Using EMR Templates to Measure Quality of Care for Children with ADHD and Obesity Jeanne Van Cleave, MD Timothy G. Ferris, MD, MPH September 26, 2007.

Using EMR Templates to Measure Quality of Care for Children with ADHD and Obesity

Jeanne Van Cleave, MDTimothy G. Ferris, MD, MPH

September 26, 2007

Childhood Obesity: Challenges to Measuring Quality of Care

Process Outcome

Recognition of elevated BMI Counseling on diet and exercise Periodic follow-up Assessing symptom progress

BMI <85th percentile

Children with ADHD: Challenges to Measuring Quality of Care

Process Outcome Correct diagnosis (DSM IV criteria) Stimulant and behavior management Periodic follow-up Assessing symptom progress

Improved attentiveness and hyperactivity

Objective To create electronic medical record

templates for ADHD and obesity with clinical decision support

Develop quality of care measures that… Are accurate Closely reflect care that is actually delivered Are technically easy and inexpensive to

measure.

Methods

Part of a larger project to examine the effect of clinical decision support on quality and safety of health care in pediatrics

Funded by AHRQ R01 “Improving Pediatric Patient Safety and Quality of Care Using Health IT”

Methods

Partners Healthcare System’s Longitudinal Medical Record (LMR)

6 general pediatric practices in Greater Boston, 37 clinicians

Methods Development of templates

Collaboration with Partners IS with input from several general pediatricians

Guideline-adherent Easy to use

Implementation Physician member of the study team

visited each practice to introduce the templates

Templates Templates are styled to be used during an

office visit When clinician sees a patient with

ADHD Obesity

Physician retrieves template from pull-down list of available templates

Templates use check boxes and free text fields

Prompt physicians to follow guidelines Can be used for both diagnosis and treatment

Obesity visit template—CC and HPI

Obesity visit template—Risk factor assessment

Obesity visit template—Exam

Obesity visit template—Assessment and plan

Developing quality measures from these templates

Use of the template and check boxes enable the development of quality measures Are accurate Closely reflect care that is actually

delivered Are technically easy and inexpensive

to measure.

Obesity

Recommendation that obese children have weight measured and counseling on exercise and nutrition provided on 2 separate occasions per year

Obesity

Claims-based quality measure Were there two visits in the past 12

months with obesity diagnosis included on billing?

Was there a claim filed by a specialist?

Obesity

Template-based measure Template used with boxes checked

for Acknowledgement of weight Counseling on specific nutrition and

exercise topics Referral to nutritionist or weight

management center

ADHD

Recommendation that children with ADHD who are on stimulant medication have follow-up visits with symptom checks at least 2 times per year

ADHD

Claims-based measure Electronic prescribing data—Is the

patient on a stimulant? Were there two visits in the past 12

months with ADHD diagnosis included on billing?

Was there a claim filed by a mental health specialist?

ADHD

Template-based measure Template used with boxes checked

for Symptom progress Side effects of medication

Claims-based measures

Limitations Inaccuracies inherent to billing

procedures and claims data Lack of specificity Fails to capture meaningful patient-

clinician encounters that are not face-to-face

Additional Quality Measures Using EMR Templates Obesity

Counseling on specific topics Follow-up of specific problems Assessment of risk factors/screening

labs Referral to nutrition counseling or

weight-control centers

ADHD Diagnosis consistent with DSMIV

criteria Prescribing long-acting stimulant

medication Having teacher and parent

evaluations Improvement in symptoms as shown

by standardized scale scores

Additional Quality Measures Using EMR Templates

Challenge: Getting Physicians to Use Templates

For example, range of use of the ADHD template Among subjects exposed to

templates, adoption varied widely

Increasing physician use of the templates will make the quality measurements more valuable

Frequency of use of ADHD templates by individual clinicians

0

5

10

15

20

25

30

35

40

45

50

Clinician

Number of times template was used by clinician

Potential reasons for varied adoption of the templates

Physician factors Style of practice Propensity to uptake new technology

Familiarity with EMR Motivation to change current practice

around ADHD and obesity

Potential reasons for varied adoption of the templates

Practice factors Use of templates by others in the

practice External environment

Use of template quality measures for pay-for-performance

Incentives to use templates

Potential reasons for varied adoption of the templates

Template factors Not modifiable Not easy to bring up in the EMR Not much better than the alternative (free

text notes or physician’s own template) Implementation process

Interaction between key administrators in quality and template development and physicians

Time

Conclusions

EMR templates with clinical decision support can improve measurement of quality of care for children with chronic conditions.

Physician use of these templates is an important barrier.

Thank you

John Co, MD, MPH Fabienne Bourgeois, MD, MPH Rainu Kaushal, MD, MPH Eric Poon, MD, MPH Sarah Johnson, BA Meghan Backus, BA