GPJ_March_mech 3/5/07 7:05 AM Page
Transforming EMRs from Data
Repositories to Tools for Quality
Improvement
BY ANDREW URY, M.D.
P
hysicians participating in prac-
tice-based research projects
through the Practice Partner
Research Network (PPRNet) have
undergone a dramatic paradigm shift
in terms of how they view and use
their electronic medical records
(EMRs), a transformation that has
pushed the boundaries of these
systems beyond daily documentation
and routine patient care to encom-
pass clinical outcomes.
What these physicians have found
is that EMRs are far more than
information repositories; the data
and tools they contain can play a crit-
ical role in improving the quality of
care, improvements that can be
quantified.
38 GROUP PRACTICE JOURNAL
38
Measuring the Premise
PPRNet was formed in May 1995
as a joint effort between the
Department of Family Medicine at
the Medical University of South
Carolina (MUSC) and Practice
Partner, a Seattle-based developer of
electronic health records (EHRs)
and practice management software.
A pioneering concept in practice-
based quality improvement and
research, PPRNet was the first prac-
tice-based research network linking
physicians using EMRs.
MUSC is primarily responsible for
the management of the network and,
together with the PPRNet advisory
board, designs and initiates research
projects. Practice Partner, which
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
primary care (4 percent).
The geographic distribution of
PPRNet practices mimics that of the
general U.S. population: 64 percent
are located in urban areas, 10 percent
in suburban areas, 9 percent in large
towns, and 17 percent in small towns
or rural settings.
Participating practices, all of
which utilize Practice Partner
Patient Records, run a simple utility
to extract data from their EMRs and
send it to PPRNet. Using the same
EMR enables the participating prac-
tices to uniformly extract the data for
evaluation, including demographic
information, diagnoses, medications,
laboratory results, and vital signs.
Progress notes, consultation reports,
MARCH 2007
GPJ_March_mech 3/5/07 7:05 AM Page 39
and discharge summaries are not
included.
In turn, PPRNet provides prac-
tices with quarterly reports showing
performance on 83 care indicators,
including cardiovascular disease,
diabetes, cancer screening, immu-
nization, respiratory illness, mental
health, nutrition/obesity, and
medication use in the elderly.
During PPRNet’s Accelerating
Translation of Research into
Practice (ATRIP) project, which
was completed in September 2006,
practices that were randomized into
the intervention arm of the study
also met quarterly with a member of
MUSC’s Family Medicine faculty.
In all, faculty completed 198 site
visits for the ATRIP project.
At these meetings, faculty
reported on the practice’s quarterly
performance on the clinical indica-
tors as compared with its peers
within the study and with national
benchmarks. The national bench-
marks were derived from published
sources, such as the annual national
quality report from the Agency for
Healthcare Research and Quality
and from the Centers for Disease
Control (CDC Wonder). Pertinent
updates to the science behind the
clinical markers were also presented
when available.
In addition to performance
measures, practices have found many
uses for the quarterly reports, includ-
ing as a tool for monitoring/enhanc-
ing the provision of preventative care
and even for calculating bonuses.
This, in turn, has expanded the use
of the EMR to help foster changes
in behaviors that lead to quality
improvements.
Seeing Is Believing
Plymouth Family Physicians, a
two-physician practice in Plymouth,
Wisconsin, first learned of PPRNet
a decade ago when they were shop-
ping for an EMR. Once their system
was up and running, they joined
MARCH 2007
Obesity
PPRNet and volunteered to partici-
pate in the Translating Research
is widespread
into Practice (TRIP) study as well as
its successor, ATRIP. The New Direction® System
offers a comprehensive weight
THE IDEA OF USING AN EMR TO MEASURE AND loss solution for individuals with
IMPROVE QUALITY WAS A NATURAL EXTENSION PHGLFDOO\ VLJQL¿FDQW REHVLW\
OF THE TECHNOLOGY. With our superior, in-person staff
training and customer support
As an intervention site, Plymouth you can implement this system
Family Physicians met quarterly with into one or more facilities in as
MUSC faculty to review its perfor- OLWWOHDVGD\V
mance. Visiting faculty offered
suggestions, described changes that
other practices had made, and encour-
aged Plymouth to go beyond the
ATRIP model of optimal practice.
“It was an organization-wide New Direction System
effort,” said Plymouth’s George allows you to:
Schroeder, M.D. “Each quarter, we
would close our office for several ‡ (VWDEOLVKDQHZSUR¿W
hours and gather our entire staff to center by implementing this
review our results. After surveying the fee-for-service program
performance reports, we would brain-
storm ways to improve our perfor-
• Partner with bariatric
mance and then set specific goals and
strategies for the next quarter. This
surgical caregivers
routine has since become a discipline
that has transformed our practice.” • Provide a new wellness
According to Schroeder, participa- approach in the prevention
tion in PPRNet required the practice and treatment of heart
to do several things they had not done disease, diabetes and
previously, including documenting
sleep apnea
care in a readily retrievable manner,
utilizing quarterly audits to continu-
ously evaluate the care provided, and • Expand market outreach to
establishing expectations for achiev- acquire new patients
ing and exceeding proven standards
of care on every audited item.
“As logical as these steps seem,
we would not have made these
changes outside the supportive envi-
ronment of PPRNet, which Contact us to learn more about
provided us with the clinical goals
and audits we needed to measure
how the New Direction System
performance and achieve outcomes,” FDQEHQH¿W\RXURUJDQL]DWLRQ
Schroeder said. “The bottom line
was achieving the established clinical
endpoints, and we utilized whatever 866-494-1216
means necessary to convince our www.robard.com/newdirection
patients to accept indicated immu-
nizations, have their lipids measured,
GROUP PRACTICE JOURNAL 39
GPJ_March_mech 3/5/07 7:06 AM Page
or take yet another medication to
control their blood pressure.”
Family Practice Partners, a four-
physician family medicine practice in
Murfreesboro, Tennessee, is another
prime example of the transformation
that has taken place among PPRNet
participants. The practice originally
implemented its EMR as a way to
save money and improve workflow
efficiencies.
“A secondary thought was that we
could do a better job,” said Susan
Andrews, M.D. “But that was
secondary. We were really thinking
about the business end.”
Andrews and her partners learned
about PPRNet at a user meeting held
by the group’s EMR vendor and
decided to join, thinking participa-
tion would be fairly easy and could
potentially benefit their patients.
They quickly found the potential
exceeded initial expectations.
“There was a realization when we
got that first practice performance
report that we weren’t doing the job
we wanted to do,” Andrews said.
“This motivated us to use EMR
features and change workflow. We
saw huge gains in quality in later
reports. PPRNet impacts almost
everything we do as far as quality
goes.”
For example, providers now make
extensive use of the disease manage-
ment and health maintenance tools
within their EMR to track care and
generate reminders when things such
as flu shots or mammograms are due.
“It’s so easy that we now do it at
every visit. It’s not something we save
for a physical exam,” said Andrews.
“If you’ve got a paper chart or an
EMR that doesn’t have that feature,
you won’t go digging for the informa-
tion because it just takes too long.”
Michael Hennigan, M.D.,
FACP, a solo practitioner who runs
the Diabetes & Lipid Center in
Decatur, Alabama, also joined
PPRNet after attending a vendor-
sponsored user meeting. For him,
40 GROUP PRACTICE JOURNAL
40
the idea of using an EMR to
measure and improve quality was a
natural extension of the technol-
ogy.“I have been an early adopter all
my life and have been on the Board
of the QIO/PRO for Alabama since
1993, so I’ve been indoctrinated on
the need for system-wide quality
improvement. Along with that, I am
aware of the cost and inefficiencies in
a typical physician’s office,”
Hennigan said.
For Hennigan, the role an EMR
could play in quality improvement
crystallized while attending an
Alabama Quality Assurance
Foundation board meeting. The
group was discussing the database
which the QIO had amassed and the
possibilities that existed for using
that data beyond what was called for
in their federal contract.
“I realized we were sitting on our
own database that currently holds
more than 4,000 patients and that
there were so many possibilities with
that data, most as of yet unfulfilled,”
he said.
Among the most dramatic exam-
ples of the power of utilizing an
EMR for quality improvement is
that of the 1,000 diabetics whom
Hennigan treats, 90 percent now
have HgbA1Cs below 7. The prac-
tice has also expanded its use of the
tools within its EMR based on its
PPRNet experiences to include
implementation of an onsite
employee screening and treatment
project for one local company; it has
been asked to consult with another.
Moving Beyond PPRNet
While PPRNet participants
utilize the same EMR system, the
lessons learned and quality improve-
ments realized are applicable to all
physician practices.
First, ensure that any data entered
into the system is clean and processes
are standardized. Then implement
internal quality measures by selecting
indicators and following them over
time to determine how well the prac-
tice is adhering to commonly
accepted guidelines.
Practices participating in PPRNet
can easily observe and measure the
effectiveness of any changes in
procedures and workflow. The quar-
terly PPRNet reports clearly show
whether the changes have made a
statistically significant difference in
quality.
Andrews stated it best: “We
might all be brilliant doctors, and we
all have the best of intentions with
every patient we see, but if we don’t
know our actual numbers, we can’t
know how well we’re really doing.
Most of us will find we’re not in the
top 10 percent; 90 percent of us
aren’t, but 90 percent of us want to
be. If you give us the information,
and you give us a way to work on
improving, we will improve. That
can’t be done with a paper record.”
In summary, by focusing on fully
utilizing an EMR to not only
streamline processes and improve
workflow but to measure perfor-
mance and improve quality, we will
ultimately achieve improved
outcomes and quality.
Andrew Ury, M.D., is the founder and
CEO of Practice Partner. Since found-
ing the Seattle-based company in 1983,
he has remained actively involved in all
aspects of the development cycle. Dr.
Ury currently serves as a Commissioner
on the Certification Commission for
Healthcare Information Technology
(CCHIT) and on the HL7 Electronic
Health Records Standards Technical
Committee. He recently completed his
elected term as co-chair of the HIMSS
Electronic Health Record Vendors
Association.
MARCH 2007