Evaluating Smart Forms and Quality Dashboards in an Electronic Health Record (EHR)

As anyone who has ever tried to implement an electronic health record (EHR) in clinical practice will tell you, if physicians and others on the frontline of care don't see the value, you won't get very far.

The demands of modern clinical practice require doctors to keep up on the latest in best practices. At the same time, doctors are under increasing pressure to meet certain care measurements for patients under pay-for-performance programs. Still, studies have found that patients only get the recommend care they need 50 percent of the time. And many EHRs are limited in their ability to provide physician performance feedback on quality.

But a new projected funded by the Agency for Healthcare Research and Quality (AHRQ) aims to change that. The project, led by Blackford Middleton, M.D., director of clinical informatics research & development for the Partners Healthcare System, and researchers at Brigham and Women's Hospital and Harvard Medical School, is examining whether information technology tools that provide both clinical-decision support and population-based performance feedback will increase the value of EHRs to clinicians while improving patient safety and quality for patients with acute respiratory illness or coronary artery disease.

In addition, researchers want to see whether these tools can have an impact on health care costs by eliminating duplicate tests and procedures. To make their EHRs more useful, researchers began implementing "smart forms" and "quality dashboards" at clinical practices in the Boston area affiliated with Massachusetts General Hospital and Brigham and Women's Hospital.

Smart forms help physicians to document relevant clinical information and integrate best practice information and ordering capabilities into care. For example, while documenting a patient encounter, the system reminds a doctor that the patient should be taking a particular medication. If appropriate, the doctor can instantly order the medication for the patient, update the EHR, and document the order in the visit note in one step.

"This is a new kind of decision support," says Jeffrey Linder, M.D., a principal investigator for the project. "The whole idea is that ithelps doctors do the right thing easily."

The quality dashboard, which works hand-in-hand with the smart forms, is a system that provides feedback to physicians on their patient population and gives them the ability to see how they are performing on certain measures of quality. The clinician can even compare how they are performing on these measures in relation to other doctors in the clinic or against national benchmarks for quality. The physician can then drill down from the population view and see individual information on patients through the smart forms.

Both Linder and Jeffrey Schnipper, M.D., another principal investigator on the project, say these tools help integrate performance measures into EHRs, making them more valuable. They also provide more accurate quality data. Most information on clinical quality is currently based on claims data, which are retrospective and don't always provide the full picture, Linder and Schnipper say.

"We'd like to push the envelope on how quality reporting is done," the researchers say.

Currently, the dashboard and smart form for acute respiratory patients has been introduced to about 1,000 doctors in 10 practices. The coronary artery disease/diabetes smart form is currently being rolled out to a similar number of practices, while the dashboard for coronary artery disease is being pilot tested in two practices to 20 physicians.

Thus far, researchers say that for technology to be accepted, it has to fit clinician's existing workflow. Introducing new technology will mean a temporary reduction in efficiency. The key is to make change as painless as possible while clearly explaining the benefits of the technology, Schnipper says.

With that in mind, Linder and Schnipper plan to integrate a new "population management" tool into the dashboard system that will allow clinicians to send batch letters to patients, reminding them that they are due for a scheduled test, or sending themuseful information about a medication they are taking. Ordering and documenting the test would also be done instantly.

"Physicians are so crunched for time. We hope that decision support is medicine that goes down well," Linder says.