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Using EHRs For Quality Improvement:  Asthma

Dr. Sanchez has attested to Meaningful Use and her first incentive check is in the mail.  She has harmonized her elective quality measures around asthma because she knows her EHR product is certified for asthma measures.  Dr. Sanchez also consistently gets the same denominator with accurate reports.  Dr. Sanchez discovers that for patients with asthma, the percentage of patients in her practice appropriately prescribed asthma control medication (NQF #0036) is much lower than shed like. Dr. Sanchez's REC representative works with IT staff and her vendor to review her system's functionality, repeat the reports, and confirm they are accurate.  Knowing these patients are more likely to need emergency care or a hospitalization due to uncontrolled asthma, Dr. Sanchez wants to learn about systematic ways to improve.  First the REC advises Dr. Sanchez to use the appropriate personnel and method for his EHR product to utilize the patient list function to identify the names and phone numbers of all patients in her practice with asthma that have not been seen in the last 6 months and are not on asthma control therapy. The REC then presents Dr. Sanchez with these options:

Engage at Risk Patients

  • Schedule individual office visits purely dedicated to respiratory care where prescription history is reviewed
  • Discuss with patient whether asthma control medication causes any intolerable side effects; explore any barrier to adherence
  • Offer an alternative controller medication if appropriate
  • If preferred asthma control medication isn't tolerated then discuss alternative treatments.
  • Ensure that the patient uses inhalers properly

Use EHRs to Engage Patients

  • Activate clinical decision support to:
    • Highlight missing asthma services at every visit; and
    • Suggest the need for asthma control medications
    • Survey problem list for symptoms of uncontrolled asthma.
  • Use the e-prescribing system to:
    • Obtain prescription and refill history if asthma control medication is recommended or required
    • Have a staff member perform a medication reconciliation
    • Have a staff member perform an adherence analysis either electronically or through patient discussion
    • For medication use, have staff review progress notes or medication list
  • Use patient education function
    • Use print-outs, websites, and/or kiosks specified for a low-health literacy audience
    • Have staff use it to assess patient knowledge and use teach back at subsequent visits

Implement a Workflow that Supports Quality Improvement

  • Start this change cycle and workflow with one provider:
    • Perfect the mechanics and team roles,
    • Repeat process measures to see if process is consistent,  
    • Repeat measurement and assess if improvement has occurred;
    • Employ a team huddle before each of these clinic sessions
      • Review the patients who have had difficulty with adherence from the entire staff’s perspective
      • Divide important educational tasks including inhaler use.
  • Spread to other providers and set up staff meetings to give provider-specific feedback
    • If the feedback is public in a peer group, the incentive to adhere to the workflow and achieve improvement is intensified.

Produced by Meaningful Use Quality Workgroup - April 12, 2012

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