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Dr. Ono has attested to Meaningful Use and her first incentive check is in the mail. She has harmonized her elective quality measures around coronary artery disease (CAD) because she knows her EHR product is certified for CAD measures. Dr. Ono also consistently gets the same denominator with accurate reports. Dr. Ono discovers that for patients with CAD and a prior myocardial infarction, the percentage of patients in her practice appropriately prescribed Beta-blocker therapy (NQF# 0070e; CMS145v9) is much lower than she'd like. Dr. Ono'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 at very high risk for myocardial infarction or other major coronary events, Dr. Ono wants to learn about systematic ways to improve. First the REC advises Dr. Ono 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 CAD and a prior myocardial infarction that have not been seen in the last 6 months, and are not on Beta-blocker therapy. The REC then presents Dr. Ono with these potential options:

Engage at Risk Patients

• Schedule individual office visits purely dedicated to cardiovascular care where prescription history is reviewed
• During visits systematically review patient history for exclusions, e.g. an allergy or hypotension
• Discuss with patient whether Beta blockers cause intolerable side effects; explore any barrier to adherence

Use EHRs to Engage Patients

• Activate clinical decision support to:
  • Highlight missing cardiovascular services at every visit
  • Suggest the need for Beta-blocker medications
  • Survey problem list for contraindications / exclusions
• Use the e-prescribing system to:
  • Obtain prescription and refill history
  • Have a staff member perform a medication reconciliation
  • Have a staff member perform an adherence analysis either electronically or through patient discussion
  • For Beta-blocker use, have staff review progress notes or medication list
• Provide patient educational 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
• 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.

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Produced by Meaningful Use Quality Workgroup - March 27, 2012