Beyond Electronic Health Records: quality outcomes management.

Since implementing an electronic clinical information system in 1999, Mid Carolina Cardiology based in Charlotte, N.C. has experienced tremendous success. The practices' streamlined operations, clinical management and billing systems have been the subject of presentations throughout the country at practice management meetings.

However, the most exciting development of the electronic patient database is just emerging: the ability to document and demonstrate clinical outcomes from an office-based environment.

Outcomes measurement and management is the sine qua non of excellence in patient care. Several quality initiatives are underway by purchasing coalitions and payers. (1-5) Due to the current and rising costs of purchasing health care benefits for companies, employers are seeking to channel their patients to hospital and physician systems that are able to document and deliver superior outcomes.

Up until now, patient outcomes were primarily measured from hospital medical records, discharge data and administrative claims review. In the absence of an electronic clinical information system (or electronic health records), the only way to document clinical outcomes from an outpatient environment was to manually review a statistically relevant sample of the clinic's charts according to predetermined measurements of quality.

There are an estimated 28,000 physicians practicing medicine in the United States just in the field of cardiology. In our practice, we had approximately 80,000 patient paper records prior to implementing the electronic medical record system.

Obviously, it would have been extremely time consuming and costly to review a significant quantity of charts to make any conclusion regarding quality systems in this environment.

With the advancement of information technology and the arrival of wide and local area networks, wireless networks, database organization, and structured electronic medical records, it became efficient to store, retrieve and query vast quantities of data.

Here's a look at some of the outcomes measurements that we are now able to track thanks to our electronic record-keeping.

Chronic atrial fibrillation

The American College of Cardiology has endorsed the concept that patients meeting certain criterion should be managed according to guidelines if no contraindication to the treatment exists. (6-8)

For example, in the absence of a documented contraindication, patients exhibiting chronic atrial fibrillation (irregular beating of the superior chambers of the heart) should be treated with an anticoagulant to help to prevent stroke.

Our first pass at data analysis was to identify all patients in our database who have the diagnosis of atrial fibrillation, and to sort that for patients taking the blood thinning medication.

Next, we reviewed all that had the diagnosis of atrial fibrillation, but who were not taking the medication to find out why they were not being treated. Once those patients identified with legitimate contraindications to therapy were culled from the database, the charts of the remaining patients (those with atrial fibrillation not on medicine without obvious contraindication) were referred to their physicians for review. Eventually, physicians either documented a contraindication or the patients were put on appropriate medicine.

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The charts demonstrate Mid Carolina Cardiology's performance compared with published national performance.

A similar methodology was used to document our clinical performance against other published clinical performance benchmarks. In all areas, Mid Carolina Cardiology exceeds national performance benchmarks.

At times there are data points that do not reside in an extractable form in our clinical information system. To add another dimension of capability, we utilize the services of MDdatacor, a clinical informatics company based in Atlanta, Ga.

We securely transmit dictated clinical records on a routine basis to MDdatacor over the Internet. The data is stored in a de-identified, HIPAA-compliant fashion.

MDdatacor responds to our requests for searches and produces a report that becomes "re-identified" in terms of patient identification upon return of the report to us. By adding this robust capability to our own internal data searches, we can magnify the depth and breadth of the data searches. At this time, MDdatacor receives data from approximately 1,900 cardiologists from 100 practices around the country.

It is clear that these quality initiatives enable the physicians to measure the quality of care of their patients, and to provide insight to all of our physicians on treatments and guidelines from a systems perspective all the way down to individual patients.

As new clinical guidelines emerge, our patients can quickly benefit from the strategies that we employ to constantly update our practice treatment patterns. This simply cannot be efficiently done in the absence of electronic clinical information systems or sophisticated databases like those of MDdatacor.

We spent the first three years using the electronic clinical information system to document and improve business processes. Now, we have moved beyond that. We are deeply involved in outcomes management.

The beneficiaries are our patients, our referring physicians who entrust the cardiology care of their patients to us, and the employers in our area who purchase these valuable health care benefits.

By joining together with our specialty medical societies, government and private payers, and employer groups, physicians can work toward providing what all of us want and deserve, excellent medical care.

Stephen A. McAdams, MD, FCCP is CEO of Mid Carolina Cardiology in Charlotte, N.C. He can be reached at 704-347-2058 or [e-mail]

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References

1. Landro, L. "The Informed Patient: Doctor 'Scorecards' Are Proposed In a Health-Care Quality Drive." The Wall Street Journal March 25, 2004.

2. The Leap Frog Group for Patient Safety, Fact Sheet. January 2004. c/o AcademyHealth www.leapfroggroup.org.

3. Kranhold, K. "Health: Effort Is Widened To Reward Doctors For IT Investment." The Wall Street Journal. May 26, 2004.

4. Thomas J. Marr, M.D. and Babette A. Apland. May 2004. Financially Rewarding Physicians for Quality: HealthPartners' Model. Group Practice Journal. p. 17.

5. Weber, DO. "Share the Wealth: Pay-for-Performance Programs Pressure and Please Physicians." The Physician Executive. May-June 2004.

6. American College of Cardiology. American Heart Association, Physician Consortium for Performance Improvement. 2003. Clinical Performance Measures; Chronic Stable Coronary Artery Disease, Tools Developed by Physicians for Physicians. American Medical Association.

7. American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. 2003. Clinical Performance Measures: Heart Failure. Tools Developed by Physicians for Physicians. American Medical Association.

8. American College of Cardiology, American Heart Association, Physician Consortium for Performance Improvement. 2003. Clinical Performance Measures: Hypertension, Tools Developed by Physicians for Physicians. American Medical Association.

By Stephen A. McAdams, MD, FCCP

Atrial Fibrillation with Warfarin Sodium Summary

33% National Benchmark from Coumadin Website

2001    91%
2002    98%
2003    99%

Note: Table made from bar graph.

Aspirin Therapy After Myocardial Infarction

72% National Benchmark from JAMA-March 13: 287(10) 1277-1287

2001     91%
2002     95%
2003     99%

Note: Table made from bar graph.

Beta Blockade After Myocardial Infarction

79% National Benchmark from ACC Performance Measures acc.org

2001   79%
2002   78%
2003   86%

Note: Table made from bar graph.

Angiotensin Converting Enzyme Therapy for Heart Failure

58% National Benchmark from ADHERE Registry

2001
2002   62%
2003   88%

Note: Table made from bar graph.