Need and Demand

							“e-indicators” of Ambulatory Care
   Quality: New Paradigms for
 Measuring Clinical Performance
 Using Electronic Health Records

Presented at the Academy Health, Washington DC June 10 2008



         Jonathan P. Weiner, DrPH
         Department of Health Policy & Management
         Johns Hopkins Bloomberg School of Public Health
         jweiner@jhsph.edu
Topics to be discussed:
 • Ideas and paradigms regarding health IT
 (HIT) as applied to ambulatory / population
 based quality performance measurement and
 reporting.
 • Findings from a multi-faceted collaborative
 project to develop electronic health record
 (EHR) based “e-indicators.”
 • Future challenges and opportunities of EHR
 based quality measurement.

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Embracing new HIT capabilities to measure quality in
the ambulatory care sector: The “e-indicator” project
 Goal: To develop innovative measures of quality that take
 advantage of new HIT capabilities and data sources.

 Development effort based at Johns Hopkins and Park Nicollet Institute:
    – Collaboration involving leading edge “wired” integrated delivery
       systems: Park Nicollet (MN), Kaiser Permanente (OR), Geisinger
       (PA), Health Partners (MN) Billings (MT), Dupont/Nemours (DE),
       Boston CHC network (MA).
    – Involves both an “adult” project focusing on chronic illness and a “child
       project” focusing on screening and development
    – Advisors include key quality groups, NCQA, NQF, AMA, Medicare,
       VA, ONCHIT, AHRQ, medical specialty societies
    – Funded by Commonwealth Fund, Robert Wood Johnson, US AHRQ,
       Nemours
    – Methods include lit review, survey of experts & early adopters, case
       study, development of starter-set of “e-indicators”.
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Applications of HIT-based performance
              measures

 • Quality improvement for organizations
    – Real time (safety / care management)
    – Retrospective evaluation


 • “Pay for Performance” (P4P) incentives


 • Community / regional reporting and strategic planning

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HIT will transform performance measurement

  • e-Indicators will be essential tool for:
     – Provider / clinician teams /organizations
     – Health plan / sponsors
     – Government / communities / public health
     – Outcomes researchers / scientists




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          Data sources and types of quality /
                performance measures
                               Type of Measure
Data Source:      Denominator Process Outcome Pt-Cent. Cost


Electronic / HIT
PH records / registry   X
Insurance files         X      X      X               X
EHR                     X      X      X               X
CPOE (order entry)                    X
PHR / Pt. “web portal”         X      X       X
CDSS (clinical support)        X      X

Non-electronic
Paper medical record           X      X
Surveys                               X       X
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      A proposed typology for
 HIT based “e-indicators” of quality

1) Translational: Traditional (e.g., paper record and
claims) measures translated for use on HIT platforms
2) HIT-facilitated: Measures that while not conceptually
limited to HIT, would not otherwise be feasible.
3) HIT-enabled: Measures that generally would not be
possible outside of EMR/EHR context.
4) HIT system management: Measures needed to
implement, manage and evaluate HIT systems
5) “e-iatrogenesis”: Measures of patient harm caused
at least in part by application of HIT.
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Examples of each type of e-indicator
1) Translational:
   -   Computerization of existing HEDIS measures

2) HIT-facilitated:
   -   % of children > BMI of x receiving intervention
   -   % of patients with e-prescriptions who did not pick up their
       Rx within x days
   -   % of clinicians reviewing and responding to abnormal lab
       value with x hours
3) HIT-enabled:
   -   % of consumer generated web-based shared care plans
       accessed by both generalist & specialists within 6 months
   -   % of in scope care that is routed through CDSS supported
       workflow algorithm
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Examples of each type of e-indicator -
               cont.
4) HIT system management:
   - Attainment of EHR interoperability targets
   - % of CDSS alerts ignored by clinicians
   - % of allergy lists updated by patient annually
5) e-iatrogenesis:
   - % of e-prescriptions that result in wrong drug
   - % of patients needlessly exposed to imaging
   radiation due to inappropriate use of CDSS module


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Broad observations re EHRs and quality
  • The needs of quality measurement have not been
  adequately addressed by most current EHR / HIT
  systems.
  • The most useful quality measures will be hard-wired
  into HIT “workflow” or “streamed” automatically.
  • Integration of real-time clinical decision support and
  provider order entry (e.g., e-prescribing) represent a
  major paradigm shift for quality measurement.
  • To date, wired organizations have replicated paper
  records and claims data methods and approaches.
  • Outside of IDSs, e-indicators at person and
  population level are not feasible without EHRs
  “interoperability.”
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Advantages of EHR based measures
• Data elements that are “streamed” or part of structured
e-workflows are likely to be most accurate.
• 100% electronic census will reduce bias associated with
sampled chart reviews and surveys.
• Abstraction errors due to poor handwriting will be
eliminated.
• There are rich new sources of information in the domains
of time and information flow.




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Challenges of EHR based measures
• The process of entering, transferring, archiving, and
analyzing EHR data introduce numerous opportunities for
inaccuracy.
• There are new types of errors associated with provider
behaviors (e.g., cut and paste “plagiarizing.”)
• CDSS or workflow algorithms can introduce and
perpetuate measurement errors by systematizing them.
• For foreseeable future, analysis of free-text section of EHR
will be fraught with difficulty.



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Some recommendations moving forward
• Quality measurement must be part of workflow and HIT
system design from the start.
• We need to develop a better understanding of how new
paradigms and data sources affect reliability and validity.
• For foreseeable future HIT “systems management”
indicators should be central part of IT CQI process.
• EHR / HIT systems offer great opportunities for population
and person based measures (moving beyond those that are
provider or patient based).
• Although there will likely be considerable positive benefit,
we must learn how to measure and monitor “e-iatrogenesis”

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Further information / Acknowledgements


   If you wish to receive copies of our project
   manuscripts please give me your card or send
   me an e-mail at jweiner@jhsph.edu


   I would like to acknowledge co-authors of this
   paper:
     – Jinnet Fowles
     – Kitty Chan
     – Betsy Kind
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