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
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.