The Journal - September 2019
Tex Med. 2019;115(9):e1.
Richard C. Howe, PhD1; Matt Murray, MD2; Sushma Sharma, PhD3
1Howe Consulting Group, Irving, Texas
2Cook Children’s Health Care System, Fort Worth, Texas
3Dallas-Fort-Worth Hospital Council Research and Education Foundation, Irving, Texas
Corresponding Author: Richard Howe firstname.lastname@example.org
Mailing Address: 917 Talbot Trail, Colleyville, TX 76034, Phone: 214-226-3394
The prevalence of diabetes mellitus, which affects 30.3 million adults in the United States, is increasing with 1.5 million newly diagnosed cases of diabetes each year. An additional 84 million adults are affected by prediabetes. Consequently, this chronic disease has become the seventh leading cause of death in our nation.1 Statistics like these have caused the Centers for Medicare & Medicaid Services (CMS) and state health departments to encourage primary care physicians to not only adopt electronic health records (EHRs) but to use them more effectively to improve management of diabetes and other chronic diseases. This paper discusses how small physician practices in North Texas improved their tracking of quality metrics for hypertension, obesity, and diabetes by leveraging available but underused EHR functionalities. We also describe five “best practices” for more effective use of ambulatory EHRs to manage chronic disease based on findings in this study.
Pilot Project for More Effective EHR Use to Manage Chronic Diseases
In 2015 the Texas Department of State Health Services (DSHS) contracted with the Dallas Fort Worth Hospital Council Education and Research Foundation (the Foundation) to perform a pilot study with small physician groups for the purpose of helping them more effectively use their EHRs to manage patients with hypertension, obesity, and diabetes.2 The scope of work included recruitment of 9 small physician practices, deployment of consultants, development of survey tools used by consultants to collect and track project data, collection of baseline patient population data (benchmark quality metrics) by each practice, creation of 32 quality intervention strategies by consultants, implementation of a few interventions in each practice, and quarterly collection and analysis of post-intervention quality improvement metrics.
The Foundation provided a consulting group of health Internet Technology (IT) experts to each physician practice. These consultants were already highly experienced with small physician practices as they were the same experts hired by the North Texas Regional Extension Center from 2011-2015, who helped more than 1,300 North Texas physicians achieve Meaningful Use. The consultants helped each practice develop and use its EHR to create reports that could track quality metrics for hypertension (NQF18), obesity, and diabetes (NQF59) across their patient populations. They instructed each practice to select only a few of the 32 intervention strategies based on what the physicians thought best fit the unique needs of their practice and patient population. They then helped practices learn how to use their EHR to collect and analyze pre-intervention and post-intervention quality data on a quarterly basis. During this process, they specifically helped each practice learn about advanced features of its EHRs and how best to leverage them to streamline the collection of data and implement their selected intervention strategies. These advanced features included reporting tools, streamlined documentation templates to more easily collect data, clinical decision support tools, and other EHR functionalities that previously were either underused or not being used at all.
At the beginning of the pilot project, most of the practices were using their EHR primarily for clinical documentation and billing. By showing the practitioners how to use their EHR to collect, analyze, and develop reports on clinical measures related to hypertension, obesity, and diabetes, the practices improved their ability to accurately track quality metrics for these chronic diseases across their patient populations. This in turn enabled them to select and implement interventions designed to improve their quality results.
Key results of this pilot project are as follows: 90.1% of the practices are now able to report on hypertension (NQF 18), up from 66% at the start of the project; 96.4% of the practices are now able to report on diabetes (NQF 59), up from 87.5% at the start of the project; 54.0% of the practices are now able to report on prediabetes, up from 50% at the start of the project; and 53.64% of the practices now record overweight and obese patients, up from 44.31% at the start of the project.
Figure 1 shows a summary of key findings from the earlier DSHS study. Full study results have been published recently in the Texas Public Health Journal.3
The expectation that EHRs would provide value by improving quality of care has not been broadly realized, especially in small physician practices. Many reasons for this include the lack of interoperability between EHRs and basic usability issues. However, this pilot project reveals that one avoidable impediment to gaining value from EHRs is the lack of familiarity many physicians have with advanced features of their EHRs. Before this pilot project, none of the pilot physician practices were using advanced features of their EHRs to their full potential. In some cases, the physicians told the consultants that they did not even know their EHRs had the capabilities they are now using.
This lack of familiarity is not uncommon and is not limited to small physician practices. During an expensive and difficult EHR implementation, physicians are inclined to focus on the clinical and operational functions that are vital to their day-to-day practice activities. As a result, EHRs are typically implemented with careful attention to the basic functions for front desk administration, clinical documentation of patient encounters, and back desk/billing operations. More advanced clinical EHR features are commonly not fully used and perhaps not implemented at all. When extensive work is necessary to configure an advanced function during an EHR implementation, a practice may decide to defer that work to another time. But finding time later becomes challenging. Furthermore, based on our experience in the pilot project, we believe some practices did not actually receive the training necessary to understand the value of certain EHR features or how best to configure and use them.
Throughout this pilot study, the Foundation’s health IT consultants visited each practice on a quarterly basis. They initially observed how each practice used its EHR during patient encounters and then observed how various new approaches helped each practice more effectively use its EHR to manage chronic disease population. Based on observations over the past 3 years, we developed the following list of “best practices” aimed at small physician practices with limited resources to more effectively use their EHRs for chronic disease management. These principles can also be extrapolated to large practices that, despite having more resources, face similar challenges.
Five Best Practices for More Effective EHR Use for Chronic Disease Management
- Understand the capabilities of your EHR
At the beginning of this pilot project, most of the practices were using their EHRs for clinical documentation and billing. By showing the practices how to collect, analyze, and develop reports that were focused on quality measures related to hypertension, obesity, and diabetes, the practices began to track these disease conditions across their patient populations. With benchmark data in hand, the practices selected interventions designed to improve on their baseline results.3
It is not unusual for small and rural practices to be under-users of EHR technology as compared with larger, more urban counterparts.4 These small practices are particularly more sensitive to financial and human resource barriers associated with demands of EHR adoption, optimization, and maintenance.
A solo practice from a small rural town in Iowa was honored in 2007 with the Nicholas E. Davies Award of Excellence for outstanding use of ambulatory EHRs to improve quality of care and achieve positive financial returns on investment.5 In this Davies Award case study, the lead physician noted that during the first 3 years using the EHR, the practice had failed to see any clinical value despite an exemplary EHR implementation from a technical perspective. In fact, after implementation the practice remained bogged down by residual paper-based processes. The lead physician eventually came to recognize that his practice had initially implemented the EHR on top of inefficient paper-based processes. The EHR was used, in essence, as if it were a paper chart. It was decided to address this first by developing a set of clinical and business goals for the practice. Extensive analysis of the practice was then performed to identify impediments to these goals. Workflow analyses were performed to identify the most troublesome clinical and operational bottlenecks in the office. The practice also learned more about the EHR’s advanced capabilities, especially those that could relieve those bottlenecks. They then began implementing more advanced features of the EHR along with redesigned clinical and operational workflows to replace inefficient paper-based work flows. Finally, the practice began using EHR capabilities that allowed it to track quality metrics and make incremental improvements to patient care.
Similarly, our consultants helped the pilot practices identify their quality goals, learn about their EHR’s capabilities, and then use those capabilities to track chronic disease quality metrics and create interventions aimed at improving those metrics. In this process, the EHR vendors were consulted to help determine which EHR tools to use and how best to use them. Vendor user conferences are another useful way for physician practices to learn about their EHR’s advanced capabilities. These events provide an opportunity to learn not only from the vendor but from other physician practices who use the same EHR.6
In summary, the implementation and use of an EHR clearly does not automatically lead to clinical value. Our pilot project highlights the need for physicians to understand more fully the capabilities of their EHRs, including reporting tools and clinical decision support tools, and to learn how best to leverage those tools to improve work flow and quality of care.
- Foster a culture that embraces change and continual quality improvement
In the pilot project, the consultants guided each practice through a standard set of activities that enabled the practitioners to track hypertension, obesity, and diabetes quality metrics. We have grouped these activities into the following generalized process:
- Set up disease-specific quality metrics reports for the practice’s patient population to identify top chronic diseases. The metrics could be derived from quality indicators under the Merit-based Incentive Payment System (MIPS), which combines part of the Physician Quality Reporting System (PQRS), the value modifier, and the Medicare electronic medical record incentive system (old Meaningful Use) into a single program.
- Use these reports to sort and analyze patients by severity level for the selected chronic disease indicators.
- Develop patient-specific plans for those patients identified by these reports who may benefit from a change in management.
- Run quality reports at least monthly.
- Use the EHR to track and manage follow-up activities on each patient.
These steps essentially follow the PDSA cycle (Plan-Do-Study-Act), also known as the Deming Cycle, which is a circular principle that uses a “trial and learn” process. See Figure 2. “Plan” is the first action in a cycle, followed by “Doing” something and then “Studying” the results. At the end of this process, the user is to “Act” on what is found. This action leads back to a “Plan” for the second cycle. Thus, the PDSA cycle is designed to maintain a continual effort to improve. It has become a popular model for quality improvement in health care as advocated by the Institute for Healthcare Improvement.7 This model also helps to avoid the tendency to “stop” after achieving one goal.
Adhering to a standard process like the PDSA cycle is important, but our consultants nevertheless observed that the most successful practices had physician leaders who could nurture an office culture that embraced change and strove for continual improvements. One example of the antithesis to “acceptance of the status quo” is Village Health Partners, a nationally recognized family medicine practice that provides preventative care, chronic disease management, and other services at multiple locations in Plano, Texas. Village Health Partners was not part of this project. Instead, they were honored nationally in 2007 with the Nicholas E. Davies Award of Excellence.8 In their award case study, they describe how, after their initial EHR implementation, the physicians and staff continued to meet regularly as a team to discuss ways to improve care. The culture of their practice changed from one of inertia to one driven by efforts to continually change and improve. The physician leadership states that this cultural change was a key factor enabling them to more successfully use their EHR.
- Focus on a few quality improvement activities most relevant to your practice
Most of the physicians in this pilot project could name, off the top of their heads, the patients who have the overall poorest health in their practice. However, when asked to rank their patients by a chronic clinical indicator measure such as NQF18 (hypertension), most practices could not do that. Before this pilot project, none of the practices were regularly using their EHR to proactively identify patients who might benefit from more aggressive management or monitoring.
In this pilot project, each practice learned to run reports on chronic disease quality metrics for the purpose of identifying patients most at risk. Each practice was offered a menu of 32 different intervention activities to apply to its selected group of higher-risk patients. But physicians were encouraged to select only a few of these interventions and to base them on the unique aspects of their own practices. This allowed them to focus on the interventions that they felt were most likely to result in actual benefits to patient care in their practice.
The most commonly selected interventions involved several key activities. The first major activity chosen was training staff and physicians on some of the basic quality metrics reporting routines. Another common intervention was training staff on basic and advanced EHR functions and work flows to allow them to enter data during each patient visit where applicable (e.g., blood pressure, BMI, and HbA1c levels) and to do so in the most streamlined manner. A third activity selected was making changes to their EHR documentation templates and clinical work flow to add data collection fields (i.e., chronic disease quality indicators) that could be entered within the natural work flow of a patient encounter. Related to that activity was a fourth intervention that involved redesigning clinical workflows to make sure that the basic chronic disease data are collected for all patients (e.g., BMI, BP, HbA1c, and blood glucose level). A final common intervention chosen was encouraging patients’ self-management of their own health.
Use technology to enhance the patient-physician relationship
Several articles in the literature describe how technology gets in the way of the patient-provider relationship. A recent article by Pelland et al. found that while EHR use may reduce medical errors, the technology is also shown to complicate the patient-provider relationship.9
However, some practices have successfully implemented an EHR and demonstrated improvements in quality of patient care, improved operations, reduced administrative burdens, and improved financials; the annual ambulatory Davies Award winners share their stories of success each year.10
We noticed that the physicians in this pilot project who were the most knowledgeable about their EHR and most proficient at using them in front of patients seemed to have the best doctor-patient relationships. Although this is a subjective observation and represents a small sample size of practices, we also reviewed the case studies of Davies Award winners who had demonstrated successful implementations and use of EHRs. Based on our observations and reviews, we developed a set of principles to follow regarding how best to use technology to enhance the doctor-patient relationship.
Doctor-patient relationships are enhanced when physicians do the following:
- Demonstrate knowledge and comfort while using the EHR in front of anyone – whether patient, staff, or another provider.
- Focus on the patient’s face and conversation rather than on the computer screen (one strategy involves positioning the screen to the side, another involves shifting some of the documentation entry to outside the patient room).
- Engage patients by turning the monitor toward them to discuss results displayed in the EHR or asking them review and verify certain information in their record.
- Provide patients a printed visit summary and educational materials at the completion of the visit, especially for patients who are not adept at accessing a patient portal from home.
- Implement a patient portal that gives interested patients easy access to medical record data such as immunization records and patient education materials.
The key to enhancing the patient-provider relationship is not so much about the EHR system itself as how the physician and practice use technology to “relate” with patients during and after office encounters.
- Ongoing EHR training, training, training
We have included “EHR Training” as a best practice because inadequate EHR training clearly was an obstacle for our pilot practices. Furthermore, the lack of adequate training has been cited in many studies on EHR use. In one recent national study, 73% of practices were found to be failing to use their EHR to its full capability. These “under-user” practices were more likely to be smaller, situated in the West, and located outside a metropolitan area.4 In a review of Davies Award case studies from the past two decades, we find a running theme of concerns about inadequate EHR training. Many of these award-winning practices cited inadequate training as a major impediment to successful use of an EHR.6
The risk of inadequate training at the time of an EHR implementation is a key factor to understand so that efforts can be made to avoid this issue. Inadequate initial EHR training in our pilot practices is likely one reason advanced capabilities of the EHRs were underused.
But the need of ongoing training also emerged as a top priority for the physician practices. This included training not only on EHR use but on nontechnical aspects of the quality improvement activities. This is illustrated in Table 1 by the 18 intervention activities across the 5 key categories that were selected by the pilot practices over the course of the 3-year study. Interventions from the “EHR Training” category comprised half (8) of the interventions selected.3 Examples of those selected interventions were “train staff how to run reports” and “train staff how to flag patients for follow up on specific patient measurements.” The quality improvement interventions developed by the practices to address a specific chronic disease typically required training on both technical and nontechnical aspects of data collection and reporting. The selection of interventions that involved training is not surprising to those who frequently engage in PDSA projects; “inadequate training” is often identified as an issue during the “Study” part of the cycle, with “retraining” subsequently being the next “Act”.
In summary, ongoing training is necessary to use EHRs more effectively for chronic disease management. Retraining is needed when new technical functions and features become available and when work flow changes. Ongoing training will more likely allow a practice to use their ’s maximum potential.
The key goal of this pilot project was to help small physician practices more effectively use their EHRs to manage patients with chronic diseases. Quality metrics for hypertension, obesity and diabetes were used as the primary focus. At the beginning of this project, most of the practices were using basic functions of their EHR for clinical documentation and billing. Without knowledge or use of the more advanced EHR tools, the physicians in these practices either had difficulty accurately tracking quality metrics or did not know how to do so at all. We intervened with consulting services to provide knowledge on how to use advanced capabilities of their EHR along with EHR-related operational work flow changes to streamline processes. By the end of the project all of the pilot practices improved their ability to accurately collect, analyze, and develop reports on the clinical measures being studied. As a result, this has helped the pilot practices migrate toward a more evidence-based approach to chronic disease management.
The authors are grateful to the Texas Department of State Health Services for awarding this contract to the Dallas Fort Worth Hospital Council Foundation (DFWHCF) via a Centers for Disease Control and Prevention funded grant (contract Number 2015-047945-002B, 2015). We are thankful to physician practices for their participation in this study and hard work. We gratefully acknowledge the support and guidance of DFWHCF President Kristin Jenkins.
None of the authors report any conflicts of interest.
- American Diabetes Association. www.diabetes.org/diabetes-basics/statistics/. Accessed August 22, 2018.
- DSHS. Texas Department of State Health Services (DSHS) contract with the Dallas Fort Worth Hospital Council Foundation (DFWHCF) via a Centers for Disease Control and Prevention (CDC) funded grant. Contract Number 2015-047945-002B, 2015.
- Howe RC, Sharma S, Murray M. Practice Intervention activities to improve population health: A case study using electronic health records (EHR) for chronic disease management. Texas Public Health Journal. Winter 2019; 71(1):24-30.
- Rumball-Smith J, Shekelle P, Damberg CL. Electronic Health Record "Super-Users" and "Under-Users" in Ambulatory Care Practices. American Journal of Managed Care. 2018; 24(1):26-31.
- HIMSS Ambulatory Davies Award Recipients. Available at: https://www.himss.org/james-f-holsinger-md-pc-davies-ambulatory-award. Accessed August 21, 2018.
- Murray, M. Gaining the best value from your EHR. The Reporter. December 2015; 5:4-26.
- Institute for Healthcare Improvement. Plan-Do-Study-Act. http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx . Accessed August 22, 2018.
- Village Health Partners (formerly Family Medical Specialists of Texas) - Davies Ambulatory Award. Available at: http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=27360.Accessed August 21, 2018.
- Pelland, KD, Baier, RR, Gardner, RL. It is like texting at the dinner table: a qualitative analysis of the impact of electronic health records on patient–physician interaction in hospitals. J Innov Health Inform. 2017; 24(2):216–223.
- HIMSS Ambulatory Davies Award Recipients. Available at: https://www.himss.org/himss-ambulatory-davies-award-recipients. Accessed August 21, 2018.