Improving quality of care

I spent Friday afternoon with a colleague at the EMR company’s headquarter. We were invited to discuss future directions for the Reporting functions of the EMR. By Reporting, I mean the ability to look at data for an entire practice, or even a group of practices.

There are many things you can produce a report for. It is much better to look for data entered in fields (consistent entry), rather than free text. We can already generate clinical reports for diagnoses, immunizations, medications and family history. We talked about adding lab results, vitals (temperatures, blood pressures, BMIs), as well as social history items such as smoking, alcohol use, marital status, allergies, etc. We also discussed automated reporting, that is, reports generated automatically on a periodic basis (every month, every 3 months).

To me, the ability to look at this data is vital to quality improvement; you can’t improve what you can’t measure. Quality in health care is measured by many things; one of the things that I want to look at is our processes. For example, the large Veteran’s Administration reengineering project in the US used EMRs, chart audits, and disease management programs to improve their quality. They improved many processes, such as preventive services (mammograms, flu shots etc), monitoring for chronic diseases (lab tests for diabetes), meeting evidence-based goals for chronic diseases (140/90 for hypertension etc).

It is not difficult to find evidence-based processes in primary care; I think we will pick select processes and start working on them. The first processes will be those with incentives. Then, processes with strong evidence of reductions in the risk of illness or death; good examples are found in the UK’s list of incentives, and deal with chronic illnesses such as diabetes. As well, we can pick preventive services that do not have incentives, but which are recommended by the US or Canadian Task Forces.

Once we decide which processes we want to improve, we then have to decide what to do about them, and how to do it. There are several ways to improve things, such as point of care alerts, proactive patients notification based on whole practice audits, and Chronic Disease Management programs.

We already have pre-programmed point of care alerts for services that have incentives, as well as self-programmed alerts for overdue services (tetanus shot more than 10 years ago). My Summary page is loaded as a default when the patient comes in; if there is a service overdue, that is the first thing I see. My patients must be getting tired of getting a Fecal Occult Blood kit (bowel cancer screen) handed to them: if you are 50 to 75, you will get the FOB kit, rather than an antibiotic, when you come in for your cold.

Patient notification by mail is already happening in my practice; we send letters if someone is overdue for one of the services with incentives. I can do more of this; I would like to use email in the future.

Chronic Disease Management programs are interesting. That is where someone is responsible for overseeing quality for a whole program (example, diabetes). This is not something I can do at a single practice level.

We are now becoming a Family Health Team. That means we will be hiring Allied Health Professionals, such as Pharmacists, Nurse Practitioners, and Social Workers, to work with us. I think the CDM program will be managed by Allied Health; we can designate one person as responsible for on-going audits, monitoring, targeted recalls, and perhaps even setting up group education and patient self-care programs, for one or several conditions, depending on the number of patients and the complexity of the program.

Because the EMR contains an integrated chart-in-common, what one team member enters in the chart is available to the other members of the primary care team who have the appropriate permissions.

The FHT has not been set up yet. However, as I mentioned previously, we already have a clinical pharmacist as part of our Academic Unit. The first electronic audit of diabetes care has already been done in my practice, by my resident. The Pharmacist has remote access to the chart-in-common, with defined permissions. I am now working with her to define standing orders: for example, if blood pressure is above 130/80, the pharmacist is authorized to increase current hypertensive medications up to a maximum of (here we put the list of possible meds and maximum doses). We have identified patients with at least two out of three parameters that are out of range (BP, LDL cholesterol, A1C). She will recall them for lifestyle counseling and medication optimization, with the changes recorded directly in the chart-in-common, whether she sees them at the hospital or in my office. If needed, she will send me an electronic message inside the EMR. Team-based care is currently recommended by the Canadian Diabetes Association’s Clinical Practice Guidelines, and it is now becoming a reality.

I view this as a pilot for CDM programs for the FHT. We will have a chance to work out the bugs on a small scale. The EMR company will program the ability to Report across several practices, so we can see how we are doing as a group, and track progress.

Once this is set up, I would like to start tracking patient outcomes as well; for example, what is the rate of heart attacks (code 410) in patients with diabetes (code 250)? That will tell us whether the changes we have made are truly making a difference to our patients’ health, but it will come after the changes in process.

We will have a problem in my FHT: there are several FHN groups that have joined, and although the majority uses the same application as my FHN does, one of the small FHNs already uses a different EMR application, and cannot change (it is very difficult to change EMRs). We will have to program the audit and tracking to work on the second platform as well. It will be difficult for the CDM lead to learn to work with two different programs. We may need to have separate CDM planning and personnel for the small group. This is not ideal; each FHT should consider using a single EMR application if at all possible.

To my mind, the ability to track quality improvement projects and protocols across several practices is one of the things that lie beyond EMR implementation. Implementation is not quite Blood, Sweat and Tears (there is no blood), but it is tough. Once it is done, though, then the bonus parts come into play; the Veteran's Administration program has shown what can be done: they have gone from poor quality to outperforming the rest of the US. We can do the same.

Michelle