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Transforming EMRs from Data Repositories to Tools for Quality Improvement BY ANDREW URY, M.D.

recently received top rankings for the third consecutive year in the AC Group 2006 Report, is responsible for the collection and storage of data provided by participating physicians. PPRNET WAS THE FIRST PRACTICE-BASED RESEARCH NETWORK LINKING PHYSICIANS USING EMRs.

P

hysicians participating in practice-based research projects through the Practice Partner Research Network (PPRNet) have undergone a dramatic paradigm shift in terms of how they view and use their electronic medical records (EMRs), a transformation that has pushed the boundaries of these systems beyond daily documentation and routine patient care to encompass clinical outcomes. What these physicians have found is that EMRs are far more than information repositories; the data and tools they contain can play a critical role in improving the quality of care, improvements that can be quantified. 38

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Measuring the Premise PPRNet was formed in May 1995 as a joint effort between the Department of Family Medicine at the Medical University of South Carolina (MUSC) and Practice Partner, a Seattle-based developer of electronic health records (EHRs) and practice management software. A pioneering concept in practicebased quality improvement and research, PPRNet was the first practice-based research network linking physicians using EMRs. MUSC is primarily responsible for the management of the network and, together with the PPRNet advisory board, designs and initiates research projects. Practice Partner, which

Since 1995, PPRNet’s longitudinal patient database has increased to 116 practices representing more than 570 physicians and 1.8 million patients in 38 states. Participating practices range in size from sole practitioners (13 percent) to groups of 10 or more physicians (8 percent). The majority (40 percent) are practices with two or three physicians. Specialties of participating practices include family medicine (78 percent), internal medicine (18 percent), and multispecialty primary care (4 percent). The geographic distribution of PPRNet practices mimics that of the general U.S. population: 64 percent are located in urban areas, 10 percent in suburban areas, 9 percent in large towns, and 17 percent in small towns or rural settings. Participating practices, all of which utilize Practice Partner Patient Records, run a simple utility to extract data from their EMRs and send it to PPRNet. Using the same EMR enables the participating practices to uniformly extract the data for evaluation, including demographic information, diagnoses, medications, laboratory results, and vital signs. Progress notes, consultation reports, MARCH 2007


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Obesity and discharge summaries are not included. In turn, PPRNet provides practices with quarterly reports showing performance on 83 care indicators, including cardiovascular disease, diabetes, cancer screening, immunization, respiratory illness, mental health, nutrition/obesity, and medication use in the elderly. During PPRNet’s Accelerating Translation of Research into Practice (ATRIP) project, which was completed in September 2006, practices that were randomized into the intervention arm of the study also met quarterly with a member of MUSC’s Family Medicine faculty. In all, faculty completed 198 site visits for the ATRIP project. At these meetings, faculty reported on the practice’s quarterly performance on the clinical indicators as compared with its peers within the study and with national benchmarks. The national benchmarks were derived from published sources, such as the annual national quality report from the Agency for Healthcare Research and Quality and from the Centers for Disease Control (CDC Wonder). Pertinent updates to the science behind the clinical markers were also presented when available. In addition to performance measures, practices have found many uses for the quarterly reports, including as a tool for monitoring/enhancing the provision of preventative care and even for calculating bonuses. This, in turn, has expanded the use of the EMR to help foster changes in behaviors that lead to quality improvements. Seeing Is Believing Plymouth Family Physicians, a two-physician practice in Plymouth, Wisconsin, first learned of PPRNet a decade ago when they were shopping for an EMR. Once their system was up and running, they joined MARCH 2007

PPRNet and volunteered to participate in the Translating Research into Practice (TRIP) study as well as its successor, ATRIP. THE IDEA OF USING AN EMR TO MEASURE AND IMPROVE QUALITY WAS A NATURAL EXTENSION OF THE TECHNOLOGY.

As an intervention site, Plymouth Family Physicians met quarterly with MUSC faculty to review its performance. Visiting faculty offered suggestions, described changes that other practices had made, and encouraged Plymouth to go beyond the ATRIP model of optimal practice. “It was an organization-wide effort,” said Plymouth’s George Schroeder, M.D. “Each quarter, we would close our office for several hours and gather our entire staff to review our results. After surveying the performance reports, we would brainstorm ways to improve our performance and then set specific goals and strategies for the next quarter. This routine has since become a discipline that has transformed our practice.” According to Schroeder, participation in PPRNet required the practice to do several things they had not done previously, including documenting care in a readily retrievable manner, utilizing quarterly audits to continuously evaluate the care provided, and establishing expectations for achieving and exceeding proven standards of care on every audited item. “As logical as these steps seem, we would not have made these changes outside the supportive environment of PPRNet, which provided us with the clinical goals and audits we needed to measure performance and achieve outcomes,” Schroeder said. “The bottom line was achieving the established clinical endpoints, and we utilized whatever means necessary to convince our patients to accept indicated immunizations, have their lipids measured, GROUP PRACTICE JOURNAL

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or take yet another medication to control their blood pressure.” Family Practice Partners, a fourphysician family medicine practice in Murfreesboro, Tennessee, is another prime example of the transformation that has taken place among PPRNet participants. The practice originally implemented its EMR as a way to save money and improve workflow efficiencies. “A secondary thought was that we could do a better job,” said Susan Andrews, M.D. “But that was secondary. We were really thinking about the business end.” Andrews and her partners learned about PPRNet at a user meeting held by the group’s EMR vendor and decided to join, thinking participation would be fairly easy and could potentially benefit their patients. They quickly found the potential exceeded initial expectations. “There was a realization when we got that first practice performance report that we weren’t doing the job we wanted to do,” Andrews said. “This motivated us to use EMR features and change workflow. We saw huge gains in quality in later reports. PPRNet impacts almost everything we do as far as quality goes.” For example, providers now make extensive use of the disease management and health maintenance tools within their EMR to track care and generate reminders when things such as flu shots or mammograms are due. “It’s so easy that we now do it at every visit. It’s not something we save for a physical exam,” said Andrews. “If you’ve got a paper chart or an EMR that doesn’t have that feature, you won’t go digging for the information because it just takes too long.” Michael Hennigan, M.D., FACP, a solo practitioner who runs the Diabetes & Lipid Center in Decatur, Alabama, also joined PPRNet after attending a vendorsponsored user meeting. For him, 40

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the idea of using an EMR to measure and improve quality was a natural extension of the technology.“I have been an early adopter all my life and have been on the Board of the QIO/PRO for Alabama since 1993, so I’ve been indoctrinated on the need for system-wide quality improvement. Along with that, I am aware of the cost and inefficiencies in a typical physician’s office,” Hennigan said. For Hennigan, the role an EMR could play in quality improvement crystallized while attending an Alabama Quality Assurance Foundation board meeting. The group was discussing the database which the QIO had amassed and the possibilities that existed for using that data beyond what was called for in their federal contract. “I realized we were sitting on our own database that currently holds more than 4,000 patients and that there were so many possibilities with that data, most as of yet unfulfilled,” he said. Among the most dramatic examples of the power of utilizing an EMR for quality improvement is that of the 1,000 diabetics whom Hennigan treats, 90 percent now have HgbA1Cs below 7. The practice has also expanded its use of the tools within its EMR based on its PPRNet experiences to include implementation of an onsite employee screening and treatment project for one local company; it has been asked to consult with another. Moving Beyond PPRNet While PPRNet participants utilize the same EMR system, the lessons learned and quality improvements realized are applicable to all physician practices. First, ensure that any data entered into the system is clean and processes are standardized. Then implement internal quality measures by selecting indicators and following them over

time to determine how well the practice is adhering to commonly accepted guidelines. Practices participating in PPRNet can easily observe and measure the effectiveness of any changes in procedures and workflow. The quarterly PPRNet reports clearly show whether the changes have made a statistically significant difference in quality. Andrews stated it best: “We might all be brilliant doctors, and we all have the best of intentions with every patient we see, but if we don’t know our actual numbers, we can’t know how well we’re really doing. Most of us will find we’re not in the top 10 percent; 90 percent of us aren’t, but 90 percent of us want to be. If you give us the information, and you give us a way to work on improving, we will improve. That can’t be done with a paper record.” In summary, by focusing on fully utilizing an EMR to not only streamline processes and improve workflow but to measure performance and improve quality, we will ultimately achieve improved outcomes and quality. Andrew Ury, M.D., is the founder and CEO of Practice Partner. Since founding the Seattle-based company in 1983, he has remained actively involved in all aspects of the development cycle. Dr. Ury currently serves as a Commissioner on the Certification Commission for Healthcare Information Technology (CCHIT) and on the HL7 Electronic Health Records Standards Technical Committee. He recently completed his elected term as co-chair of the HIMSS Electronic Health Record Vendors Association.

MARCH 2007


Transforming EMRs from Data Repositories to Tools for Quality Improvement