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Using EHRs For Quality Improvement:  Hypertension

Dr. Singh has attested to Meaningful Use and his first incentive check is in the mail. He has harmonized his elective quality measures around hypertension because he knows his EHR product is certified for hypertension measures. Dr. Singh also consistently gets the same denominator with accurate reports. Dr. Singh discovers that for patients with hypertension the percentage of patients in his practice with controlled high blood pressure (NQF# Not Applicable; CMS165v9) is much lower than he'd like. Dr. Singh’s REC representative works with IT staff and his vendor to review his system's functionality, repeat the reports, and confirm they are accurate. Knowing these patients are at very high risk of major coronary or vascular events, Dr. Singh wants to learn about systematic ways to improve. First the REC advises Dr. Singh 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 his practice with uncontrolled hypertension that have not been seen in the last 3 months. The REC then presents Dr. Singh with these potential options:

Engage at Risk Patients

  • Schedule individual office visits purely dedicated to cardiovascular care
  • During visits systematically review patient history for exclusions, (e.g. renal failure or pregnancy).
  • Discuss any barriers to adherence - e.g. fear of the medicine, price issues, side effects
  • Once adherence is determined, the practice could consider evidence based protocols to intensify medical therapy using nursing visit BP measurements or home measurements. The protocols could be administered electronically or by phone by an office nurse

Use EHRs to Engage Patients

  • Activate clinical decision support to:
    • Highlight missing cardiovascular services at every visit; and
    • Suggest the need for appropriate medication
    • Survey problem list for contraindications / exclusions
  • Use the e-prescribing system to:
    • Obtain prescription and refill history 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
  • 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
      • Use hypothetical cases to ensure that the team understands the protocols well
      • Ensure that appropriate lab work is gathered and / or ordered as appropriate
      • Divide important educational tasks.
  • 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 - June 7, 2012

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