Using EMR Templates to Measure Quality of Care for Children with ADHD and Obesity Jeanne Van Cleave, MD Timothy G. Ferris, MD, MPH September 26, 2007

Childhood Obesity: Challenges to Measuring Quality of Care ProcessOutcome Recognition of elevated BMI Counseling on diet and exercise Periodic follow-up Assessing symptom progress BMI <85 th percentile

Children with ADHD: Challenges to Measuring Quality of Care ProcessOutcome Correct diagnosis (DSM IV criteria) Stimulant and behavior management Periodic follow-up Assessing symptom progress Improved attentiveness and hyperactivity

Objective To create electronic medical record templates for ADHD and obesity with clinical decision support Develop quality of care measures that… Are accurate Closely reflect care that is actually delivered Are technically easy and inexpensive to measure.

Methods Part of a larger project to examine the effect of clinical decision support on quality and safety of health care in pediatrics Funded by AHRQ R01 “Improving Pediatric Patient Safety and Quality of Care Using Health IT”

Methods Partners Healthcare System’s Longitudinal Medical Record (LMR) 6 general pediatric practices in Greater Boston, 37 clinicians

Methods Development of templates Collaboration with Partners IS with input from several general pediatricians Guideline-adherent Easy to use Implementation Physician member of the study team visited each practice to introduce the templates

Templates Templates are styled to be used during an office visit When clinician sees a patient with ADHD Obesity Physician retrieves template from pull-down list of available templates Templates use check boxes and free text fields Prompt physicians to follow guidelines Can be used for both diagnosis and treatment

Obesity visit template—CC and HPI

Obesity visit template—Risk factor assessment

Obesity visit template—Exam

Obesity visit template— Assessment and plan

Developing quality measures from these templates Use of the template and check boxes enable the development of quality measures Are accurate Closely reflect care that is actually delivered Are technically easy and inexpensive to measure.

Obesity Recommendation that obese children have weight measured and counseling on exercise and nutrition provided on 2 separate occasions per year

Obesity Claims-based quality measure Were there two visits in the past 12 months with obesity diagnosis included on billing? Was there a claim filed by a specialist?

Obesity Template-based measure Template used with boxes checked for Acknowledgement of weight Counseling on specific nutrition and exercise topics Referral to nutritionist or weight management center

ADHD Recommendation that children with ADHD who are on stimulant medication have follow-up visits with symptom checks at least 2 times per year

ADHD Claims-based measure Electronic prescribing data—Is the patient on a stimulant? Were there two visits in the past 12 months with ADHD diagnosis included on billing? Was there a claim filed by a mental health specialist?

ADHD Template-based measure Template used with boxes checked for Symptom progress Side effects of medication

Claims-based measures Limitations Inaccuracies inherent to billing procedures and claims data Lack of specificity Fails to capture meaningful patient-clinician encounters that are not face-to-face

Additional Quality Measures Using EMR Templates Obesity Counseling on specific topics Follow-up of specific problems Assessment of risk factors/screening labs Referral to nutrition counseling or weight- control centers

ADHD Diagnosis consistent with DSMIV criteria Prescribing long-acting stimulant medication Having teacher and parent evaluations Improvement in symptoms as shown by standardized scale scores Additional Quality Measures Using EMR Templates

Challenge: Getting Physicians to Use Templates For example, range of use of the ADHD template Among subjects exposed to templates, adoption varied widely Increasing physician use of the templates will make the quality measurements more valuable

Frequency of use of ADHD templates by individual clinicians Clinician Number of times template was used by clinician

Potential reasons for varied adoption of the templates Physician factors Style of practice Propensity to uptake new technology Familiarity with EMR Motivation to change current practice around ADHD and obesity

Potential reasons for varied adoption of the templates Practice factors Use of templates by others in the practice External environment Use of template quality measures for pay- for-performance Incentives to use templates

Potential reasons for varied adoption of the templates Template factors Not modifiable Not easy to bring up in the EMR Not much better than the alternative (free text notes or physician’s own template) Implementation process Interaction between key administrators in quality and template development and physicians Time

Conclusions EMR templates with clinical decision support can improve measurement of quality of care for children with chronic conditions. Physician use of these templates is an important barrier.

Thank you John Co, MD, MPH Fabienne Bourgeois, MD, MPH Rainu Kaushal, MD, MPH Eric Poon, MD, MPH Sarah Johnson, BA Meghan Backus, BA