronic health record (EHR) systems to measure childhood developmental screening and follow-up rates in primary care settings. METHODS: A group of pediatric clinicians and health informatics experts was convened to develop quality indicators reflecting different aspects of the developmental screening process. These indicators included the administration of a standardized, validated instrument to screen children for developmental delays, the documentation of abnormal screening results, and the provision of follow-up care. Six integrated provider systems across the United States, with fully implemented EHR systems, were evaluated to determine the feasibility of implementing these measures within each system. Barriers related to measure implementation were identified. RESULTS: The EHR systems of all 6 health care organizations could implement measures examining developmental screening rates and could identify and track children with abnormal screening results. However, most of the systems did not have the ability to capture data for more-complex EHR-based measures. In particular, data elements based on workflow actions could not be captured with current EHR system designs. CONCLUSIONS: This study identified 2 main barriers to the implementation of developmental quality measures: concerns about data reliability and the tracking of care coordination within patient records. Potential solutions to these problems, including terminology standardization, patient portal use, and use of a single developmental screening instrument, are discussed.

Smoking-related attitudes and clinical practices of medical personnel in Minnesota.

CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Patients' interest in reading their medical record: relation with clinical and sociodemographic characteristics and patients' approach to health care.

BACKGROUND: Although opportunities for patients to review their medical records are increasing, nothing is known about which patients want to take advantage of those opportunities. The objective of this study was to determine the proportion and characteristics of patients who are very interested in examining their clinic medical record and the reasons for their interest. METHODS: Cross-sectional, mailed survey (conducted in May 2001) to a random sample of 4500 adults who had a recent clinic visit. RESULTS: The response rate was 81%; 36% were very interested in reading their medical record (dependent variable). In multivariate logistic regression, the significantly related factors were seeking health information (finding the Internet very important for health information [adjusted odds ratio, 2.09], having a health newsletter subscription [adjusted odds ratio, 1.23], and using a health resource book in last month [adjusted odds ratio, 1.36]); being very concerned about errors in care (adjusted odds ratio, 2.52); and lacking trust in their physician (adjusted odds ratio, 1.55). Health status, use of health care, education, and income were not independently related to patients' interest. The most common reasons for patients wanting to look at their medical record were to see what their physician said about them (74%), to be more involved in their health care (74%), and to understand their condition better (72%). CONCLUSIONS: Patients' interest in reading their medical record is better predicted by their consumer approach to health care than it is by their clinical characteristics. Demographic characteristics of sex and race were related, while socioeconomic factors of education and income were not.

Consumer response to a report card comparing healthcare systems.

OBJECTIVE: Report cards to date have focused on quality of care in health plans rather than within healthcare delivery systems. The purpose of this study was to evaluate consumer response to the first healthcare system-level report card. STUDY DESIGN: Qualitative assessment of consumer response. METHODS: We conducted 5 focus groups of community members to evaluate consumer response to the report card; 2 included community club members, 3 included community-dwelling retired persons. Discussions were audiotaped and transcribed; comments were categorized by topic area from the script, and common themes identified. RESULTS: Focus group participants, in general, were unaware of the current emphasis on medical quality improvement initiatives. However, they believed that the opinion that the descriptive clinic information and patient survey data contained in the report card would be most useful mainly for choosing a healthcare system if they were dissatisfied with current medical care, if their healthcare options changed, or if they were in poor health. Personal experience was considered a more trustworthy measure of healthcare quality than were patient survey results. Trustworthiness was perceived to be higher if the report card sponsor was not affiliated with the healthcare systems being evaluated. Participants also believed care system administrators should use the data to enact positive clinic-level and physician-level changes. CONCLUSIONS: Healthcare consumers appreciated the attention to patient experiences and supported healthcare quality improvement initiatives. Report cards were considered important for choosing a healthcare system in certain circumstances and for guiding quality improvement efforts at all levels.