Tuesday, February 14, 2012

It Seems We Are Not The Only Ones Bumping Up Against EHR Data Quality Issues. PCEHR Implications Are Worth Considering.

This very interesting report appeared a little while ago.
Thursday, February 09, 2012

EHR Data Not Ready for Prime Time, Studies Show

by Ken Terry, iHealthBeat Contributing Reporter
Two new studies cast doubt on whether the data in electronic health records are reliable enough to be used as the basis for publicly reported quality measurements and performance-based payments. A third study shows that EHR data on cervical cancer screening may be dependable, but only under certain circumstances.
Taken together, the studies -- all published in the Journal of the American Medical Informatics Association -- provide a snapshot of how well U.S. physicians are documenting preventive services and other clinical data in EHRs. This is important because public and private payers are beginning to require EHR-derived data to support programs aimed at lowering costs and improving the quality of care.
For example, Stage 1 of the meaningful use incentive program requires physicians to provide specific quality data through attestation. As early as 2013, they will have to submit the data electronically to CMS. Physicians already have the option of sending EHR data to Medicare's Physician Quality Reporting System.
Starting in 2015, CMS will use PQRS data to calculate a portion of physicians' Medicare payments under its value-based purchasing program. The ability of health care providers who join accountable care organizations to share in Medicare savings also will depend partly on electronically submitted quality data. And it's likely that private insurers will follow suit in their own ACO programs.
A lot is riding on the reliability of EHR data. But, in regard to the CMS programs, "we're not ready" to use this data, said Eric Schneider, distinguished chair in health care quality at the RAND Corporation. Moreover, he noted, "Until we get the EHR fully operational, we're pretty limited in the types of quality measures we can produce."
Structured Data Are Incomplete
In a study of New York City primary care practices that used the same publicly subsidized EHR, researchers assessed the accuracy of the structured data used for quality measurement. Structured data are computable information entered in discrete fields of the EHR. Researchers manually reviewed electronic charts to identify diagnoses related to preventive care measures anywhere within the record, including free text. According to the researchers, "the average practice missed half of the eligible patients for three of the 11 quality measures."
Because many preventive services were not documented as discrete data, the study also found that practices underreported the services their doctors provided on six of the 11 measures.
Another study -- conducted in a primary care network affiliated with Brigham & Women's Hospital in Boston -- focused on a clinical decision support tool designed to improve the completeness of EHR diagnosis lists, also known as "problem" lists. The program combed through lab, medication and billing data to find hints of missing diagnoses. Physicians who received prompts about these diagnoses through the EHR system added nearly three times as many old and new diagnoses to problem lists as doctors in the control group did.
The authors pointed out that in their prior research, a large portion of diagnoses had been missing from problem lists. For instance, only 51% of hypertension and 62% of diabetes diagnoses had been included. "Other institutions have found similar results," they added.
The third JAMIA study looked at whether EHR data could be used to detect overutilization of cervical cancer screening tests, known as Pap tests. Comparing manual e-chart reviews to the results of EHR queries, the researchers ascertained that EHR data could be used to measure accurately the overuse of Pap tests among low-risk women.
Jason Matthias -- the lead author and a research fellow in the Feinberg School of Medicine at Northwestern University -- said he was confident that every Pap test ordered during the study period had been documented as structured data. The EHR system had a lab interface, and "any results that returned from the pathologists were captured automatically," he said, adding, "If you didn't have results and you didn't have an order, the test hadn't been done."
Consequently, he said that data would be adequate for a quality measure. However, he added that similar information probably would be less accurate in a practice that had recently adopted an EHR system than in the university-affiliated clinic he studied. In a practice that was new to the technology, he said, it's likely that physicians would be less aware of the importance of problem lists and other discrete data.
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MORE ON THE WEB

Lots more with some comments here:
If ever there was an example of “garbage in, garbage out” in operation this has to be it. There has to be a great deal of care taken as we move from the most simplest data sharing to more complex efforts.
This very interesting study which is reported from the UK makes a similar point showing that after many years simple is actually starting to work!

Summary Care Record improving GP out-of-hours prescribing and helping patients die where they choose, DH data shows

By Nigel Praities | 03 Feb 2012
Exclusive: Out-of-hours GPs are changing their prescribing decisions after accessing a patient's Summary Care Record in around a third of cases, Pulse has learned, as the Department of Health prepares to publish data outlining the achievements of the programme so far.
Some 1,600 records are now viewed each week by out-of-hours providers and in other urgent care and hospital settings, with the programme's clinical director Dr Gillian Braunold claiming the rollout has now reached a ‘critical mass' in some areas.
One in five patients across England has now had a care record created – some 11 million in total – while more than 35 million patients have been contacted and told they will have a record created for them if they do not opt out.
Dr Braunold told Pulse the Summary Care Record was now proving of real benefit to clinicians, with the Department of Health due to publish official data imminently.
She said: ‘Primary care out-of-hours clinicians are finding that access to the information is making their consultations safer.'
‘On average, we are finding one in five of patients that turn up in out-of-hours, that is when we are finding it is making a difference. About 30% of cases, they are finding it is changing their therapeutic decisions because they have access to the Summary Care Record.'
Dr Braunold said there was also evidence from areas where end-of-life care plans had been uploaded to care records that more patients were dying in their preferred place.
She added that the future was to increase the scope of the Summary Care Record to help the 111 pilots run by NHS Direct and implement the Government's much-trumpeted ‘Information Revolution'.
Lots more here:
In the UK, as in Scotland, what is shared is the current information from the GP system on just demographics, current medications, reactions and allergies. Because this information is coded and is from the GP’s current record it has a high chance of being very reliable as the GP has a major interest in the information being correct so they can  provide repeats and the like.
All this supports my long held intention that the PCEHR is just way too much too soon. What we need is to scope the PCEHR back to just these basics, get it working as desired and then slowly and carefully grow from there.
You can read the scope of the UK Shared Care Record here:
Because the UK system is Opt-Out (and very few have) where available we are starting to see some real use and some clinical adoption. This, once confirmed with relevant studies, will be very good news indeed. I am very keen to see confirmation that a really simple basic approach can make a difference! I look forward to the official studies coming out.
There is a lesson for the PCEHR here. The UK has taken near to a decade to get a very simple system going and we are hoping to have a much more complex monster going nationally in 18 elapsed months. They are dreaming!
David.

2 comments:

Anonymous said...

As you said: There is a lesson for the PCEHR here. The UK has taken near to a decade to get a very simple system going and we are hoping to have …………….

Let’s face it – DOHA is about to back peddle. Any day now it will announce it has learn’t from the lessons of the past and from outcomes overseas and is now focussing on getting a simpler module of the ‘very complex’ system up and running as a first step by 1 July 2012.

Online prescribing will be the go as it will solve the very urgent problem of doctor shopping and save many lives at the same time.

The prescribing doctors will be left out of the loop until the pharmacists have worked out how the dispensing end of the system should work!

DOHA will invite the doctors to participate much later once they discover that the doctor is positioned at the beginning of the medication process and not at the end.

InformaticsMD said...

Re: "EHR Data Not Ready for Prime Time, Studies Show"

I would extend that to saying "EHRs are not yet ready for prime time."

I've been writing about both for years, and the need to proceed slowly, with the rigor of any other type of human subjects research using experimental medical devices.

(That includes informed consent of the subjects - both patients and clinicians - as well.)

S. Silverstein, MD