Mining an EHR for Quality Data:

Mining an EHR for Quality Data:

Practice Culture, Workflow &

Technical Issues

Bill Jones, Deborah Mielke, M.D., Theresa L. Cleary, RN

October 23, 2009

Theresa L. Cleary, RN

Clinical Informatics Nurse

OCHC’s History & Mission

The mission of Open

Cities Health Center is to

provide culturally

competent primary and

preventive health care

and related services to

all people throughout the

Twin Cities metropolitan

area.

The goal is to improve

the health and well-being

of high-risk and

vulnerable populations

through the provision of

affordable medical and

dental care and related

services.

Who Does OCHC Serve?

65% of our patients have

income levels at or below

the Federal Poverty Level.

31% of our patients are

uninsured.

Over two-thirds are

people of color.

39% African American

21% South East Asian

5% Hispanic/Latino

1% Native American

13% are better served in a

language other than

English.

62% of our patients are

female.

An Organic Approach to EHR

Implementation

"Many times we let barriers stop us in our

tracks - we have to go around them and

keep on walking. There are a lot of people

that are cheering for you to be successful."

Executive EHR Committee

Medical Director, Deborah Mielke, MD

IT Director, Bill Jones

Health Information Manager, Pamela Akins

Clinical Informatics Nurse, Theresa L. Cleary, RN

Clinical Director, Sherry Pittman, RN

OCHC Receives MN e-Health

Implementation Grant

12/1/2007 – MN e-Health Grant project

begins.

Clinical Informatics Nurse joins EHR

committee.

OCHC’s EHR/HIT Vision

“To have a fully

integrated,

interoperable system

that incorporates

evidence-based

standards to enhance

workflow, promote

patient safety, and elicit

clinical outcomes to

improve patient care.”

A Stepwise Approach to

Implementation

Asthma Template Measures

Diabetic Flow Sheet

Building the Foundation….

Create policies for quality reporting based

on funding requirements and/or quality

measures.

Define/Maintain Clinical documentation

standards.

Select the right tools to support effective

documentation.

Strengthen the knowledge and

understanding of staff regarding the value

of their clinical data documentation toward

population health monitoring and

Disease Specific Flow sheets

Summary of quality

measures

Retrievable and

Reportable

Standardizes

documentation

Patient centered

approach

Warnings included

for omissions

Balancing act…..

Revise workflows to

ensure user-friendly

process for capturing

comprehensive data.

Keep EHR code sets

up to date to ensure

compliance and HL7

exchange.

Perform routine

Deborah Mielke, MD

Medical Director

How do we use EMR in real

practice?

Data needs to be entered into the

computer by support staff and

providers

How and where the data is entered

affects the ability to use this data in

reports

How the system retrieves the data

also affects the reports

How is data entered into EMR?

Clinical Reference Items- Vitals, labs

Preventative Health Module

Immunization module

Prescription writer

Template trees***

Free text ***

Preventative Health Maintenance

(PHM) Reminders & Reports

Clinical Decision Support

Specialized visit templates and flow

sheets

Online references & calculators

Best practice order sets

Data forms that are not

retrievable

Template trees

Free text

Dictations

Hand written notes

Scanned items

S:

This patient is in today for follow-up

on his multiple medical problems. Patient has a

history of renal insufficiency and is being

followed by nephrology at this time. The

patient states that he refuses to have dialysis.

Patient also has a history of heart disease. He

has a history of hypertension, history of

elevated cholesterol, he has had abdominal

aortic aneurysm repair in the past, degenerative

arthritis of multiple joints and obesity. Patient

also comes in today complaining of erectile

dysfunction.

O:

Vitals: Age: 70. Weight: 300 pounds.

Height: 5’11”. Temperature: 97.4. Blood

pressure: 150/72. Pulse: 76. Respirations: 20.

Generally, the patient is an obese male seen in

no distress. Lungs: Clear. Heart: Rhythm

regular. No murmurs or gallops heard. GI:

Abdomen is obese. No masses or tenderness.

Extremities: There is trace edema in the lower

extremities.

A:

1) Diabetes Mellitus, Type II.

2) Arteriosclerotic heart disease.

4) Hyperlipidemia

5) Renal insufficiency, severe.

6) Status post aortic aneurysm repair.

7) Anemia, probably associated with

renal insufficiency.

8) Degenerative arthritis of multiple

sites, primarily of the knees and ankles.

9) Erectile dysfunction.

P:

Patient will be restarted on

Furosemide 80 mg. daily. He also was given

samples of Cialis 20 mg. every 36 hours as

needed. Continue Plavix 75 mg. daily, Norvasc

10 mg. daily, Cozaar 100 mg., Coreg 25 mg.

twice daily, Prilosec 20 mg. daily, Clonidine

0.2 mg. twice daily, Simvastatin 40 mg. daily,

and NovoLog mix insulin

How is the data retrieved?

Some one has to ask the right

questions

Too much data is not useful

Total counts of patients not useful

What population are you looking at?

Numerator and Denominator

Useful reports and data

Patient registries

Dashboards for providers

UDS reports

Pay for performance reports

How are we doing with these?

Problem with registries- too much

data, incomplete, need to add and

change over time.

Provider dashboards- Data linked to

diagnosis and is not consistent

MN community measures- Our

reports missing data that is in

dictations and not retrievable

What is working?

Prenatal registry using information

from prenatal module

Ongoing data collection for diabetic

patients

Beginning to build a diabetic registry

List of children needing shots

Reporting “influenza like illness” to

CDC

Considerations

1.

Data Integrity

2.

Work back from report to data

3.

Continuous verification (don’t expect

to be notified of process changes)

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Electronic Medical Records provides

an opportunity to quickly monitor/audit

patients and see how well they and

we are doing

This is not an easy process but it is

worth every hour and every dollar we

spend on it.

Questions?

Please contact:

[email protected]

[email protected]