In this assignment you will imagine yourself in the role of a recently hired Practice Manager for a physician office called Welby-Eichman healthCare (WeCare). The practice is located in a small urban

Economics M ining EHR data for quality im provem ent KEN TERRY | STAFF CORRESPONDENT Ma n y p h y s i c i a n s d o u b t th a t electronic h e a lth re c o rd s (EHRs) im p ro v e q u a lity of ca re. But relatively few p ra c tic e s a re m in in g t h e ir EHR d a ta to see h o w well th e y ’re d o in g or to u p d a te t h e ir c a re d e ­ livery processes. M ost are collecting data m a in ly for e x te r n a l re p o rtin g p u rp o s e s, u s u a lly w ith th e h elp of a u to m a te d EHR fe atu res.

A ccording to a re c e n t s tu d y in Health Affairs, b e tw e e n 2007 a n d 2013 th e p e r­ ce n ta g e of large p ra c tic e s t h a t collected d a t a o n q u a lity m e a s u r e s n e a r ly d o u ­ bled; t h a t a c tiv ity in c re a s e d ev e n m o re in sm all a n d m e d iu m -s iz e d practices b e ­ tw e e n 2009 a n d 2013. But th e u s e of elec­ tro n ic re g istrie s to identify p a tie n t care gaps a n d t h e fe e d b a c k of p e r fo rm a n c e d a ta to p h y sician s re m a in e d co n fin e d to a sm all p erc e n ta g e of practices.

T h e re a re several possible re a so n s for th e low in te re st in m in in g d a ta for q u a l­ ity im p ro v e m e n t. M ost p h y s ic ia n s b e ­ lieve t h e y 'r e a lre a d y d o in g a g o o d job, a n d th e y m a y feel th e y ’re to o b u s y to d e ­ vote t im e to r u n n i n g r e p o r ts a n d look­ in g a t d a ta . E s p e c ia lly if t h e y 'r e w o rk ­ in g in s m a ll p r a c tic e s , t h e y m a y feel i n t im i d a t e d by t h e t e c h n i c a l r e q u i r e ­ m e n ts of d a ta m in in g . It’s also d ifficult for p ro v id e rs to e n te r d a ta c o n siste n tly in th e r ig h t EHR fields so t h a t th e y h a v e e n o u g h d a ta to y ield so lid in fo rm a tio n on in d iv id u a l p a tie n ts or p o p u la tio n s .

W ith t h e g ro w in g u s e of v a lu e - b a s e d re im b u rse m e n t, however, p ra ctices find th e m s e lv e s u n d e r i n c r e a s e d p r e s s u r e to p ro v e t h a t t h e y a r e p r o v id in g h ig h - q u a l i t y c a r e to p a t i e n t s . At t h e s a m e tim e , p a y e r s ’ a r e e m p h a s i z in g p o p u ­ la tio n h e a l t h m a n a g e m e n t, w h ic h r e ­ q u i r e s p r a c tic e s to id e n tif y c a r e g a p s a n d r e a c h o u t to th o s e w h o n e e d care, re g a rd le ss of w h e th e r th e y ’ve b e e n see n recently.

E x p e rts a n d d o c to rs in te rv ie w e d by Medical Economics say d a ta m in in g is v ita l to h e lp in g p r a c t i c e s m e e t th o s e o bjectives. Each p ra c tic e m u s t fin d a n a p p r o a c h t h a t fits its n e e d s a n d goals; b u t w h a te v e r t h a t is, th e s o o n e r y o u get s t a r t e d , t h e b e t t e r off y o u ’ll b e in t h e long ru n .DATA M I N I N G O P T IO N S H e alth IT experts advise practices to take a close look a t th e i r EHR’s c a p a b ilitie s b efore th in k in g a b o u t u s in g o u tsid e s o ­ lu tio n s or o u ts o u rc in g . In m a n y p r o d ­ u cts, th e s e c a p a b ilitie s in c lu d e h e a lth m a in te n a n c e a le rts a n d r e p o r t w riters.

H e a lth m a i n t e n a n c e a le r ts , w h ic h a r e r e m i n d e r s a b o u t p r e v e n t i v e o r c h r o n ic c a r e se r v ic e s t h a t a r e r e c o m ­ m e n d e d for a p a r tic u la r p a tie n t, p o p u p w h e n e v e r a n e lec tro n ic c h a rt is open e d .

W h ile th e i r u s e m a y n o t b e c o n s id e re d d a t a m i n in g , w h e n y o u c r e a te a n e w h e a lt h m a in te n a n c e alert, you a r e m i n ­ in g y o u r EHR d a ta for a p u rp o s e .

I t’s d iffic u lt to p r o g r a m n e w h e a lt h m a in te n a n c e a le rts in m o s t EHRs, says E rn ie H o o d , s e n io r d ire c to r, r e s e a r c h a n d insights, for th e A dvisory B o ard Co.

B ut Jen Brull, M.D., says t h a t h e r n in e - p r o v id e r f a m ily p r a c tic e in P la in v ille , K an., c u s to m iz e d s e v e ra l a le r ts w i t h ­ o u t a n y tro u b le. T h e re a l p ro b le m w ith p ro m p ts , s h e says, is t h a t th e y c a n be o v e r w h e lm in g . "If y o u t u r n o n e v e ry ­ t h i n g a ll a t o n ce , y o u d o n ’t p a y a t t e n ­ tio n to a n y th in g .” A n o th e r m e th o d of d a ta m in in g is to r u n th e re p o r ts av a ila b le in t h e EHR or to w rite t h e re p o rts you w a n t a n d th e n r u n th e m . T h is is a n a r e a w h e re EHRs d iffe r w id ely . Dr. B ru ll, for e x a m p le , "But there's still a lot of setup that you have to do, and many people never get to it. So even though a lot of EHRs offer this functionality, it's underutilized." Michelle Holmes, M.B.A.

ECG Management Consultants, Seattlesays t h a t h e r EHR in c lu d e s p r e b u ilt r e ­ p o r ts for all of th e q u a lity m e a s u r e s in t h e M e a n in g f u l Use in c e n tiv e p ro g r a m a n d t h e P h y s ic ia n Q u a lity R e p o rtin g S ystem (PQRS). H ow ever, h e r p ra c tic e c a n n o t m o d ify t h e s e r e p o r t s b e c a u s e t h e y ’re w r i t t e n to m e e t EHR c e r tif ic a ­ tio n re q u ir e m e n ts . To p ro d u c e c u sto m r e p o r ts , t h e p r a c t i c e ’s IT s t a f f d e v e l­ o p e d a s p e c ia l w e b - b a s e d a p p lic a tio n t h a t q u e rie s t h e EHR d a ta b a se .

In co n tra st, M ichelle Holm es, M.B.A., a S e a t t l e - b a s e d p r i n c i p a l w i t h ECG M a n a g e m e n t C o n s u l t a n t s , s a y s t h e p ro b le m w ith m a n y EHRs is t h a t th e y d o n ’t offer e n o u g h p r e b u ilt re p o rts . I n ­ stead, th e y su p p ly a "sa n d b o x ” a n d a v a - rie ty of to o ls t h a t p r a c tic e s c a n u s e to w rite t h e ir o w n re p o rts.

T h e v e n d o rs do th is, sh e n o tes, so ev­ eryone c a n c reate th e re p o rts th e y w ant.

“But t h e r e ’s still a lot of s e tu p t h a t you h av e to do, a n d m a n y p e o p le n e v e r get to it. So ev e n th o u g h a lot of EHRs offer th is fu n c tio n a lity , it ’s u n d e r u tiliz e d .” D R A W B A C K S O F E H R R E P O R T S Ify o u r EHR p ro v id es p re b u ilt re p o rts r e ­ la te d to M e a n in g f u l U se a n d / o r PQRS m e a s u r e s , th e y m ig h t b e p r o g r a m m e d for a p a r tic u la r r e p o r tin g p e rio d . W h e n you r u n th o se reports, th e y will om it d ata o n p a tie n ts w h o h av e n o t so u g h t c a re or h av e m is s e d a p p o in tm e n ts d u r in g t h a t p e rio d . You c a n l e n g th e n t h e p e r io d for w h ic h th e re p o rt se a rch e s th e EHR d a ta ­ b a se to a y e a r or two, Dr. Brull notes. But so m e p a tie n ts o n y o u r p a n e l w ill still b e left o u t—a sig n ifican t ch a lle n g e ifyou're tr y in g to m a n a g e th e h e a lth of y o u r e n ­ tire p a tie n t p o p u la tio n .

A n o t h e r p r o b l e m is t h a t s o m e o n e h a s to r u n EHR r e p o r ts —w h e th e r p r e ­ b u ilt o r c u s to m iz e d —to e x tra c t th e lat­ est d a ta from th e m . T h e y ’re n o t r u n n in g in t h e b a c k g r o u n d a n d u p d a t e d every ti m e y o u se e a p a t i e n t o r w a n t to s e e h o w y o u ’re d o in g o n a p a r ti c u la r q u a l­ ity m e a s u r e . C on seq u en tly , t h e y ’re n o t in te g ra te d in to th e workflow a t th e p o in t of care, n o te s B ruce Bagley, M.D., p re s i­ d e n t a n d CEO of TransforM ED, th e p a ­ tie n t - c e n te r e d m e d ic a l h o m e s u b s id ­ ia ry of th e A m e ric a n A c ad em y of Fam - EHR D A T A MINING s e e p a g e 5 2 D e O F D E R M A T O L O G Y AUGUST 2015 / DERMAT0L0GYTIIV1ES.comDermatology Times E H R D A T A M I N I N G :

Identify patient care gaps, get performance feedback from page 5 1 ily P h y s ic ia n s (AAFP). He s e e s t h i s as a s e r io u s d e fic ie n c y of E H R -b a sed r e ­ p o rts, b e c a u s e th e re p o rts c a n ’t b e u s e d to in fo rm m e d ic a l decisions.

T h e c u r r e n t w ay of g a th e r in g in fo r­ m a tio n for m e d ic a l d e c is io n -m a k in g , h e says, is to scro ll t h r o u g h t h e c h a r t u n til you h ave w h a t you n ee d . "The new way w o u ld b e to have it all p re s e n te d on a single sc re e n t h a t show s you th e ca re gap s y o u c a n fo c u s o n ,” h e says. “T h a t c a n m a k e th e visit m o re efficient a n d ef­ fective.” STANDALONE REGISTRIES T h i r d p a r t y r e g i s t r y s o f t w a r e i n t e r ­ faced w ith E H R s c a n provide a u to m a te d re p o rts t h a t a re available to p h y sician s w h e n th e y ’re providing care. In addition, a good registry ca n give you up-to-date in ­ form ation on all ofyour patients, w h e th e r or n o t y o u ’ve see n th e m recently.

T h e p u r p o s e of re g is trie s is to m a n ­ ag e c h r o n ic a n d p r e v e n tiv e c a r e a n d k e e p t r a c k o f h i g h - r i s k p a t i e n t s , Dr.

B ag ley say s. T h e m o r e s o p h i s ti c a t e d re g istrie s a r e d e s ig n e d to:

> p ro v id e lists of s u b p o p u la tio n s , su ch as p a tie n ts w ith h y p e rte n s io n a n d d i­ abetes, > i d e n t i f y p a t i e n t s w i t h c a r e g a p s , b a s e d o n ev id e n c e -b a se d guidelines, I s u p p o r t o u t r e a c h to p a t i e n t s w h o h av e c a re gaps, > p ro v id e fe e d b a c k o n h o w e a c h p h y ­ sic ia n is d o in g o n p a r ti c u la r ty p e s of care, su c h as th e p e r c e n ta g e of th e ir d i a b e t i c p a t i e n t s w h o h a v e t h e i r H b a lc levels or blood p re s su re u n d e r control, a n d I g e n e r a t e q u a l i t y r e p o r t s f o r t h e p ra c tic e Dr. B rull’s p ra c tic e u se s outside re g is­ tr y so ftw a re w ith its EHR. T h e p ro g r a m in c lu d e s a d a s h b o a r d t h a t sh e looks at w h e n she sees p a tie n ts. T h is d a s h b o a rd sh o w s d a ta fro m six c h r o n ic c a re su ites a n d 11 p re v e n tiv e c a r e s u ite s t h a t a r e a p p lie d to e a c h p a t i e n t for w h o m th e y a r e a p p ro p ria te .

REGISTRIES IN ACTION Dr. B rull a n d h e r co lle a g u e s look at th e r e g is tr y d a ta for t h e w h o le g ro u p a n d use itto design q u ality im p ro v em en t in i­ tiatives. Recently, th e y e x a m in e d t h e ir d a ta o n p a tie n ts w ith h y p e r te n s io n a n d m e ta b o lic sy n d ro m e . A fter c o m p a r in gth e d a ta w ith p a s t in fo rm a tio n o n th e s e p a tie n ts , th e y d e c id e d to fo c u s o n p a ­ tie n ts w h o h a d h y p e r te n s io n a n d m o d ­ e ra te re n a l in su ffic ie n c y a n d w e re n o t ta k in g a n ACE inhibitor. Lists of p a tie n ts in t h a t c a te g o ry w e re p ro v id e d to p h y si­ cian s, w h o co u ld d e c id e if th is m e d ic a ­ tio n w a s a p p ro p ria te .

Yul E jn e s , M .D ., MACP, a f o r m e r A m e ric a n College of P h y sic ian s b o a r d c h a ir m a n w h o p ra c tic e s in Providence, RI, sa y s h is p r a c t i c e u s e s t h i r d - p a r t y so ftw a re a tta c h e d to its EHR. T he g ro u p h a s a n IT d e p a r t m e n t t h a t m in e s a n d a n a ly z e s th e d a ta a n d s e n d s re p o r ts on p a tie n t c a re gaps to p h y sician s.

W hile Dr. Ejnes finds th is in fo rm atio n helpful, h e n o tes t h a t h e receives th e re ­ p o r ts o n ly o n c e a m o n t h or q u a rte rly .

T h a t c a n m a k e t h e m less u s e f u l w h e n h e sees p a tie n ts to w a rd th e e n d of a r e ­ p o rtin g p eriod. But th e d a ta is far m ore tim ely t h a n h e a lth p la n claim s data.

HIGH COST FOR SMALL PRACTICES E x p erts a g re e t h a t s o p h is tic a te d re g is ­ try so ftw a re c a n b e cost-prohibitive, e s ­ p e c ia lly for s m a lle r p ra c tic e s. An in s u r ­ a n c e c o m p a n y p a id for th e a p p lic a tio n t h a t Dr. B rull's g ro u p u s e s as p a r t of a statewide patient-centered m edical hom e p ro g ra m . O th erw ise, it w o u ld h av e cost h e r p ra c tic e a lot, sh e says. But sh e a d d s th a t it’s so valuable to th e group th a t th e y p ro b a b ly w o u ld h av e b o u g h t it anyw ay.

Very basic registry applications, w hich a re available o n lin e, c a n b e fairly inex­ p en siv e a n d ea sy to im plem ent, says Ms.

H olm es. But Mr. H o o d n o tes t h a t th e s e p r o g r a m s r e q u ir e s o m e t e c h n i c a l ex­ p e r tis e to g e n e ra te u s e f u l re p o rts . T h e less co stly th e tool, th e m o re te c h n ic a l know ledge n e e d e d to m a k e it work.

S m a ll p r a c t i c e s c a n c o n s i d e r o u t ­ s o u r c in g d a t a m i n in g a n d a n a ly s is to t h e ir EHR v e n d o r or o n e of its t e c h n o l­ ogy p a r t n e r s . S om e v e n d o r s , s u c h as Epic, C e rn e r, M e d ite c h , a n d a t h e n a - h e a lth , a r e in c o rp o r a tin g a n a ly tic s in to th e i r EHRs a n d w ill do t h e w o rk for y o u in t h e cloud, Mr. H o o d says.

R o se m a rie N elson, a S yracuse, N ew Y ork-based c o n s u l t a n t w ith th e M e d ­ ic a l G ro u p M a n a g e m e n t A s s o c ia tio n (MGMA), says t h i s c a n b e a ffo rd a b le for p ra c tic e s of a n y size, d e p e n d in g on t h e co st-b e n e fit ratio. If a g ro u p c o n s id ­ ers b u y in g a less costly p ro d u c t, its le a d ­ers s h o u ld a sk th e m s e lv e s w h e th e r th e p ra c tic e h a s t h e te c h n ic a l e x p e rtise to b u ild it out. “You’re going to p ay on e w ay or th e o th e r,” sh e says.

You s h o u l d a ls o lo o k a t h o w d a t a m i n in g fits i n to y o u r b u s in e s s p la n . If y o u ’re c re a tin g a p a tie n t-c e n te re d m e d ­ ical h o m e or a re p a r tic ip a tin g in a n a c ­ c o u n ta b le c a r e o r g a n iz a tio n , it m ig h t m a k e s e n s e to in v e s t in r e g is tr y s o ft­ w a re or o u tso u rc in g , b e c a u s e y o u h av e f in a n c ia l in c e n tiv e s t h a t c o u ld r e c o u p y o u r in v e s tm e n t in tim e . Dr. Bagley b e ­ liev es t h a t t h e u s e of r e g is tr ie s to c o l­ lect a n d a n a ly z e d a ta c a n h e lp p ra c tic e s r e a p c a r e m a n a g e m e n t fees a n d o th e r in c e n tiv e s . E ven a s im p le d o -it- y o u r ­ s e lf r e g i s t r y b a s e d o n a s p r e a d s h e e t c a n s p u r a p ra c tic e "to b u ild t h e work- flow s t h a t a r e r e q u ir e d to e n s u r e t h a t d a ta is u s e d a t t h e p o in t of c a re . E ven­ tually, y o u ’ll h av e it in te g ra te d in to th e EHR. B ut y o u ’ll h a v e t h e w o rk f lo w in p la c e already.” GETTING THE DATA YOU NEED Good d a ta gets you actionable results. To s ta r t w ith , lab re s u lts m a y n o t b e a v a il­ able in s tr u c tu r e d form , d e p e n d in g on w h e th e r th e EHR in te rfa c e s w ith a p a r ­ t i c u l a r lab. Dr. E jn es' p ra c tic e , fo r ex­ am ple, d o e s n 't h a v e in te rfa c e s w ith all o f t h e la b s it u s e s , so e m p lo y e e s m u s t e n te r so m e faxed lab r e s u lts m a n u a lly in to th e EHR.

Dr. Ejnes a lso u n d e r li n e s th e p r o b ­ lem of g e ttin g all of t h e g ro u p 's p h y s i­ c ia n s a n d n u r s e p r a c titio n e r s to e n te r d a ta in s t r u c t u r e d fields, r a th e r t h a n as free text. T h e g ro u p h a s m e d ic a l a s s is ­ ta n ts in p u ttin g so m e of th is d a ta so m i n ­ ers h a v e s o m e th in g to m in e , h e says.

Even w h e n p ro v id e r s e n te r t h e d a ta in s tru c tu re d fields, Dr. Ejnes notes, th e EHR allows th e m to p u t it in a n y of sev­ e ra l p la c e s —a f e a tu r e t h a t m a n y v e n ­ dors h ave b u ilt in to th e ir p ro d u c ts, says Nelson.

M s. N e ls o n sa y s t h e s o lu t io n is to t r a i n s t a f f m e m b e r s to e n t e r d a t a in a g r e e d - u p o n fields. But th a t 's d ifficu lt if a p ra c tic e tack le s 15 or 20 q u a lity im ­ p ro v e m e n t a re a s all at once. Ms. H olm es s u g g e s t s f o c u s in g o n j u s t o n e a r e a , s u c h as b r e a s t c a n c e r s c r e e n in g . T h is e n s u r e s th e o rg a n iz a tio n receives a c c u ­ ra te d a ta to c h a n g e p ro v id er a n d p a tie n t b ehavior. D T Copyright ofDermatology Timesisthe property ofAdvanstar Communications Inc.andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.