A Partnership for Clinician Electronic Health Record (EHR) Use and Quality of Care (Michigan)

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A Partnership for Clinician Electronic Health Record (EHR) Use and Quality of Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017191
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,184,765
  • PDF Version: 
    (PDF, 199.15 KB)

Summary: With the emphasis on health information technology (IT) in ambulatory care deriving from the Health Information Technology for Economic and Clinical Health Act, current use of electronic health records (EHRs) in ambulatory settings is increasing. However, after a health center makes a financial investment in an EHR, barriers - including the need to redesign workflow to incorporate use of the EHR before, during, and after a patient visit - to full and effective use of the system remain. It is especially important for clinical decision support (CDS) systems that these barriers be overcome, because if information is not available at the point-of-care and decisionmaking, health IT cannot improve the quality and outcomes of care.

The Institute for Nursing Centers and the Alliance of Chicago Community Health Services (Alliance) studied the effectiveness of a partnership that shares resources and utilizes a data-driven approach to promote full clinician use of an EHR. Three nurse-managed health centers and three community health centers participated in this effort to improve the quality of preventive care, chronic disease management, and medication management for vulnerable populations. These partners have a record of highly productive research, successful EHR implementation, commitment to data-supported high-quality health care for vulnerable populations, and a history of building and maintaining strong collaborations.

This project addressed one of the key problems in leveraging health IT to support high-quality patient care: despite its potential, CDS is often not used effectively or consistently by clinicians. The design of this project incorporated qualitative investigations and quantitative analyses at both the individual- and the center-level. The critical link between full use of EHR functionality - including CDS features, and clinical performance and quality outcomes - was examined with rigorous statistical methods. The project's EHR product was the integrated General Electric (GE) Centricity Practice Management EHR System with substantial customization of CDS in templates developed by the Alliance. The quality indicators selected were those that the Institute of Medicine has identified as priority areas for improvement and where significant disparities across racial, ethnic, and income groups exist. Qualitative methodology added to the field's understanding of health center leadership and change management required for successful use of EHR.

Specific Aims:

  • Study the effectiveness of a partnership that shares resources and uses a data-driven approach to promote full use of an EHR by clinicians in settings that serve vulnerable populations to improve the quality of care in the areas of preventive care, chronic disease management, and medication management. (Achieved)
  • Test the links between clinician use of an EHR and quality of preventive care, chronic disease management, and medication safety. (Achieved)
  • Examine organizational processes in the implementation and full use of an EHR in relationship to care delivery and outcomes. (Achieved)

2011 Activities: All study sites were live on the GE Centricity practice management and EHR systems. All sites were also connected to a laboratory interface and the GE data warehouse. A 1-year no-cost extension period was used to complete data collection at all sites. As last self-reported in the AHRQ Research Reporting System, project progress was completely on track and project budget spending was on target. The project was completed in August 2011.

Impact and Findings: Overall quality improvement was shown to occur over time following EHR implementation as measured by structure, process, and outcome metrics. Additionally, when compared to pre-implementation surveys, clinician experience and satisfaction, which dropped during implementation, rebounded after a year. Clinician expectations for EHRs were generally moderated, but overall, clinicians expected and continued to believe in the EHR's positive effect on quality and safety.

Project attempts to measure the depth and quality of EHR use by individual clinicians, and thus measure the association with quality at the clinician level, was hampered by several methodological challenges. It was not possible to track usage of chronic disease management templates directly. The project employed proxy measures that reduced accuracy. In diabetes management, the project was able to infer that the diabetes management template was used if foot exam results were recorded because this was the only place to enter that result. This raises two validity concerns: 1) clinicians not conducting or documenting foot exams may have used the form to document other things; and 2) the diabetes management use metric is indistinguishable from the quality indicator for conducting a foot exam. With regard to hypertension management, the CDS template that was measured was also used to measure cardiovascular disease management. This template did not support the clinical workflow of hypertension management and was not a fair measure of clinician CDS use. The more general metric of creating a clinical note also contains the potential for error. Nevertheless, the validity of the note use measure was supported by a significant correlation to self-reported use of EHR rather than paper.

The project did measure use of the evaluation and management coding advisor, a tool that validates coding of the complexity of the visit for billing. This metric was significantly correlated with relative value unit and full-time equivalent. This finding was expected and supports the argument that EHRs can ensure that providers document and code the complexity of office visits accurately. This feature is important for nurse-managed health centers, which are known to under-code.

The project demonstrated that careful EHR implementation using a model of sustained partnership and focused attention on quality of EHR use by clinicians has a positive impact on quality of care and experience of care by clinicians. However, the resources used to support this model were extensive and, without funding, may not be practical or realistic for most small primary care settings.

Target Population: Chronic Care*, Medically Underserved

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use 

* This target population is one of AHRQ's priority populations.

A Partnership for Clinician Electronic Health Record (EHR) Use and Quality of Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017191
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,184,765
  • PDF Version: 
    (PDF, 551.79 KB)


Target Population: Chronic Care*, Medically Underserved

Summary: Despite the emphasis on health information technology (IT) in ambulatory care, current use of electronic health records (EHRs) in ambulatory settings remains low. After a health center makes a monetary investment in an EHR, there remain significant barriers to full and effective use of the system, including redesigning workflow to incorporate use of the EHR before, during, and after a patient visit. It is especially important for clinical decision support (CDS) systems that these barriers be overcome. If information is not available at the point of care and decisionmaking, health IT cannot impact quality and outcomes of care. Therefore, it is important to identify and disseminate strategies to overcome barriers to full EHR use, and strengthen the link between technology adoption and improved quality of patient care.

The Institute for Nursing Centers and the Alliance of Chicago Community Health Services’ (Alliance) project studies the effectiveness of a partnership that shares resources and utilizes a data-driven approach to promote full clinician use of an EHR. Three nurse-managed health centers and three community health centers are participating to improve the quality of care in areas of preventive care, chronic disease management, and medication management for vulnerable populations. These partners have a record of highly productive research, successful EHR implementation, commitment to data-supported high quality health care for vulnerable populations, and a history of building and maintaining strong collaborations.

The goals of this project address one of the key problems in leveraging health IT to support high-quality patient care: despite the potential, CDS is often not used effectively or consistently by clinicians. The design of this project incorporates qualitative investigations and quantitative analyses at both the individual- and the center-level. The critical link between full use of EHR functionality, including CDS features, and clinical performance and quality outcomes will be examined with rigorous statistical methods. The product is the integrated General Electric (GE) Centricity Practice Management EHR System and is Certification Commission for Health Information Technology-certified with substantial customization of CDS in templates developed by the Alliance. The quality indicators selected are those that the Institute of Medicine has identified as priority areas for improvement and where significant disparities across racial, ethnic, and income groups exist. Qualitative methodology will add to the field’s understanding of health center leadership and change management required for successful use of EHR.

Specific Aims:
  • Study the effectiveness of a partnership that shares resources and uses a data-driven approach to promote full use of an EHR by clinicians in settings that serve vulnerable populations to improve the quality of care in the areas of preventive care, chronic disease management, and medication management. (Ongoing)
  • Test the links between clinician use of an EHR and quality of preventive care, chronic disease management, and medication safety. (Ongoing)
  • Examine organizational processes in the implementation and full use of an EHR in relationship to care delivery and outcomes. (Ongoing)

2010 Activities: Data collection was the main focus of 2010. EHR usage data with a one-quarter and a one-year look-back period has been collected for the Alliance sites, Campus Health Center (Detroit, MI), and Glide Health Services (San Francisco, CA). Productivity data continues to be queried on a quarterly basis at the Alliance sites, Campus Health Center, Glide Health Services, and Arizona State University (ASU)’s NP Healthcare clinics, Downtown and Scottsdale. Qualitative (interview) data collection is complete for Alliance sites, Campus Health Center, Glide Health Services, and ASU’s NP Healthcare-Downtown site. ASU’s NP Healthcare – Scottsdale site had completed baseline and during-implementation interviews.

Computer literacy data collection is complete at all sites. Clinician satisfaction data collection is complete for Alliance sites, Campus Health Center, Glide Health Services, and ASU NP Healthcare-Downtown. The ASU NP Healthcare-Scottsdale site completed the during-implementation survey for its new NP in November 2010. The post survey will be collected from this NP in February 2011. Patient satisfaction surveys have been collected at ASU NP Healthcare-Downtown, Detroit Campus Health Center, NP Healthcare-Scottsdale, and Glide Health Services at both the pre- and post-implementation time points. Physician Practice Patient Safety Assessment data collection is complete for all sites. Medication Safety data have been collected from Campus Health Center and Glide Health Services during preload, and were being collected from the two ASU sites as they enter historical medications for existing patients.

Clinical performance and outcome measures have been collected at one year post-go-live for Glide Health Services, and data have been collected from the Alliance centers at roughly three years post-implementation. Data collection for one year post-go-live at Campus Health Center is in progress. A full set of quality measures will be collected at the ASU NP Healthcare sites once they have been live on the EHR for one full year. Since Campus Health Center, Glide Health Services, and the Alliance sites will have been live on the EHR for over two years before the end of the study, the team will be able to obtain performance data at a second time point for each of these sites.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is mostly on track and project spending is roughly on target. Efforts during the no-cost extension focus on data collection, analysis, and development of manuscripts to publish project results.

Preliminary Impact and Findings: The mean score for perceived effect of an EHR on clinical practice at the nurse-managed center sites (evaluated 8–13 months post-go-live) was 2.95 on a scale of 1–5, and the CHCs’ (evaluated 19–23 months post-go-live) mean score was 3.48. There could be an effect of time yielding more recognition of the beneficial effects as providers gain EHR experience and competence.

Variation in end-user satisfaction and use is highly contextual: the implementation at the center with the lowest satisfaction was hampered by problems with connectivity and lack of lab interface. Nurse-managed health center sites face additional EHR implementation challenges that may affect end-user satisfaction, including high numbers of part-time providers and financial instability. A challenge in the measurement of use of CDS is that providers have multiple ways to document and receive support (e.g., multiple forms/templates). Use of chronic disease and preventive care templates is relatively low, which requires additional investigation. Variation of CDS use around specific chronic disease forms appears to be related to the predominant type of patients in the health center.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

With the emphasis on health information technology (IT) in ambulatory care deriving from the Health Information Technology for Economic and Clinical Health (HITECH) act, current use of electronic health records (EHRs) in ambulatory settings is increasing. However, after a health center makes a financial investment in an EHR, barriers—including the need to redesign workflow to incorporate use of the EHR before, during, and after a patient visit—to full and effective use of the system remain. It is especially important for clinical decision support systems that these barriers be overcome, because if information is not available at the point-of-care for decisionmaking, health IT cannot improve the quality and outcomes of care.

This study explored the challenges to adopting EHRs in safety net practices including nurse-managed health centers (NMHCs) and federally-qualified health centers (FQHCs). The project helped these centers assess their organizational readiness for EHRs to foster vision, incentives, resources, skills, and action plans; and to provide guided implementation through an industry partnership. Three NMHCs and three FQHCs participated in this effort to improve the quality of preventive care, chronic disease management, and medication management for vulnerable populations. These partners have a record of highly productive research, successful EHR implementation, commitment to data-supported high-quality health care for vulnerable populations, and a history of building and maintaining strong collaborations. The specific aims of the project were to:

  • Study the effectiveness of a partnership that shares resources and uses a data-driven approach to promote full use of an EHR by clinicians in settings that serve vulnerable populations to improve the quality of care in the areas of preventive care, chronic disease management, and medication management.
  • Test the links between clinician use of an EHR and quality of preventive care, chronic disease management, and medication safety.
  • Examine organizational processes in the implementation and full use of an EHR in relationship to care delivery and outcomes.

The research design incorporated quantitative and qualitative methods as well as individual- and center-level analyses. Data were collected and analyzed using a longitudinal design to examine the developmental pattern of clinician use of EHR and its temporal association with various performance, outcome, and medication safety measures. NMHCs went live during the course of the study, allowing for comparison of pre- and post-data. FQHCs went live on the EHR prior to the study. As a result, their longitudinal data was not expected to show trends related to go-live, and no pre-implementation or during implementation data were collected from these three FQHCs.

The project demonstrated that careful EHR implementation in a model of sustained partnership focusing on the quality of EHR use by clinicians had a positive impact on quality of care and experience of care by clinicians. The project showed that ongoing partnership support of centers facing significant implementation barriers can lead to successful outcomes.

A Partnership for Clinician Electronic Health Record (EHR) Use and Quality of Care - Final Report

Citation:
Pohl J. A Partnership for Clinician Electronic Health Record (EHR) Use and Quality of Care - Final Report. (Prepared by Michigan Public Health Institute under Grant No. R18 HS017191). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 571.07 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Principal Investigator: 
Document Type: 

Electronic Health Record End User Survey

This is a questionnaire designed to be completed by clinical staff in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.

Year of Survey: 
2011
Survey Link: 
Electronic Health Record End User Survey (PDF, 156.53 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.

Computer Literacy Survey: Michigan Public Health Institute

This is a questionnaire designed to be completed by clinical staff in an ambulatory setting. The tool includes questions to assess the current state of electronic health records.

Year of Survey: 
Created prior to 2010
Survey Link: 
Computer Literacy Survey: Michigan Public Health Institute (PDF, 113.05 KB) (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
Population: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.

Qualitative Interview Questions for Electronic Health Record Implementation

This is an interview guide designed to be conducted with administrators, clinical staff, implementers, and office staff across a health care system. The tool includes questions to assess user's perceptions of electronic health records.

Year of Survey: 
Created prior to 2011
Survey Link: 
Qualitative Interview Questions for Electronic Health Record Implementation (PDF, 86.37 KB)
Document Type: 
Research Method: 
Copyright Status: 
Permission has been obtained from the survey developers for unrestricted use of this survey; it may be modified or used as is without additional permission from the authors.
This project does not have any related story.
This project does not have any related emerging lesson.