1. Use of Commercial EMRs for Quality Reporting & Improvement: The Experience of Physician Practices Joy M. Grossman, PhD and Hoangmai Pham, MD, MPH AcademyHealth Annual Research Meeting, June 10, 2008

2. Study Motivation  EMRs have potential to improve quality measurement and reporting Base measures on clinical rather than claims data Reduce administrative burden Provide better, more timely feedback to physicians  Policymakers are promoting EMR adoption to support quality reporting  Little research on how commercial EMRs are being used for quality initiatives

3. Research Questions  How are physician practices using commercial EMRs to generate quality reports for internal and external purposes?  What are the facilitators and barriers that physicians face in using EMRs for these purposes?  What are the implications for efforts to promote quality improvement via performance measurement?

4. Qualitative Research Design  27 telephone interviews conducted 5/07 -8/07  8 leading edge physician practices and CHCs w/ commercial EMRs and quality reporting Average of 2 respondents per practice (clinical and IT)  11 expert respondents including clinical informaticists, quality measure developers, EMR vendors, policymakers

5. Participating Physician Practices/CHCs  Selected purposively from three Community Tracking Study sites with most quality reporting activity (Boston, Seattle, Orange County, CA)  Most large (>100 physicians), multispecialty practices  All using mainstream EMR products  All participating in multiple quality reporting programs and internal quality improvement initiatives Health plans, MHQP, IHA, NCQA/BTE, and HRSA Health Disparities Collaboratives

6. EMRs Used For Internal Rather Than External Quality Reporting  Limited use of EMRs to produce reports for external quality programs Many programs rely on claims data  Active use of EMRs for internal quality reporting and improvement activities  EMRs provide opportunities for quality improvement but must be supplemented with other IT tools and dedicated staff

7. Substantial Barriers to Using EMRs to Automate Quality Activities  Difficulty capturing needed data in structured and coded fields  Limited ability to query system, extract patient lists, generate reports  Automated quality improvement tools have limited application

8. Barriers to Data Capture  Missing or multiple fields  Data from external providers doesn’t autopopulate EMR  Lack of standardized clinical terminology  Inaccuracy of diagnosis coding  Physician resistance to capturing data if workflow impeded

9. Barriers to Data Extraction and Reporting  Difficult to generate lists of patients that meet multiple criteria  Reports require additional programming  Difficult to automate certain aspects of measure specification, e.g. exclusions  Lack of consistent measure specification across quality reporting programs and over time

10. Barriers to Automating Quality Improvement Tools  Limited capability to refine quality improvement parameters, e.g. account for exclusions  Practices may want to specify different guidelines for clinical targets than what is programmed in EMR or used in performance measurement  Depending on EMR design and practice workflow, physician may not see reminders/alerts

11. Practice Responses to Barriers  EMR customization  Use of additional IT tools Data warehouses, chronic disease registries, reporting tools and spreadsheets  Dedicated analyst and technical staff, over and above clinical quality and IT staffs  Changes in work flow processes for clinical and administrative staff  Physician and staff education

12. Conclusions  EMR viewed as valuable tool for quality activities  Numerous barriers exist to using EMR to automate process  Leading practices invest substantial resources to automate quality activities  Smaller practices face even more difficulty since they do not have the financial or staff resources

13. Policy Implications  Gap between reality today and assumption behind policy proposals that EMRs can support quality activities  Reducing gap will require moving from ad-hoc “fixes” within practices and by EMR vendors to more systematic solutions  Recent efforts by AHIC Quality Workgroup, NQF HIT Expert Panel, and AMA-CMS-NCQA Working Group to develop feedback loops between quality measure and guideline developers and EMR vendors and other IT organizations can help address barriers

14. Policy Implications (2)  Quality measure and guideline developers Standardize measures, linking them to guidelines Consider data requirements and ease of automating specifications Provide guidelines for developing standards  IT and standards organizations (e.g. CCHIT/HITSP) Develop standards for clinical terminology, data exchange and quality reporting Develop certification criteria  EMR vendors Develop more user-friendly reporting tools Create canned reports for reporting programs

15. Acknowledgement  Project was funded by the Robert Wood Johnson Foundation