Cardiovascular disease is the leading cause of morbidity

electronic health records Implementation of an Electronic Health Record with an Embedded Quality Improvement Program to Improve the Longitudinal Care of Outpatients with Coronary Artery Disease Allan G. Simpson, MD, Pamela B. DeGuzman, RN, MSN, MBA, Kirk E. Barbieri, BS, Cherie M. Parks, BS, RN, Gregory C. Megginson, BS, and C. Renée Viette, MBA Abstract Objective: To describe the development and implementation of an electronic health record (EHR) with an embedded continuous quality improvement program for care of patients with stable coronary artery disease. Setting: Outpatient cardiology clinic at an academic medical center. Methods: The EHR was embedded with evidencebased treatment guidelines and performance measures developed by the American College of Cardiology/American Heart Association and others. The EHR provided treatment reminders at the point of service, physician report cards, patient registries, and health record summaries for patients. Regular feedback was provided to the health care team. Results: After 4 years of EHR use, performance ratings and clinical outcomes improved significantly. Treatment of hypertension and low-density lipoprotein cholesterol improved by 50%, and there was nearly a 40% improvement in all measured outcomes (P < 0.001). Conclusion: A well-designed EHR can significantly improve physician adherence to treatment guidelines and capture pertinent patient data and clinical outcomes in patients with coronary artery disease. Cardiovascular disease is the leading cause of morbidity and mortality in the United States [1], with total costs for 2008 estimated to be $448.5 billion [2]. Despite the availability of evidence-based guidelines, deficiencies in patient care have been documented. Observational studies have shown that after hospital discharge, there is a progressive decline in adherence to prescribed coronary artery disease (CAD) therapy, with 50% to % of patients either discontinuing or only intermittently taking their medications [3,4]. In addition, there is a large gap between guideline recommendations and use of recommended therapy in practice [5 8]. As a result, only 20% to 40% of patients with CAD have their blood pressure or total cholesterol treated to goal [9 11]. The Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) trial, a study of patients hospitalized with acute coronary syndromes, demonstrated that with physician feedback, order sets, and discharge protocols, prescription of indicated medications can be significantly improved. This was accompanied by a combined reduction of mortality and recurrent myocardial infarction rate from 14.8% to 6.4% in 1 year, a 56% reduction [12]. Although many institutions have developed quality improvement programs incorporating guidelines into the hospital phase of treatment, relatively little attention has been paid to the outpatient phase of treatment. In an effort to improve clinician and patient adherence with evidence-based treatment recommendations, we developed a continuous quality improvement program for our cardiology clinics. We hypothesized that the program, which included visual prompts and regular physician feedback, would improve clinical performance in achieving target goals. Methods Setting The cardiology clinics at the University of Virginia Health System are staffed by 32 physicians, including 17 cardiology attendings and 15 cardiology fellows who provide care for more than 24,000 outpatients visits annually. From the Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, VA. 338 JCOM July 2008 Vol. 15, No. 7 www.turner-white.com

reports from the field quality improvement Table 1. Clinical Performance Measures for the Use of Pharmacologic Agents in the Treatment of Chronic Stable Coronary Artery Disease (CAD) Therapy Angiotensin-converting enzyme inhibitor therapy Antilipemic therapy Antiplatelet therapy β-blocker therapy Recommendation Prescribe for patients with CAD who also have diabetes and/or left ventricular systolic dysfunction Also for patients with CAD or other vascular disease Prescribe for all patients with CAD Prescribe for all patients with CAD; routine use of aspirin is recommended in the absence of contraindications Prescribe for all patients with CAD with prior myocardial infarction in the absence of contraindications Electronic Health Record On 1 July 2004, we implemented a client-server based comprehensive electronic health record (EHR). The EHR interfaces with hospital information systems to reduce data entry at the time or point of service. Minimal data entry is required, such as for new vital signs, outside laboratory results, and verification or reconciliation of medications. Clinical guidelines and performance measures for the longitudinal care of patients with a diagnosis of CAD were embedded into the EHR. Performance measures. The EHR assesses 12 quality measures for care of patients with chronic stable CAD, which we divided into 3 categories: clinic performance, physician performance, and clinical outcomes. The clinic performance measures are weighing the patient, assessing cardiac pain/ functional capacity using the New York Heart Association (NYHA) classification system, and medication reconciliation for each clinic visit. We added medication reconciliation when it was established as a national patient safety goal by the Joint Commission in 2006 [13]. The physician performance measures are appropriate use of 4 classes of medications shown to reduce cardiovascular mortality in patients with CAD: angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antilipemic medications, antiplatelet medications, and β blockers (Table 1). The physician performance measures are based on measures developed by the American College of Cardiology (ACC) and American Heart Association (AHA) in collaboration with the American Medical Association s Physician Consortium for Performance Improvement [14]. The patient outcomes measures are achievement of blood pressure and lipid goals (ie, goals for total cholesterol, high-density Table 2. Clinical Performance Measures for Lipid and Blood Pressure Management Clinical Assessment Total cholesterol High-density lipoprotein cholesterol Low-density lipoprotein cholesterol Triglycerides Blood pressure Performance Goal < 200 mg/dl > 40 mg/dl < mg/dl < 150 mg/dl < 140/90 mm Hg lipoprotein cholesterol, low-density lipoprotein [LDL] cholesterol, and triglycerides) (Table 2). The goal values are derived from ACC/AHA and National Cholesterol Education Program guidelines [15,16]. Quality improvement tools. Several quality improvement tools were incorporated into the EHR, including point-ofservice reminders, physician report cards, benchmarking, and patient education. During the clinic visit, patient care technicians weigh the patient and obtain their vital signs, including blood pressure, and enter these data into the EHR. If the patient s blood pressure is above the established threshold, the reading is evaluated as not meeting the goal. The nursing staff then reviews clinical information with each patient, assesses and records the patient s functional capacity using the NYHA classification system, and reconciles the medication list, all of which are documented electronically. The medications are entered by class of medication allowing for assessment of use per AHA/ ACC guidelines. If medication reconciliation is not performed at the point of care, a reminder in red appears on the screen. After the patient leaves, the user is given 7 days to reconcile the patient s medications or document that medications were unable to be reconciled. If documentation is not completed within the 7-day window, the user s access to the EHR is restricted until this documentation has been completed. This lock-out feature has led to % of patient s medications being reconciled within a 1-week period. Patient laboratory values or vital signs lying outside the reference/goal range are highlighted in red on the screen as a prompt to physicians to consider further treatment. Physician report cards are provided confidentially to each physician on a quarterly basis. The report card includes the number of patients included in the analysis, the percentage of patients prescribed indicated therapies, and the percentage of patients treated to target goals. Only patients who have been seen at least 3 times by the physician are included in the analysis. This number of visits was selected by our physicians as the minimum number of visits necessary to reflect the care that they directed. Physicians www.turner-white.com Vol. 15, No. 7 July 2008 JCOM 339

electronic health records Table 3. Baseline Characteristics of Study Population (n = 2890) Characteristic Value Mean age, yr 69 Gender, n (%) Female 925 (32) Male 1965 (68)0 Cardiovascular risk factors, n (%) Diabetes 983 (34) Hyperlipidemia/dyslipidemia 2283 (79)0 Hypertension 2081 (72)0 Cardiovascular history, n (%) Previous myocardial infarction 694 (24) Cardiac catheterization 1965 (68)0 Percutaneous coronary intervention 636 (22) Coronary artery bypass grafting 838 (29) Mean no. of clinic visits/yr 2.3 Mean no. of antihypertensive medications/patient 2.6 Mean no. of antilipemic medications/patient 1.6 have the opportunity to exclude patients from the analysis if the patient is unable to tolerate a medication, if the medication is not indicated, or if the patient refuses to take the medication. Two benchmarks are provided for each measured parameter: the mean of the practice (all other physicians in the group) and the mean of the top 10% of the practice (3 physicians). A patient registry that lists all patients not at goal, with parameters outside goal outlined in red, is also provided to each physician upon request. This enables the physician to verify the validity of the data. The patients phone numbers are also provided with the registry to facilitate physician intervention. At the close of the clinic visit, a patient summary is generated from the EHR, printed, and given to the patient. The summary contains the patient s diagnoses, medications, vital signs, and pertinent laboratory results. The patient s data are graphically displayed along with their goals. The physician and nurse use the summary to review the patient s treatment goals with the patient and discuss ways to achieve them, including making heart-healthy lifestyle modifications and adhering to prescribed medications. This summary is updated at each clinic visit. Results Baseline characteristics of the study cohort are shown in Table 3. Mean age was 69 years, and 68% were men. There was a high prevalence of traditional cardiovascular risk factors among the study population, including diabetes, dyslipidemia, and hypertension. Patients were considered to have CAD if they had a clinical diagnosis of previous myocardial infarction, had demonstrable disease on cardiac catheterization, or had undergone coronary revascularization, either by percutaneous coronary intervention or coronary artery bypass grafting. Patients averaged 2.3 clinic visits annually and were taking 1.6 antilipemic agents and 2.6 antihypertensive medications on average. The EHR quality improvement program was initiated on 1 July 2004. The initial analysis provides baseline data on the measured variables, except for medication reconciliation (which was added in 2006), and includes 2890 patients. Subsequent analyses were performed each year on 1 July. By 2007, the CAD population had increased to 5180 patients. Figure 1, Figure 2, and Figure 3 show performance measure ratings for the 3 categories of performance from 2004 through 2007. Improvement occurred markedly after the first year for most measures, with all improvements in clinical outcome measures sustained over the subsequent years. The statistical test for proportions was used to determine if results achieved in 2007 were significantly different than those achieved in 2004. All tests were significant at P < 0.001. Statistical analyses were performed using Minitab Statistical Software, version 15 (Minitab, State College, PA). Discussion To improve and provide continuous analysis of our clinic s performance, we developed clinic, physician, and clinical outcome performance measures with a built-in feedback loop within the context of our newly designed EHR. This EHR allowed for the search and summary report of more than 25,000 patient records in less than 1 minute. The program resulted in significantly improved clinic, physician, and clinical outcome performance including % compliance with medication reconciliation. Of the patient outcomes, high blood pressure and dyslipidemia are the most treatable risk factors in patients with CAD. After 4 years of program implementation, blood pressure goals were achieved in 78% of clinic patients (compared with 52% at baseline) and LDL cholesterol goals were achieved in 62% of patients (up from 39% at baseline). These improvements, which in clinical studies have been associated with a reduction in morbidity and mortality in CAD patients, have been sustained in an expanding population of clinic patients. Our findings are limited, as they are the result of a team approach to quality improvement in a large group practice with a highly functional EHR and smaller practices may not have access to the same resources. Our patient mix likely has more barriers to care, such as lower income and lack of insurance, than typically exist in smaller, private practices. 340 JCOM July 2008 Vol. 15, No. 7 www.turner-white.com

reports from the field quality improvement 2004 2005 2006 2007 97 97 98 80 73 70 Patients, % 40 44 56 52 Figure 1. Annual results of clinic performance, assessed as the weighing of patients, assessment of functional status, and reconciliation of medications, for calendar years 2004 2007. 20 0 Patient weighed 2 Functional status assessed Medications reconciled 2004 2005 93 92 92 2006 90 90 89 2007 Patients, % 80 40 59 68 76 71 79 79 58 64 75 70 Figure 2. Annual results of physician performance, assessed as the prescribing of indicated classes of medications, for calendar years 2004 2007. ACE = angiotension-converting enzyme. 20 0 ACE inhibitor Antilipemic Antiplatelet β Blocker Also, smaller practices may not have access to EHRs designed specifically for a cardiology practice. Further studies are needed to explore affordable systems of care that may lead to improved patient outcomes. Such studies may help establish national benchmarks for physician performance and expected patient outcomes. With the introduction of pay-for-performance programs by health care insurers and the Center for Medicare and Medicaid Services, which align payment of physicians to documented quality care, it becomes imperative to establish such benchmarks. www.turner-white.com Vol. 15, No. 7 July 2008 JCOM 341

electronic health records 2004 2005 2006 2007 Patients, % 80 40 52 66 77 78 54 64 73 74 44 45 43 38 62 50 39 56 54 48 41 Figure 3. Clinical outcome results, assessed as achievement of the treatment goals for blood pressure (BP), total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides, for calendar years 2004 2007. 20 0 Blood pressure Total cholesterol HDL LDL Triglycerides In conclusion, the EHR intervention implemented in our cardiology clinics was a success, altering processes of care and resulting in significantly improved clinic, physician, and clinical outcome performance. As we move nationally toward the use of EHRs, such a capability will become both increasingly available and necessary. Corresponding author: Pamela B. DeGuzman, RN, MSN, MBA, University of Virginia Health System, Box 800134, Charlottesville, VA 22908-0134, deguzman@virginia.edu. References 1. Hoyert DL, Kung HC, Smith BL. Deaths: preliminary data for 2003. National Vital Stat Rep 2005;53:1 48. Available at www. cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_15.pdf. Accessed 9 Jun 2008. 2. American Heart Association. Heart disease and stroke statistics 2008 update. Available at www.americanheart. org. Accessed 9 Jun 2008. 3. Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med 2005;165:1147 52. 4. Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation 2006;113:203 12. 5. Pearson TA, Peters TD. The treatment gap in coronary artery disease and heart failure: community standards and the post-discharge patient. Am J Cardiol 1997;80:45H 52H. 6. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease [published erratum appears in Am J Cardiol 1999;84:1143]. Am J Cardiol 1999;83:1303 7. 7. Frolkis JP, Zyzanski SJ, Schwartz JM, Suhan PS. Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATP II) guidelines. Circulation 1998; 98:851 5. 8. Stafford RS, Radley DC. The underutilization of cardiac medications of proven benefit, 1990 to 2002. J Am Coll Cardiol 2003; 41:56 61. 9. Lloyd-Jones DM, Evans JC, Levy D. Hypertension in adults across the age spectrum: current outcomes and control in the community. JAMA 2005;294:466 72. 10. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988 2000. JAMA 2003;290:199 206. 11. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291:335 42. 12. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol 2001;87:819 22. 13. The Joint Commission. 2008 National patient safety goals: hospital program. Available at www.jointcommission. org/nr/rdonlyres/82b717d8-b16a-4442-ad00-ce- 3188C2F00A/0/08_HAP_NPSGs_Master.pdf. Accessed 9 Jun 2008. 14. American College of Cardiology, American Heart Association, and Physician Consortium for Performance Improvement. Clinical performance measures: chronic stable coronary artery disease. Chicago: American Medical Association; 2003:8. 15. Fraker TD Jr, Fihn SD. Chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Associated Task Force on Practice Guidelines Writing Group to develop a focused update of the 2002 guidelines for the management of patients with chronic stable angina [published erratum appears in J Am Coll 342 JCOM July 2008 Vol. 15, No. 7 www.turner-white.com

reports from the field quality improvement Cardiol 2007;50:e1]. J Am Coll Cardiol 2007;50:2264 7. 16. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda (MD): U.S. Department of Health and Human Services; 2001. Available at www.nhlbi.nih.gov/ guidelines/cholesterol/atp3xsum.pdfnih Publication No. 01-3670. Accessed 9 Jun 2008. Copyright 2008 by Turner White Communications Inc., Wayne, PA. All rights reserved. www.turner-white.com Vol. 15, No. 7 July 2008 JCOM 343