McKesson's Electronic Medical Records help improve the quality of patient care and healthcare services

1. Transforming EMRs from Data
Repositories to Tools for Quality
Improvement
BY ANDREW URY, M.D.
recently received top rankings for the
third consecutive year in the AC
Group 2006 Report, is responsible
for the collection and storage of data
provided by participating physicians.
PPRNET WAS THE FIRST PRACTICE-BASED
RESEARCH NETWORK LINKING PHYSICIANS
USING EMRs.
Since 1995, PPRNet’s longitudinal
patient database has increased to 116
practices representing more than 570
physicians and 1.8 million patients in
38 states. Participating practices range
in size from sole practitioners (13
percent) to groups of 10 or more
physicians (8 percent). The majority
(40 percent) are practices with two or
three physicians. Specialties of partici-
pating practices include family medi-
cine (78 percent), internal medicine
(18 percent), and multispecialty
P
hysicians participating in prac- primary care (4 percent).
Measuring the Premise
tice-based research projects PPRNet was formed in May 1995 The geographic distribution of
through the Practice Partner as a joint effort between the PPRNet practices mimics that of the
Research Network (PPRNet) have Department of Family Medicine at general U.S. population: 64 percent
undergone a dramatic paradigm shift the Medical University of South are located in urban areas, 10 percent
in terms of how they view and use Carolina (MUSC) and Practice in suburban areas, 9 percent in large
their electronic medical records Partner, a Seattle-based developer of towns, and 17 percent in small towns
(EMRs), a transformation that has electronic health records (EHRs) or rural settings.
pushed the boundaries of these and practice management software. Participating practices, all of
systems beyond daily documentation A pioneering concept in practice- which utilize Practice Partner
and routine patient care to encom- based quality improvement and Patient Records, run a simple utility
pass clinical outcomes. research, PPRNet was the first prac- to extract data from their EMRs and
What these physicians have found tice-based research network linking send it to PPRNet. Using the same
is that EMRs are far more than physicians using EMRs. EMR enables the participating prac-
information repositories; the data MUSC is primarily responsible for tices to uniformly extract the data for
and tools they contain can play a crit- the management of the network and, evaluation, including demographic
ical role in improving the quality of together with the PPRNet advisory information, diagnoses, medications,
care, improvements that can be board, designs and initiates research laboratory results, and vital signs.
quantified. projects. Practice Partner, which Progress notes, consultation reports,
38 GROUP PRACTICE JOURNAL MARCH 2007

2. Obesity
is widespread
and discharge summaries are not PPRNet and volunteered to partici-
included. pate in the Translating Research
In turn, PPRNet provides prac- into Practice (TRIP) study as well as
tices with quarterly reports showing its successor, ATRIP. The New Direction® System
performance on 83 care indicators,
offers a comprehensive weight
including cardiovascular disease,
loss solution for individuals with
THE IDEA OF USING AN EMR TO MEASURE AND
diabetes, cancer screening, immu-
IMPROVE QUALITY WAS A NATURAL EXTENSION
nization, respiratory illness, mental
With our superior, in-person staff
OF THE TECHNOLOGY.
health, nutrition/obesity, and
training and customer support
medication use in the elderly.
you can implement this system
During PPRNet’s Accelerating As an intervention site, Plymouth
into one or more facilities in as
Translation of Research into Family Physicians met quarterly with
Practice (ATRIP) project, which MUSC faculty to review its perfor-
was completed in September 2006, mance. Visiting faculty offered
practices that were randomized into suggestions, described changes that
the intervention arm of the study other practices had made, and encour-
also met quarterly with a member of aged Plymouth to go beyond the
MUSC’s Family Medicine faculty. ATRIP model of optimal practice.
New Direction System
In all, faculty completed 198 site “It was an organization-wide
allows you to:
visits for the ATRIP project. effort,” said Plymouth’s George
At these meetings, faculty Schroeder, M.D. “Each quarter, we
reported on the practice’s quarterly would close our office for several
center by implementing this
performance on the clinical indica- hours and gather our entire staff to
fee-for-service program
tors as compared with its peers review our results. After surveying the
within the study and with national performance reports, we would brain-
benchmarks. The national bench- storm ways to improve our perfor-
• Partner with bariatric
marks were derived from published mance and then set specific goals and
surgical caregivers
sources, such as the annual national strategies for the next quarter. This
quality report from the Agency for routine has since become a discipline
Healthcare Research and Quality that has transformed our practice.” • Provide a new wellness
and from the Centers for Disease According to Schroeder, participa- approach in the prevention
Control (CDC Wonder). Pertinent tion in PPRNet required the practice and treatment of heart
updates to the science behind the to do several things they had not done disease, diabetes and
clinical markers were also presented previously, including documenting
sleep apnea
when available. care in a readily retrievable manner,
In addition to performance utilizing quarterly audits to continu-
• Expand market outreach to
measures, practices have found many ously evaluate the care provided, and
uses for the quarterly reports, includ- establishing expectations for achiev- acquire new patients
ing as a tool for monitoring/enhanc- ing and exceeding proven standards
ing the provision of preventative care of care on every audited item.
and even for calculating bonuses. “As logical as these steps seem,
This, in turn, has expanded the use we would not have made these
of the EMR to help foster changes changes outside the supportive envi-
in behaviors that lead to quality ronment of PPRNet, which Contact us to learn more about
improvements. provided us with the clinical goals
how the New Direction System
and audits we needed to measure
performance and achieve outcomes,”
Seeing Is Believing
Plymouth Family Physicians, a Schroeder said. “The bottom line
two-physician practice in Plymouth, was achieving the established clinical
866-494-1216
Wisconsin, first learned of PPRNet endpoints, and we utilized whatever
www.robard.com/newdirection
a decade ago when they were shop- means necessary to convince our
ping for an EMR. Once their system patients to accept indicated immu-
was up and running, they joined nizations, have their lipids measured,
39
GROUP PRACTICE JOURNAL
MARCH 2007

3. or take yet another medication to the idea of using an EMR to time to determine how well the prac-
control their blood pressure.” measure and improve quality was a tice is adhering to commonly
Family Practice Partners, a four- natural extension of the technol- accepted guidelines.
physician family medicine practice in ogy.“I have been an early adopter all Practices participating in PPRNet
Murfreesboro, Tennessee, is another my life and have been on the Board can easily observe and measure the
prime example of the transformation of the QIO/PRO for Alabama since effectiveness of any changes in
that has taken place among PPRNet 1993, so I’ve been indoctrinated on procedures and workflow. The quar-
participants. The practice originally the need for system-wide quality terly PPRNet reports clearly show
implemented its EMR as a way to improvement. Along with that, I am whether the changes have made a
save money and improve workflow aware of the cost and inefficiencies in statistically significant difference in
efficiencies. a typical physician’s office,” quality.
“A secondary thought was that we Hennigan said. Andrews stated it best: “We
could do a better job,” said Susan For Hennigan, the role an EMR might all be brilliant doctors, and we
Andrews, M.D. “But that was could play in quality improvement all have the best of intentions with
secondary. We were really thinking crystallized while attending an every patient we see, but if we don’t
about the business end.” Alabama Quality Assurance know our actual numbers, we can’t
Andrews and her partners learned Foundation board meeting. The know how well we’re really doing.
about PPRNet at a user meeting held group was discussing the database Most of us will find we’re not in the
by the group’s EMR vendor and which the QIO had amassed and the top 10 percent; 90 percent of us
decided to join, thinking participa- possibilities that existed for using aren’t, but 90 percent of us want to
tion would be fairly easy and could that data beyond what was called for be. If you give us the information,
potentially benefit their patients. in their federal contract. and you give us a way to work on
They quickly found the potential “I realized we were sitting on our improving, we will improve. That
exceeded initial expectations. own database that currently holds can’t be done with a paper record.”
“There was a realization when we more than 4,000 patients and that In summary, by focusing on fully
got that first practice performance there were so many possibilities with utilizing an EMR to not only
report that we weren’t doing the job that data, most as of yet unfulfilled,” streamline processes and improve
we wanted to do,” Andrews said. he said. workflow but to measure perfor-
“This motivated us to use EMR Among the most dramatic exam- mance and improve quality, we will
features and change workflow. We ples of the power of utilizing an ultimately achieve improved
saw huge gains in quality in later EMR for quality improvement is outcomes and quality.
reports. PPRNet impacts almost that of the 1,000 diabetics whom
everything we do as far as quality Hennigan treats, 90 percent now Andrew Ury, M.D., is the founder and
goes.” have HgbA1Cs below 7. The prac- CEO of Practice Partner. Since found-
For example, providers now make tice has also expanded its use of the ing the Seattle-based company in 1983,
extensive use of the disease manage- tools within its EMR based on its he has remained actively involved in all
ment and health maintenance tools PPRNet experiences to include aspects of the development cycle. Dr.
within their EMR to track care and implementation of an onsite Ury currently serves as a Commissioner
generate reminders when things such employee screening and treatment on the Certification Commission for
as flu shots or mammograms are due. project for one local company; it has Healthcare Information Technology
“It’s so easy that we now do it at been asked to consult with another. (CCHIT) and on the HL7 Electronic
every visit. It’s not something we save Health Records Standards Technical
for a physical exam,” said Andrews. Committee. He recently completed his
Moving Beyond PPRNet
“If you’ve got a paper chart or an While PPRNet participants elected term as co-chair of the HIMSS
EMR that doesn’t have that feature, utilize the same EMR system, the Electronic Health Record Vendors
you won’t go digging for the informa- lessons learned and quality improve- Association.
tion because it just takes too long.” ments realized are applicable to all
Michael Hennigan, M.D., physician practices.
FACP, a solo practitioner who runs First, ensure that any data entered
the Diabetes & Lipid Center in into the system is clean and processes
Decatur, Alabama, also joined are standardized. Then implement
PPRNet after attending a vendor- internal quality measures by selecting
sponsored user meeting. For him, indicators and following them over
40 GROUP PRACTICE JOURNAL MARCH 2007