Rina V. Dhopeshwarkar

Accuracy of Electronically Reported “Meaningful Use” Clinical Quality Measures: A Cross-sectional Study

BACKGROUND The federal Electronic Health Record Incentive Program requires electronic reporting of quality from electronic health records, beginning in 2014. Whether electronic reports of quality are accurate is unclear. OBJECTIVE To measure the accuracy of electronic reporting compared with manual review. DESIGN Cross-sectional study. SETTING A federally qualified health center with a commercially available electronic health record. PATIENTS All adult patients eligible in 2008 for 12 quality measures (using 8 unique denominators) were identified electronically. One hundred fifty patients were randomly sampled per denominator, yielding 1154 unique patients. MEASUREMENTS Receipt of recommended care, assessed by both electronic reporting and manual review. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and absolute rates of recommended care were measured. RESULTS Sensitivity of electronic reporting ranged from 46% to 98% per measure. Specificity ranged from 62% to 97%, positive predictive value from 57% to 97%, and negative predictive value from 32% to 99%. Positive likelihood ratios ranged from 2.34 to 24.25 and negative likelihood ratios from 0.02 to 0.61. Differences between electronic reporting and manual review were statistically significant for 3 measures: Electronic reporting underestimated the absolute rate of recommended care for 2 measures (appropriate asthma medication [38% vs. 77%; P < 0.001] and pneumococcal vaccination [27% vs. 48%; P < 0.001]) and overestimated care for 1 measure (cholesterol control in patients with diabetes [57% vs. 37%; P = 0.001]). LIMITATION This study addresses the accuracy of the measure numerator only. CONCLUSION Wide measure-by-measure variation in accuracy threatens the validity of electronic reporting. If variation is not addressed, financial incentives intended to reward high quality may not be given to the highest-quality providers. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Consumer Support for Health Information Exchange and Personal Health Records: A Regional Health Information Organization Survey

In order to characterize consumer support for electronic health information exchange (HIE) and personal health records (PHRs) in a community where HIE is underway, we conducted a survey of English speaking adults who visited primary care practices participating in a regional community-wide clinical data exchange, during August, 2008. Amongst the 117 respondents, a majority supported physicians’ use of HIE (83%) or expressed interest in potentially using PHRs (76%). Consumers’ comfort sending personal information electronically over the Internet and their perceptions regarding the potential benefits of HIE were independently associated with their support for HIE. Consumers’ prior experience using the Internet to manage their healthcare, perceptions regarding the potential benefits of PHRs and college education were independently associated with potential PHR use. Bolstering consumer support for HIE and PHRs will require addressing privacy and security concerns, demonstrating clinical benefits, and reaching out to those who are less educated and computer literate.

Healthcare Consumers’ Attitudes Towards Physician and Personal Use of Health Information Exchange

Health information exchange (HIE), the electronic transmission of patient medical information across healthcare institutions, is on the forefront of the national agenda for healthcare reform. As healthcare consumers are critical participants in HIE, understanding their attitudes toward HIE is essential. To determine healthcare consumers’ attitudes toward physician and personal use of HIE, and factors associated with their attitudes. Cross-sectional telephone survey. English-speaking residents of the Hudson Valley of New York. Consumer reported attitudes towards HIE. Of 199 eligible residents contacted, 170 (85%) completed the survey: 67% supported physician HIE use and 58% reported interest in using HIE themselves. Multivariate analysis suggested supporters of physician HIE were more likely to be caregivers for chronically ill individuals (OR 4.6, 95% CI 1.06, 19.6), earn more than

Measuring the Effects of Health Information Technology on Quality of Care: A Novel Set of Proposed Metrics for Electronic Quality Reporting

100,000 yearly (OR 3.5, 95% CI 1.2, 10.0), and believe physician HIE would improve the privacy and security of their medical records (OR 2.9, 95% CI 1.05, 7.9). Respondents interested in using personal HIE were less likely to be female (OR 0.4, 95% CI 0.1, 0.98), and more likely to be frequent Internet-users (OR 3.3, 95% CI 1.03, 10.6), feel communication among their physicians was inadequate (OR 6.7, 95% CI 1.7, 25.3), and believe personal HIE use would improve communication with their physicians (OR 4.7, 95% CI 1.7, 12.8). Consumer outreach to gain further support for ongoing personal and physician HIE efforts is needed and should address consumer security concerns and potential disparities in HIE acceptance and use.BACKGROUNDHealth information exchange (HIE), the electronic transmission of patient medical information across healthcare institutions, is on the forefront of the national agenda for healthcare reform. As healthcare consumers are critical participants in HIE, understanding their attitudes toward HIE is essential.OBJECTIVETo determine healthcare consumers’ attitudes toward physician and personal use of HIE, and factors associated with their attitudes.DESIGNCross-sectional telephone survey.PARTICIPANTSEnglish-speaking residents of the Hudson Valley of New York.MAIN MEASUREConsumer reported attitudes towards HIE.KEY RESULTSOf 199 eligible residents contacted, 170 (85%) completed the survey: 67% supported physician HIE use and 58% reported interest in using HIE themselves. Multivariate analysis suggested supporters of physician HIE were more likely to be caregivers for chronically ill individuals (OR 4.6, 95% CI 1.06, 19.6), earn more than

Health Care Consumers’ Preferences Around Health Information Exchange

100,000 yearly (OR 3.5, 95% CI 1.2, 10.0), and believe physician HIE would improve the privacy and security of their medical records (OR 2.9, 95% CI 1.05, 7.9). Respondents interested in using personal HIE were less likely to be female (OR 0.4, 95% CI 0.1, 0.98), and more likely to be frequent Internet-users (OR 3.3, 95% CI 1.03, 10.6), feel communication among their physicians was inadequate (OR 6.7, 95% CI 1.7, 25.3), and believe personal HIE use would improve communication with their physicians (OR 4.7, 95% CI 1.7, 12.8).CONCLUSIONSConsumer outreach to gain further support for ongoing personal and physician HIE efforts is needed and should address consumer security concerns and potential disparities in HIE acceptance and use.

Health Information Exchange and Ambulatory Quality of Care

BACKGROUND Electronic health records (EHRs), in combination with health information exchange, are being promoted in the United States as a strategy for improving quality of care. No single metric set exists for measuring the effectiveness of these interventions. A set of quality metrics was sought that could be retrieved electronically and would be sensitive to the changes in quality that EHRs with health information exchange may contribute to ambulatory care. METHODS A literature search identified quality metric sets for ambulatory care. Two rounds of quantitative rating of individual metrics were conducted. Metrics were developed de novo to capture additional expected effects of EHRs with health information exchange. A 36-member national expert panel validated the rating process and final metric set. RESULTS Seventeen metric sets containing 1,064 individual metrics were identified; 510 metrics met inclusion criteria. Two rounds of rating narrowed these to 59 metrics and then to 18. The final 18 consisted of metrics for asthma, cardiovascular disease, congestive heart failure, diabetes, medication and allergy documentation, mental health, osteoporosis, and prevention. Fourteen metrics were developed de novo to address test ordering, medication management, referrals, follow-up after discharge, and revisits. DISCUSSION The novel set of 32 metrics is proposed as suitable for electronic reporting to capture the potential quality effects of EHRs with health information exchange. This metric set may have broad utility as health information technology becomes increasingly common with funding from the federal stimulus package and other sources. This work may also stimulate discussion on improving how data are entered and extracted from clinically rich, electronic sources, with the goal of more accurately measuring and improving care.

Electronic health records and ambulatory quality of care.

PURPOSE Consumer buy-in is important for the success of widespread federal initiatives to promote the use of health information exchange (HIE). Little is known, however, of consumers’ preferences around the storing and sharing of electronic health information. We conducted a study to better understand consumer preferences regarding the privacy and security of HIE. METHODS In 2008 we conducted a cross-sectional, random digit dial telephone survey of residents in the Hudson Valley of New York State, a state where patients must affirmatively consent to having their data accessed through HIE. RESULTS There was an 85% response rate (N = 170) for the survey. Most consumers would prefer that permission be obtained before various parties, including their clinician, could view their health information through HIE. Most consumers wanted any method of sharing their health information to have safeguards in place to protect against unauthorized viewing (86%). They also wanted to be able to see who has viewed their information (86%), to stop electronic storage of their data (84%), to stop all viewing (83%), and to select which parts of their health information are shared (78%). Among the approximately one-third (n = 54) of consumers who were uncomfortable with automatic inclusion of their health information in an electronic database for HIE, 78% wished to approve all information explicitly, and most preferred restricting information by clinician (83%), visit (81%), or information type (88%). CONCLUSION Consumers in a state with an opt-in consent policy are interested in having greater control over the privacy and security of their electronic health information. These preferences should be considered when developing and implementing systems, standards and policies.

Low-income, ethnically diverse consumers' perspective on health information exchange and personal health records

BACKGROUND Health information exchange is a national priority, but there is limited evidence of its effectiveness. OBJECTIVE We sought to determine the effect of health information exchange on ambulatory quality. METHODS We conducted a retrospective cohort study over two years of 138 primary care physicians in small group practices in the Hudson Valley region of New York State. All physicians had access to an electronic portal, through which they could view clinical data (such as laboratory and radiology test results) for their patients over time, regardless of the ordering physician. We considered 15 quality measures that were being used by the community for a pay-for-performance program, as well as the subset of 8 measures expected to be affected by the portal. We adjusted for 11 physician characteristics (including health care quality at baseline). RESULTS Nearly half (43%) of the physicians were portal users. Non-users performed at or above the regional benchmark on 48% of the measures at baseline and 49% of the measures at followup (p = 0.58). Users performed at or above the regional benchmark on 57% of the measures at baseline and 64% at follow-up (p<0.001). Use of the portal was independently associated with higher quality of care at follow-up for those measures expected to be affected by the portal (p = 0.01), but not for those not expected to be affected by the portal (p = 0.12). CONCLUSIONS Use of an electronic portal for viewing clinical data was associated with modest improvements in ambulatory quality.