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Report from Premier Conference

June 9, 2010
by David Raths
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Unintended consequences of EHR on quality reporting

One of the disquieting aspects of rolling out an electronic health record (EHR) is that it can initially have a negative impact on the reporting of quality measures. Processes that were paper-based may not easily translate to the electronic environment and can fall by the wayside, impacting chart abstraction.

At the Premier Breakthroughs conference in Washington, D.C., on June 9, clinical quality leaders from the 12-hospital Texas Health Resources (THR) described the unintended consequences of its Epic implementation on reporting core measures and some of the strategies it used to overcome disruptions to clinical workflow and quality reporting. (Owned by more than 2,000 hospitals and health systems, the Charlotte, N.C.-based Premier alliance shares knowledge on group contracting and clinical quality improvement. A significant number of the sessions at its annual conference focus on data-driven clinical practice.) Texas Health Resources kicked off a lively session with a description of its efforts to tie core quality measures to its EHR efforts. After seeing several of its core measure scores fall off after the Epic rollout, THR created collaborative interdisciplinary work teams to focus on ways Epic could be used to remind clinicians of evidence-based procedures, said Christy Benson, director of clinical informatics analysis.

Many reports can be automatically pulled from Epic, saving abstractors time, Benson said, but her organization also found that it needed to modify Epic to accommodate work flows, such as creating checklists and a Sticky Note feature to replicate the former paper-based process. Concurrent care reviewers can now leave notes for clinicians reminding them to follow best practices. The THR system features "hard stops" that do not allow nurses to print discharge instructions unless pneumonia/influenza vaccination practices have been followed. Problem lists are another aspect of the EHR the organization had struggled with, according to Ferdinand Velasco, M.D., chief medical information officer at THR. Although the problem lists improve clinician communication, trigger relevant clinical decision support and facilitate quality reporting, THR had difficulty getting physicians to enter data into them. "We launched a pilot project to allow nurses to document on the problem list based on physician documentation elsewhere in the chart," Velasco said, noting that it has dramatically improved the value of the problem list in those hospitals. The process is now being rolled out to all 12 hospitals. All of these efforts have led to improvements in performance, Velasco said. "A lot of the change is cultural," he added. "It’s about a collaborative approach to the EHR and remembering that the EHR implementation is dynamic, so you have to keep the users engaged."