A first step towards translating evidence into practice: heart failure in a community practice-based research network

Objective To determine the validity of an electronic health record (EHR) in the identification of patients with left ventricular dysfunction in a primary care setting. Design A cross-sectional study. Setting Nine clinics participating from the Providence Research Network (PRN) comprising 75 physicians serving approximately 200 000 patients. All clinics utilise the Logician™ EHR for all patient care activities. Patients The study included all PRN patients with an active chart. Interventions All patients with a heart failure diagnosis in the problem list were identified by database query. Left ventricular ejection fraction (LVEF) data were identified through query of local cardiology and hospital echocardiography databases. Additional LVEF data were sought in a manual search of paper charts. Measurements and main results To determine the problem list coding accuracy for a heart failure (HF) diagnosis we evaluated sensitivity, positive predictive value and related derived statistical measures using documented LVEF as the ‘gold standard’.Of 205 755 active PRN patients, 1731 were identified with a problem list entry of HF. Based on comparison with documented LVEF, the sensitivity for problem list entry was 43.9% and 54.4% when HF was defined as an LVEF ≤55% and ≤40%, respectively. Conclusion The validity of an EHR problem list entry of HF was poor. The problem list validity could be enhanced through reconciliation with other data sources. Inaccurate EHR problem lists may have clinical consequences, including underprescribing of beneficial therapies

The impact of a physician-directed health information technology system on diabetes outcomes in primary care: a pre- and post-implementation study

Purpose To determine the impact of a physiciandirected, multifaceted health information technology (HIT) system on diabetes outcomes. Methods A pre/post-interventional study. Setting and participants The setting was Providence Primary Care Research Network in Oregon, with approximately 71 physicians caring for 117 369 patients in 13 clinic locations. The study covered Network patients with diabetes age 18 years and older. Intervention The study intervention included implementation of the CareManagerTM HIT system which augments an electronic medical record (EMR) by automating physician driven quality improvement interventions, including point-of-care decision support and care reminders, diabetes registry with care prompts, performance feedback with benchmarking and access to published evidence and patient educational materials. Measures The primary clinical measures included the change in mean value for low density lipoprotein (LDL) target <100 mg/dL or 2.6 mmol/l, blood pressure (BP) target <130/80 mmHg and glycated haemoglobin (HbA1c) target <7%, and the proportion of patients meeting guideline-recommended targets for those measures. All measures were analysed using closed and open cohort approaches. Results A total of 6072 patients were identified at baseline, 70% of whom were continuously enrolled during the 24-month study. Significant improvements were observed in all diabetes related outcomes except mean HbA1c. LDL goal attainment improved from 32% to 56% (P=0.002), while mean LDL decreased by 13 mg/dL (0.33 mmol/l, P=0.002). BP goal attainment increased significantly from 30% to 52%, with significant decreases in both mean systolic and diastolic BP. The proportion of patients with an HbA1c below 7% was higher at the end of the study (P=0.008). Mean patient satisfaction remained high, with no significant difference between baseline and follow-up. Total Relative Value Units per patient per year significantly increased as a result of an increase in the number of visits in year one and the coding complexity throughout. Conclusion Implementation of a physician-directed, multifaceted HIT system in primary care was associated with significantly improved diabetes process and outcome measures