Improving Performance on Preventive Health Quality Measures Using Clinical Decision Support to Capture Care Done Elsewhere and Patient Exceptions.

Preventive services required for performance measurement often are completed in outside health systems and not captured in electronic medical records (EMRs). A before-after study was conducted to examine the ability of clinical decision support (CDS) to improve performance on preventive quality measures, capture clinician-reported services completed elsewhere, and patient/medical exceptions and to describe their impact on quality measurement. CDS improved performance on colorectal cancer screening, osteoporosis screening, and pneumococcal vaccination measures ( P < .05) but not breast or cervical cancer screening. CDS captured clinician-reported services completed elsewhere (2% to 10%) and patient/medical exceptions (<3%). Compared to measures using only within-system data, including services completed elsewhere in the numerator improved performance: pneumococcal vaccine (73% vs 82%); breast (69% vs 75%), colorectal (58% vs 70%), and cervical cancer (53% vs 62%); and osteoporosis (72% vs 75%) screening ( P < .05). Visit-based CDS can capture clinician-reported preventive services, and accounting for services completed elsewhere improves performance on quality measures.

The good, the bad and the early adopters: providers' attitudes about a common, commercial EHR.

RATIONALE, AIMS AND OBJECTIVES: To describe primary care providers' (PCP) attitudes about the impact of a mature, commercial electronic health records (EHR) on clinical practice in settings with experience using the system and to evaluate whether a provider's propensity to adopt new technologies is associated with more favourable perceptions. METHOD: We surveyed PCPs in 11 practices affiliated with three health systems in Texas. Most practices had greater than 5 years of experience with the Epic EHR. The effect of early adopter of technology status was evaluated using logistic regression. RESULTS: One hundred forty-six PCPs responded (70%). Most thought the EHR had a positive impact on routine tasks, such as prescription refills (94%), whereas fewer agreed for complex tasks, such as delivery of guideline-concordant care for chronic illnesses (51%). Two-thirds (62%) thought it interfered with eye contact with patients, and 40% reported that it interfered with in-visit communication. Early adopters of technology reported greater positive effects of the EHR, even after adjusting for age, ranging from 2% to 15% higher on satisfaction ratings. CONCLUSION: PCPs practicing in settings with considerable experience using a common commercial EHR identified many positive effects, as well as two key areas for improvement - patient centredness and intelligent decision support. Providers with a propensity to adopt new technologies have more favourable perceptions of the EHR.

Use and satisfaction with key functions of a common commercial electronic health record: a survey of primary care providers.

BACKGROUND: Despite considerable financial incentives for adoption, there is little evidence available about providers' use and satisfaction with key functions of electronic health records (EHRs) that meet "meaningful use" criteria. METHODS: We surveyed primary care providers (PCPs) in 11 general internal medicine and family medicine practices affiliated with 3 health systems in Texas about their use and satisfaction with performing common tasks (documentation, medication prescribing, preventive services, problem list) in the Epic EHR, a common commercial system. Most practices had greater than 5 years of experience with the Epic EHR. We used multivariate logistic regression to model predictors of being a structured documenter, defined as using electronic templates or prepopulated dot phrases to document at least two of the three note sections (history, physical, assessment and plan). RESULTS: 146 PCPs responded (70%). The majority used free text to document the history (51%) and assessment and plan (54%) and electronic templates to document the physical exam (57%). Half of PCPs were structured documenters (55%) with family medicine specialty (adjusted OR 3.3, 95% CI, 1.4-7.8) and years since graduation (nonlinear relationship with youngest and oldest having lowest probabilities) being significant predictors. Nearly half (43%) reported spending at least one extra hour beyond each scheduled half-day clinic completing EHR documentation. Three-quarters were satisfied with documenting completion of pneumococcal vaccinations and half were satisfied with documenting cancer screening (57% for breast, 45% for colorectal, and 46% for cervical). Fewer were satisfied with reminders for overdue pneumococcal vaccination (48%) and cancer screening (38% for breast, 37% for colorectal, and 31% for cervical). While most believed the problem list was helpful (70%) and kept an up-to-date list for their patients (68%), half thought they were unreliable and inaccurate (51%). CONCLUSIONS: Dissatisfaction with and suboptimal use of key functions of the EHR may mitigate the potential for EHR use to improve preventive health and chronic disease management. Future work should optimize use of key functions and improve providers' time efficiency.