Keywords electronic health records - implementation - quality - note - order set
Background and Significance
Background and Significance
Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis,
is an incurable chronic condition, is often diagnosed at a young age, and can require
a lifetime of medical care. Almost 1 million Americans have IBD and approximately
30% of those are diagnosed during childhood.[1 ] IBD can significantly impact individual health and quality of life, and it can also
be of great financial burden to patients, families, and society at large. The Centers
for Disease Control and Prevention estimates that IBD accrues direct medical costs
of $6.3 billion each year, while indirect costs, such as missed work opportunities,
contribute an additional $5.5 billion annually.[2 ]
Of interest, the heterogeneity of disease phenotypes and the multitude of treatment
options for IBD lead to wide variation in treatment and resource utilization. Studies
have shown that physicians often make different diagnoses, order various studies,
and prescribe different therapies when given the same clinical data.[3 ] Significant variation in care is largely considered an indicator of poor quality
health care.[4 ] The development and use of quality measures strive to standardize aspects of care
for IBD and ultimately lead to improved outcomes.
Additionally, the quality of care provided can also be assessed by determining how
often quality measures are being followed.[5 ] The Centers for Medicare and Medicaid Services (CMS) believes quality measures that
are meaningful should be used to address high impact areas of disease management with
significant opportunity for improvement while minimizing the level of burden for providers.[6 ] Furthermore, CMS has tied provider reimbursement to adherence with documenting these
measures. The first IBD quality measures were introduced by the American Gastroenterological
Association (AGA) in 2011. The AGA established ten quality metrics for IBD with the
intent of improving health outcomes by emphasizing preventive care and noncorticosteroid-based
treatment options.[4 ] These measures were eventually narrowed into seven performance measures that apply
to outpatient IBD care for the Physician Quality Reporting System (PQRS), a quality
reporting program initiated by CMS. Since that time, the landscape for quality metrics
reporting has changed with the introduction of merit-based incentive payment system
and advanced alternative payment models.[7 ] In addition, prior studies have shown adherence with IBD quality measures to be
poor overall.[8 ]
[9 ]
[10 ] While it remains unclear which specific measures will be chosen for the next iteration
of quality metrics reporting, sustained adherence with the measures remains essential.
During this time of transition, simplified EHR improvements are useful in aiding with
this shift in documentation.
Objectives
Our aim for this study was to assess documentation adherence with select PQRS performance
measures at one academic medical center before and after the implementation of a multifaceted,
EHR driven approach including: (1) an IBD order set; (2) note template; and (3) patient
education handout. Patient encounters were evaluated both immediately following the
EHR enhancements and 1 year after its implementation to assess for sustained improvement
in documentation rates.
Methods
This quality improvement project was conducted at our tertiary care academic medical
center, Wake Forest Baptist Medical Center (WFBMC), in Winston Salem, North Carolina.
Participation was limited to two different sites within our institution: (1) an academic
gastroenterology practice and (2) a fellows' clinic, where several different attending
physicians and nine fellows provide care.
Outpatient encounters from September 1, 2015 to June 30, 2016 for patients aged 18
years and older with a visit diagnosis of IBD (including all applicable International
Classification of Diseases [ICD]-10 codes as outlined by PQRS)[11 ] were included in the study. Fifty patient charts were selected for review using
a random number generator, regardless of whether the encounter note utilized the IBD-specific
note template, other template, or dictation software. Using Epic, the EHR system employed
at WFBMC, each chart was manually reviewed by one of the authors for adherence with
PQRS quality measures ([Table 1 ]). Of the seven PQRS measures, evaluation for adherence with the management of patients
with corticosteroid-sparing therapies was excluded. Additionally, the measure involving
tobacco use was evaluated for both screening and cessation separately.
Table 1
2016 PQRS measures for inflammatory bowel disease
Measure #110: Preventative care and screening: influenza immunization
Percentage of patients aged 6 months and older seen for a visit between October 1
and March 31 who received an influenza immunization or who reported previous receipt
of an influenza immunization.
Measure #111: Pneumonia vaccination status
Percentage of patients 65 years of age and older who have ever received a pneumococcal
vaccine.
Measure #226: Preventive care and screening: tobacco use: screening and cessation
intervention
Percentage of patients aged 18 years and older who were screened for tobacco use
one or more times within 24 months and who received cessation counseling intervention if identified as a tobacco user.
Measure #270: Preventive care: corticosteroid sparing therapy[a ]
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel
disease (IBD) who have been managed by corticosteroids greater than or equal to 10
mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription
equating to 600-mg prednisone or greater for all fills that have been prescribed corticosteroid
sparing therapy within the last 12 months.
Measure #271: Preventive care: corticosteroid related iatrogenic injury—bone loss
assessment
Percentage of patients aged 18 years and older with an IBD encounter who were prescribed
prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive
days or a single prescription equating to 600-mg prednisone or greater for all fills
and were documented for risk of bone loss once during the reporting year or the previous
calendar year.
Measure #274: Testing for latent tuberculosis (TB) before initiating anti-tumor necrosis
factor (TNF) therapy
Percentage of patients aged 18 years and older with a diagnosis of IBD for whom a
TB screening was performed and results interpreted within 6 months prior to receiving
a first course of anti-TNF (tumor necrosis factor) therapy.
Measure #275: Assessment of hepatitis B virus (HBV) status before initiating anti-TNF
(tumor necrosis factor) therapy
Percentage of patients aged 18 years and older with a diagnosis of IBD who had HBV
status assessed and results interpreted within 1 year prior to receiving a first course
of anti-TNF (tumor necrosis factor) therapy.
a Measure excluded from study.
Assessing documentation adherence to each measure was performed in accordance with
PQRS criteria.[11 ] A chart was eligible for the influenza measure if the visit occurred between October
1 and March 31. The measure was met if the encounter note documented that the patient
received immunization or reported previous receipt of an influenza immunization during
the current season. All patients were eligible for pneumonia vaccination measure,
as only patients aged 18 years and older were included in the study. This measure
was met if there was documentation in the encounter note that the pneumonia vaccine
was administered or previously received. All patients in the study were eligible for
tobacco screening, and cessation intervention was assessed for the tobacco users.
Patients were eligible for bone loss assessment if they received 10 mg/d or greater
of prednisone equivalents for 60 or more consecutive days or if prescribed 600 mg
or greater of prednisone equivalents. Eligible charts were reviewed for central dual-energy
X-ray absorptiometry (DXA) in the preceding 2 years. Regarding patients with recently
initiated anti-tumor necrosis factor (TNF) therapy, a patient was considered for latent
tuberculosis (TB) and hepatitis B measures if the therapy was started within 1 year
of the encounter date. This was done because of the low number of visits for initiation
of anti-TNF therapy. Latent TB and hepatitis B screening measures were fulfilled if
testing was performed within 6 months and 1 year of anti-TNF initiation, respectively.
After the baseline data was collected, an IBD note template ([Fig. 1 ]), order set ([Fig. 2 ]), and patient education handout were created. The IBD-specific note template provided
prepopulated sections and nonmodal clinical decision support (CDS) for information
pertaining to the measures. Nonmodal CDS does not prevent users from interacting with
the rest of the EHR. This modality was selected so to not interfere with the workflows
of different providers, but to also serve as a prompt to include information relevant
to the quality measures. The dynamic IBD order-set, organized with single-click diagnosis
association and placement of orders, offered a simplified approach for commonly prescribed
medicines, tests, procedures, and referrals for IBD care. The order set also provided
reminders of important PQRS measures with one-click access to vaccines, DXA, TB, and
hepatitis B testing. Furthermore, with the use of the order set, a patient education
handout containing basic health maintenance information regarding vaccinations, bone
health, cancer screening, and tobacco cessation resources was autopopulated into the
after-visit summary (AVS) provided to the patient ([Fig. 3 ]). Review of the baseline adherence data and a tutorial for the IBD note template,
order set, and patient education handout were discussed with faculty and fellows during
a section conference prior to the second phase of the study. Additionally, emails
outlining the EHR changes were sent to those not in attendance.
Fig. 1 Portion of IBD note template with nonmodal CDS for many PQRS quality @IMM@ inserts
vaccination history for the patient. Nonmodal CDS denoted as { } does not interfere
with workflow, but prompts provider include information prior to signing note. CDS,
clinical decision support; IBD, inflammatory bowel disease; PQRS, physician quality
reporting system.
Fig. 2 Screenshot of inflammatory bowel disease order set.
Fig. 3 Patient education handout.
Following these interventions, another 50 patient charts were randomly selected from
outpatient IBD visits occurring between September 1, 2016 and June 30, 2017, just
after the changes were implemented on September 1, 2016. Using the same methods described
above, an additional 50 charts were reviewed for encounters between September 1, 2017
and June 30, 2018 to assess for a sustained response.
Categorical variables are described as frequencies and proportions, while continuous
variables are described as medians and ranges. SAS 9.4 statistical software was used
to analyze data described below. Analysis of categorical variables was performed using
chi-square analysis or Fisher's exact test when sample sizes were less than five.
p -Values less than 0.05 were considered statistically significant. Demographic data
containing continuous variables were analyzed using Kruskal–Wallis test, whereas categorical
variables were analyzed using a 3 × 2 chi-square analysis.
All authors had access to the data and approved the final manuscript. The project
was deemed not human subjects research and received exempt approval by the Institutional
Review Board at WFBMC (IRB#: IRB00040399). Additionally, the EHR screenshots included
were approved for distribution by Epic Systems Corporation.
Results
Demographics
This study analyzed 150 different patient encounters, with each study group consisting
of 50 different patients. There were no significant differences in age among the groups.
The proportion of males in each group varied from 38 to 56%, but was not significantly
different, (p = 0.195). While the preintervention group had the highest proportion of patient with
ulcerative colitis (48%), there was no statistically significant difference in subtype
of IBD among the groups. See [Table 2 ] for additional demographic information.
Table 2
Demographic characteristics of each study group
Preintervention group (n = 50)
Postintervention group (n = 50)
1-year follow-up group (n = 50)
p -Value
Median age, y (range)
46 (18–87)
46 (22–84)
41 (19–82)
0.41
Males, n (%)
23 (46)
28 (56)
19 (38)
0.195
Median BMI, kg/m2 (range)
27.1 (16–49)
26.1 (17–55)
26.4 (12–56)
0.893
IBD type, n (%)
0.122
Crohn's disease
26 (52)
35 (70)
34 (68)
Ulcerative colitis
24 (48)
15 (30)
16 (32)
Provider type, n (%)
0.846
Attending physician
44 (88)
43 (86)
42 (84)
Gastroenterology fellow
6 (12)
7 (14)
8 (16)
Abbreviations: BMI, body mass index; IBD, inflammatory bowel disease.
Comparing Adherence Between Pre- and Postintervention Groups
Preintervention and postintervention rates of adherence with PQRS measures studied
are presented in [Table 3 ]. Baseline adherence for all evaluated quality measures was 40.6%, with high variation
in adherence rates for each specific measure in the preintervention group. When compared
with the preintervention group, the cohort immediately after the EHR changes were
implemented revealed significant increases in EHR documentation rates of influenza
immunization (19–59%, p < 0.001), pneumococcal immunizations (2–38%, p < 0.001), tobacco cessation (28.6–77.8%, p = 0.049), and proportion of all eligible measures (40.6–62.2%, p < 0.001). While sample sizes were low for latent TB and hepatitis B measures (n = 3, n = 1, respectively), there was no significant difference in rates of documentation
adherence.
Table 3
Adherence with PQRS measures before and after EHR changes
Measure
Preintervention group (n = 50)
Postintervention group (n = 50)
Delta (%)
p- Value
Influenza immunization, n (%)
7/36 (19.4)
22/37 (59.5)
40
<0.001
Pneumococcal immunization, n (%)
1/50 (2)
19/50 (38)
36
<0.001
Tobacco screening, n (%)
50/50 (100)
50/50 (100)
0
1
Tobacco cessation, n (%)
2/7 (28.6)
7/9 (77.8)
49
0.049
Bone loss assessment, n (%)
0/11 (0)
2/16 (12.5)
12
0.223
Latent TB testing before anti-TNF-α therapy, n (%)
2/3 (66.7)
1/1 (100)
33
1
HBV testing before anti-TNF-α therapy, n (%)
3/3 (100)
1/1 (100)
0
1
Total combined measures, n (%)
65/160 (40.6)
102/164 (62.2)
22
<0.001
Abbreviations: EHR, electronic health record; HBV, hepatitis B virus; PQRS, physician
quality reporting system; TB, tuberculosis; TNF, tumor necrosis factor.
Assessing for Sustained Adherence
[Table 4 ] presents the proportion of PQRS measures appropriately documented in the 1-year
follow-up group when compared with the postintervention group. Charts were evaluated
for sustained adherence using randomly selected encounters that occurred 1 year after
the postintervention group. No additional interventions or alterations to the EHR
occurred between the two study periods. While documentation adherence rates did not
decrease in the 1-year follow-up group, there were significant increases in bone loss
assessment (12.5–62.5%, p = 0.011) and influenza immunization (59.5–85%, p = 0.047) when compared with the postintervention group.
Table 4
Adherence with PQRS measures after EHR changes and 1-year follow-up
Measure
Postintervention group (n = 50)
1-year follow-up group (n = 50)
Delta (%)
p- Value
Influenza immunization, n (%)
22/37 (59.5)
17/20 (85)
26
0.047
Pneumococcal immunization, n (%)
19/50 (38)
19/50 (38)
0
1
Tobacco screening, n (%)
50/50 (100)
50/50 (100)
0
1
Tobacco cessation, n (%)
7/9 (77.8)
3/4 (75)
−3
1
Bone loss assessment, n (%)
2/16 (12.5)
5/8 (62.5)
50
0.011
Latent TB testing before anti-TNF-α therapy, n (%)
1/1 (100)
5/6 (83.3)
−17
1
HBV testing before anti-TNF-α therapy, n (%)
1/1 (100)
5/6 (83.3)
−17
1
Total combined measures, n (%)
102/164 (62.2)
104/144 (72.2)
10
0.062
Abbreviations: EHR, electronic health record; HBV, hepatitis B virus; PQRS, physician
quality reporting system; TB, tuberculosis; TNF, tumor necrosis factor.
Discussion
This study suggests that simple improvements to the EHR via streamlined order set,
note template, and patient education handout may contribute to sustained improvements
in documentation adherence of outpatient IBD quality measures. Prior to the implementation
of the EHR changes, the aggregate baseline adherence rate for documentation of 2016
PQRS measures at our academic institution was 40.6% of total eligible measures. Adherence
with individual measures ranged widely from 0 to 100%, for bone loss assessment and
screening for hepatitis B prior to initiation of anti-TNF α therapy, respectively.
Many prior studies have shown infrequent and inconsistent adherence with PQRS measures
for IBD.[8 ]
[9 ]
[10 ] One study reported rates as little as 3% for pneumococcal immunization to 98% for
corticosteroid-sparing therapy.[12 ] As previously described, wide variation in care is considered to be an indicator
of low quality care.[4 ] Hence, wide variation in adherence with quality measures may also represent poor
care.
While there was low baseline documentation adherence, there was robust adherence with
tobacco screening. This was thought to be due to prior process improvement measures
at our institution, where nursing staff is prompted to document the information in
a specific location in the EHR during the patient intake process. It was postulated
that a similar physician-oriented process for other measures would prove effective
in improving overall adherence in documentation. Additionally, it was felt that easier
access to the studies utilized in each quality measure would improve efficiency and
consequently improve adherence. Thus, an IBD note template, order set, and patient
education handout were designed to improve documentation adherence with PQRS measures.
The initial comparison between pre- and postintervention groups showed significant
increases in documentation adherence rates of influenza and pneumococcal vaccine measures.
One benefit of the implemented order set includes a section for vaccinations, where
orders for influenza, pneumococcal, and other immunizations can easily be placed.
Utilizing the order set serves as an inherent, secondary reminder for the clinician
to document quality measures. Additionally, use of the order set automatically populates
the patient's AVS with education materials, including resources for smoking cessation.
Therefore, use of the order set passively leads to adherence with the smoking cessation
measure, as seen with the significant increase in tobacco cessation adherence. While
latent TB and hepatitis B screening measures had robust adherence at baseline, there
was no statistically significant change after the improvements to the EHR. This was
likely attributable to the small number of eligible patients for each measure (n = 3, n = 1, respectively), as few patients initiated anti-TNF α therapy within the preceding
year.
While assessing for sustained adherence, there were no significant decreases in adherence
rates when comparing the 1-year follow-up group to the postintervention group. There
were, however, significant increases in bone loss assessment and influenza immunization
measures. Increased adherence with the influenza measure reflects our health system's
efforts to stress the importance of vaccination to providers during influenza season.
The rise in adherence to the bone loss assessment measure can be attributed to the
criteria of the measure itself. CMS states that the measure is met if a DXA scan was
ordered or performed in the preceding 2 years.[11 ] Thus, the delayed increase in adherence during the 1-year follow-up group (occurring
12–21 months after the EHR changes) is likely due to the inclusion of patients with
more postintervention encounters occurring in the preceding 2 years.
Our study is unique due to its demonstrated sustained overall improvement in adherence
to documentation of quality measures. Prior studies have shown that bundle-based EHR
interventions led to sustained reductions in pediatric ventilator-associated pneumonia
and surgical site infections.[13 ]
[14 ] However, to our knowledge, published data on IBD performance measures have not evaluated
adherence beyond the initial implementation period. One aspect of our EHR interventions
that may have improved the sustainability is the modifiability of the note template.
Faculty were encouraged to use either the entire IBD note template or add the PQRS
measures portion ([Fig. 1 ]) into existing personalized note templates, making it easier to implement into individualized
workflows. Although this study was not designed to assess for usage of the note template,
it was noted that performance measures were typically missed when the template was
not utilized. Additional barriers to address in the future include how to increase
the fidelity of provider use in using the EHR interventions.
While assessing for improvements in documentation of IBD quality measures through
the use of a note template has been studied in the past,[15 ] coupling the template with an order set has not been investigated. Prior studies
suggest the implementation of CDS and order sets in different clinical environments
has improved efficiency and outcomes and decreased ordering errors and treatment variance.[16 ]
[17 ]
[18 ]
[19 ] The order set implemented in this study provides physicians in our institution with
an efficient way to order studies, medicines, procedures, and referrals common to
IBD encounters ([Fig. 2 ]). The simplicity of ordering the specific tests associated with PQRS quality measures
by using a limited number of clicks likely led to improved stakeholder buy-in and
sustained culture change at our institution. This approach highlights the useful framework
of the CDS Five Rights model, as outlined by the Agency for Healthcare Research and
Quality, by utilizing the right intervention format through the right channel at the
right time in the workflow.[20 ] Additionally, the order set also serves as an additional reminder for providers
to explore whether quality measures have been completed.
A chasm exists between improved documentation of quality measures and a realized improvement
in clinical practice. One limitation of our study is that the design strictly focused
on documentation of quality measures, but did not investigate differences in the frequency
of tests or therapies being ordered or completed. In theory, increased documentation
or increased prompting for documentation of quality measures may lead to increased
completion of the quality measures, but this needs to be studied. There may be patient
encounters where quality measures were completed, but not documented, leading to no
additional benefit to the patient. Quality measures were designed to standardize and
ultimately improve care and outcomes for patients with IBD. Future studies are needed
to evaluate the differences in actual completion of appropriate tests with utilization
of the IBD order set, as well as changes to patient outcomes.
Additionally, the design of the study limits the ability to detect underlying secular
trends that may have influenced changes in the documentation of quality measures.
While our study team was not aware of coexisting initiatives comprehensively addressing
vaccinations, IBD, documentation, or quality measures at our institution during the
study period, it remains unknown if external factors influenced the results. Future
studies will strive to incorporate a control group into the design.
With recent changes to reimbursement models, compensation is now tied to documentation
adherence through the use of quality measures. The simplified approach and EHR changes
implemented in this study were designed to help satisfy quality measures while also
improving efficiency. While this study demonstrates sustained improvements within
the gastroenterology section of a tertiary academic center, similar interventions
may lead to improved documentation of quality measures when applied to other practice
settings or chronic conditions such as rheumatoid arthritis or chronic kidney disease.
Because there is constant change in specific quality measures, yearly updates to the
note template may be helpful in the long-term for continued adherence with up-to-date
measures.
Conclusion
A multifaceted, EHR focused approach utilizing an IBD note template, order set, and
patient education handout contributed to significant and sustained improvements in
documentation and completion of outpatient IBD quality measures.
Clinical Relevance Statement
Clinical Relevance Statement
We reported on the impact of an electronic health record bundle specifically designed
for outpatient encounters with patients who suffer from inflammatory bowel disease.
Our findings suggest that combining a note template, order set, and patient education
handout leads to improvements in the rates of documentation of specific inflammatory
bowel disease quality measures that are sustained.
Multiple Choice Questions
Multiple Choice Questions
Wide variation in the treatment of inflammatory bowel disease can be attributable
to:
The heterogeneity of disease phenotypes.
The multitude of treatment options.
Inconsistent resource utilization.
All of the above.
Correct Answer: The correct answer is option d, all of the above.
Quality measures are intended to:
Standardize aspects of care with significant opportunity for improvement.
Increase the level burden for providers.
Increase the costs of health care.
Have no effect on health outcomes.
Correct Answer: The correct answer is option a, standardize aspects of care with significant opportunity
for improvement.
