Performance Measures Using Electronic Health Records: Five Case Studies

Presents the experiences of five provider organizations in developing, testing, and implementing four types of electronic quality-of-care indicators based on EHR data. Discusses challenges, and compares results with those from traditional indicators

Accuracy of medical billing data against the electronic health record in the measurement of colorectal cancer screening rates.

ObjectiveMedical billing data are an attractive source of secondary analysis because of their ease of use and potential to answer population-health questions with statistical power. Although these datasets have known susceptibilities to biases, the degree to which they can distort the assessment of quality measures such as colorectal cancer screening rates are not widely appreciated, nor are their causes and possible solutions.MethodsUsing a billing code database derived from our institution's electronic health records, we estimated the colorectal cancer screening rate of average-risk patients aged 50-74 years seen in primary care or gastroenterology clinic in 2016-2017. 200 records (150 unscreened, 50 screened) were sampled to quantify the accuracy against manual review.ResultsOut of 4611 patients, an analysis of billing data suggested a 61% screening rate, an estimate that matches the estimate by the Centers for Disease Control. Manual review revealed a positive predictive value of 96% (86%-100%), negative predictive value of 21% (15%-29%) and a corrected screening rate of 85% (81%-90%). Most false negatives occurred due to examinations performed outside the scope of the database-both within and outside of our institution-but 21% of false negatives fell within the database's scope. False positives occurred due to incomplete examinations and inadequate bowel preparation. Reasons for screening failure include ordered but incomplete examinations (48%), lack of or incorrect documentation by primary care (29%) including incorrect screening intervals (13%) and patients declining screening (13%).ConclusionsBilling databases are prone to substantial bias that may go undetected even in the presence of confirmatory external estimates. Caution is recommended when performing population-level inference from these data. We propose several solutions to improve the use of these data for the assessment of healthcare quality

Using Smartphone Technology to Enhance Self-Management Support in Adults with Type 2 Diabetes in Primary Care

Background: Self-care is a crucial component in the management of Type 2 Diabetes Mellitus (T2DM). The literature shows that frequent feedback on blood sugar recordings together with reminders can lead to improvements in patient’s glucose control and diabetic self-care. The Chronic Care Model developed by Wagner emphasizes the importance of patient participation in the management of their chronic diseases. Purpose: To explore the possibility of using smartphone technology to help adults with T2DM better manage this chronic disease in a primary care clinic in New England. Methods: A smartphone application (App) OnTrack Diabetes (OnTrack) and text messaging were used to enhance communication between the patient and the provider. After receiving facility and IRB waivers, participants were recruited and trained on the downloaded App. Data was generated through text messages, the App and DNP student journaling, which was evaluated for patient and provider satisfaction with the App. Results: This project lasted about five months with five out of the seven participants recruited actually completing the project. Many (60%) of the participants found the App useful, 80% followed through with the instructions in the text messages and 60% intend to continue to use the App. Three out of five providers liked the App and intend to continue to use it. Most (80%) of the participants noticed a decrease in blood sugar, hemoglobin A1C and weight. Conclusion: This project confirms that an App and text messaging may be a useful tool for primary care providers to enhance self management in patients with T2DM and that frequent communication with the patient in between face to face office visits keeps them engaged and more compliant with diabetes management

Design and introduction of a quality of life assessment and practice support system: perspectives from palliative care settings

Background: Quality of life (QOL) assessment instruments, including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs), are increasingly promoted as a means of enabling clinicians to enhance person-centered care. However, integration of these instruments into palliative care clinical practice has been inconsistent. This study focused on the design of an electronic Quality of Life and Practice Support System (QPSS) prototype and its initial use in palliative inpatient and home care settings. Our objectives were to ascertain desired features of a QPSS prototype and the experiences of clinicians, patients, and family caregivers in regard to the initial introduction of a QPSS in palliative care, interpreting them in context. Methods: We applied an integrated knowledge translation approach in two stages by engaging a total of 71 clinicians, 18 patients, and 17 family caregivers in palliative inpatient and home care settings. Data for Stage I were collected via 12 focus groups with clinicians to ascertain desirable features of a QPSS. Stage II involved 5 focus groups and 24 interviews with clinicians and 35 interviews with patients or family caregivers during initial implementation of a QPSS. The focus groups and interviews were recorded, transcribed, and analyzed using the qualitative methodology of interpretive description. Results: Desirable features focused on hardware (lightweight, durable, and easy to disinfect), software (simple, user-friendly interface, multi-linguistic, integration with e-health systems), and choice of assessment instruments that would facilitate a holistic assessment. Although patient and family caregiver participants were predominantly enthusiastic, clinicians expressed a mixture of enthusiasm, receptivity, and concern regarding the use of a QPSS. The analyses revealed important contextual considerations, including: (a) logistical, technical, and aesthetic considerations regarding the QPSS as a technology, (b) diversity in knowledge, skills, and attitudes of clinicians, patients, and family caregivers regarding the integration of electronic QOL assessments in care, and (c) the need to understand organizational context and priorities in using QOL assessment data. Conclusion: The process of designing and integrating a QPSS in palliative care for patients with life-limiting conditions and their family caregivers is complex and requires extensive consultation with clinicians, administrators, patients, and family caregivers to inform successful implementation

Primary health care for Aboriginal and Torres Strait Islander children

This final report presents the findings from each of the phases of the Engaging Stakeholders in Identifying Priority Evidence-Practice Gaps and Strategies for Improvement in Primary Health Care (ESP) Project. This report is designed for people working in a range of roles including national and jurisdictional policy makers, managers, community-controlled organisations and government health authorities, peak bodies, clinical leaders, researchers, primary health care staff and continuous quality improvement (CQI) practitioners who may have an interest in the interpretation and use of aggregated CQI data to drive decision making. Stakeholders across services and systems that deliver Aboriginal and Torres Strait Islander primary health care (PHC) engaged in a process to analyse and interpret national continuous quality improvement (CQI) data from 132 health centres. We used a consensus process to identify priority evidence-practice gaps in child health care, based on these data. Stakeholders drew on their knowledge and experience working in Aboriginal and Torres Strait Islander PHC to identify barriers and enablers to addressing the priority evidence- practice gaps, and to suggest strategies to overcome barriers and strengthen enablers to addressing the priority evidence-practice gaps. Important messages emerge from these findings

Application of Smartphone Technology in the Management and Treatment of Mental Illnesses

Abstract: Background: Mental illness continues to be a significant Public Health problem and the innovative use of technology to improve the treatment of mental illnesses holds great public health relevance. Over the past decade telecommunications technology has been used to increase access to and improve the quality of mental health care. There is current evidence that the use of landline and cellular telephones, computer-assisted therapy, and videoconferencing can be effective in improving treatment outcomes. Smartphones, as the newest development in communications technology, offer a new opportunity to improve mental health care through their versatile nature to perform a variety of functions. Methods: A critical literature review was performed to examine the potential of smartphones to increase access to mental health care, reduce barriers to care, and improve patient treatment outcomes. The review was performed by searching several electronic databases using a combination of keywords related to smartphones and mental health interventions using mobile devices. Literature concerning the use of cell phones, handheld computers, and smartphones to improve access to mental health care and improve treatment outcomes was identified.Results: The majority of studies identified were feasibility and pilot studies on patients with a variety of diagnosed mental illnesses using cell phones and PDAs. Authors report that most study participants, with some exceptions, were capable of using a mobile device and found them acceptable to use. Few studies extensively measured treatment outcomes and instead reported preliminary results and presented case illustrations. Studies which used smartphones successfully used them collect data on patients and deliver multimedia interventions. Discussion: The current literature offers encouraging evidence for the use of smartphones to improve mental health care but also reflects the lack of research conducted using smartphones. Studies which examine care provider use of smartphones to improve care is encouraging but has limited generalizability to mental health care. The feasibility of patient use of smartphones is also encouraging, but questions remain about feasibility in some sub-populations, particularly schizophrenia patients. Pilot testing of mobile devices and applications can greatly increase the feasibility of using smartphones in mental health care. Patients who are unfamiliar with smartphones will likely need initial training and support in their use. Conclusion: The literature identified several ways in which smartphones can increase access to care, reduce barriers, and improve treatment outcomes. Study results were encouraging but scientifically weak. Future studies are needed replicating results of studies using cell phones and PDAs on smartphones. Larger and higher quality studies are needed to examine the feasibility, efficacy, and cost-effectiveness of smartphones to deliver multiple component interventions that improve access to mental health care and improve treatment outcomes