Using Electronic Health Record Data to Support Research and Quality Improvement: Practical Guidance from a Qualitative Investigation

Abstract

Objective The aim of the study is to identify how academic health centers (AHCs) have established infrastructures to leverage electronic health record (EHR) data to support research and quality improvement (QI).

Methods Phone interviews of 18 clinical informaticians with expertise gained over three decades at 24 AHCs were transcribed for qualitative analysis on three levels. In Level I, investigators independently used NVivo software to code and identify themes expressed in the transcripts. In Level II, investigators reexamined coded transcripts and notes and contextualized themes in the learning health system paradigm. In Level III, an informant subsample validated and supplemented findings.

Results Level I analysis yielded six key “determinants”—Institutional Relationships, Resource Availability, Data Strategy, Response to Change, Leadership Support, and Degree of Mission Alignment—which, according to local context, affect use of EHR data for research and QI. Level II analysis contextualized these determinants in a practical frame of reference, yielding a model of learning health system maturation, over-arching key concepts, and self-assessment questions to guide AHC progress toward becoming a learning health system. Level III informants validated and supplemented findings.

Discussion Drawn from the collective knowledge of experienced informatics professionals, the findings and tools described offer practical support to help clinical informaticians leverage EHR data for research and QI in AHCs.

Conclusion The learning health system model builds on the tripartite AHC mission of research, education, and patient care. AHCs must deliberately transform into learning health systems to capitalize fully on EHR data as a staple of health learning.

Keywords

electronic health records - institutional relationships - secondary use - clinical data management - clinical research informatics - quality improvement - academic health center

Protection of Human and Animal Subjects

The University of Vermont and Children’s Hospital of Philadelphia Institutional Review Boards approved this study.

• References

• 1 Blumenthal D. Launching HITECH. N Engl J Med 2010; 362 (05) 382-385
• 2 Grossman C, Goolsby WA, Olsen L, McGinnis JM. Clinical Data as the Basic Staple of Health Learning: Creating and Protecting a Public Good. Washington, DC: Institute of Medicine; 2011
• 3 Wartman SA, Zhou Y, Knettel AJ. Health reform and academic health centers: commentary on an evolving paradigm. Acad Med 2015; 90 (12) 1587-1590
• 4 Roper WL, Newton WP. The role of academic health centers in improving health. Ann Fam Med 2006; (04) (Suppl. 01) S55-S60
• 5 Washington V, DeSalvo K, Mostashari F, Blumenthal D. The HITECH era and the path forward. N Engl J Med 2017; 377 (10) 904-906
• 6 Office of the National Coordinator for Health Information Technology. Health IT Playbook. Available at: https://www.healthit.gov/playbook/ . Accessed March 18, 2019
• 7 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014; 89 (09) 1245-1251
• 8 Suri H. Purposeful sampling in qualitative research synthesis. Qual Res J 2011; 11 (02) 63-75
• 9 Fusch P, Ness L. Are we there yet? Data saturation in qualitative research. Qual Rep 2015; 20 (09) 1408-1416
• 10 Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358 (9280): 483-488
• 11 Berg BL, Lune H, Lune H. Qualitative Research Methods for the Social Sciences. Boston, MA: Pearson; 2004
• 12 Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work 2012; 11 (01) 80-96
• 13 Ash JS, Smith AC, Starvi PZ. Performing subjectivist studies in the qualitative traditions responsive to users. In: Kathryn JH, Marion JB. Evaluation Methods in Biomedical Informatics. New York, NY: Springer; 2006: 267-300
• 14 Borkan J. Immersion/Crystallization. In: BF Crabtree, WL Miller, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications; 1999
• 15 Angen MJ. Evaluating interpretive inquiry: reviewing the validity debate and opening the dialogue. Qual Health Res 2000; 10 (03) 378-395
• 16 Smith MD. , Institute of Medicine (US), Committee on the Learning Health Care System in America. Best Care at Lower Cost: the path to continuously learning health care in America. Washington, DC: National Academies Press; 2012
• 17 Forrest CBMP, Margolis P, Seid M, Colletti RB. PEDSnet: how a prototype pediatric learning health system is being expanded into a national network. Health Aff (Millwood) 2014; 33 (07) 1171-1177
• 18 Friedman CP, Wong AK, Blumenthal D. Achieving a nationwide learning health system. Sci Transl Med 2010; 2 (57) 57cm29
• 19 Friedman C, Rubin J, Brown J. , et al. Toward a science of learning systems: a research agenda for the high-functioning Learning Health System. J Am Med Inform Assoc 2015; 22 (01) 43-50
• 20 DiLaura R, Turisco F, McGrew C, Reel S, Glaser J, Crowley Jr WF. Use of informatics and information technologies in the clinical research enterprise within US academic medical centers: progress and challenges from 2005 to 2007. J Investig Med 2008; 56 (05) 770-779
• 21 Murphy SN, Dubey A, Embi PJ. , et al. Current state of information technologies for the clinical research enterprise across academic medical centers. Clin Transl Sci 2012; 5 (03) 281-284
• 22 Knosp BM, Barnett WK, Anderson NR, Embi PJ. Research IT maturity models for academic health centers: early development and initial evaluation. J Clin Transl Sci 2018; 2 (05) 289-294
• 23 (HIMSS) HIMSS. Electronic Medical Record Adoption Model (EMRAM). Secondary Electronic Medical Record Adoption Model (EMRAM); 2018 . Available at: https://www.himssanalytics.org/sites/himssanalytics/files/North_America_EMRAM_Information_2018.pdf . Accessed March 15, 2019
• 24 Grajek S. The digitization of higher education: charting the course. EDUCAUSE Review 2016 . Available at: https://er.educause.edu/articles/2016/12/the-digitization-of-higher-education-charting-the-course . Accessed March 22, 2019
• 25 McGinnis JM, Powers B, Grossmann C. Digital Infrastructure for the Learning Health System: the Foundation for Continuous Improvement in Health and Health Care: Workshop Series Summary. Washington, DC: National Academies Press; 2011
• 26 Egberg MD, Kappelman MD, Gulati AS. Improving care in pediatric inflammatory bowel disease. Gastroenterol Clin North Am 2018; 47 (04) 909-919
• 27 Fleurence RL, Curtis LH, Califf RM, Platt R, Selby JV, Brown JS. Launching PCORnet, a national patient-centered clinical research network. J Am Med Inform Assoc 2014; 21 (04) 578-582
• 28 Grumbach K, Lucey CR, Johnston SC. Transforming from centers of learning to learning health systems: the challenge for academic health centers. JAMA 2014; 311 (11) 1109-1110