Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges

Abstract

Background: As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. Methods: In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. Results: In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of communityand population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. Discussion: Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.

Documentation of breakthrough pain in narrative clinical records of children with life-limiting conditions: Feasibility of a retrospective review

“…Another factor possibly contributing to poor interrater reliability are the inconsistencies in the narrative nature of the notes and the lack of a routinely used structured pain assessment rating scale (Chang et al, 2015;Hunt, 2012). Correspondingly, a lack of structure has been highlighted in previous studies on documentation in palliative care (Curtis et al, 2018;Furuno et al, 2017;Gunhardsson et al, 2008;McEvoy, 2000;Stewart et al, 2017;Yawn and Wollan, 2005). In one study, pain was commonly noted but different terminology was used, with pain characteristics often lacking (Gunhardsson et al, 2008).…”

Accountability for Community-Based Programs for the Seriously Ill

“…Andrew Ryan, PhD, and Phillip Rogers, MD, as part of this special supplement outline the pros and cons of various models for linking quality and costs. 18 Improving EHR and other data platforms As Curtis et al discuss, there are important barriers to electronic health record (EHR) functionality, including missing and inaccessible data elements, to measure the care of the seriously ill. 19 With the implementation of the IMPACT Act, data elements and quality measures from postacute care patient assessments are being standardized across settings. 20 These standardized elements and measures, including functional and cognitive status, can be mapped and made interoperable with EHRs.…”

Evaluating the care provision of a community-based serious-illness care program via chart measures

“…Of the 17 prescribed opiates at the initial visit, 12 received a bowel regimen and 1 had a contraindication for a bowel regimen b Of the 37 patients who had a history of benzodiazepine use prior to the initial visit, 3 received a prescription at the initial visit. One patient who had not received a benzodiazepine prescription previously, received one at the initial visit measurement such as time commitment and data fidelity [11]. Longitudinal work is needed to determine if the quality domains with low frequency of assessment were reviewed at later time points, and how best to assess these standards.…”

“…Operational gaps currently impede the ready adoption of quality-of-care measurement in community-based serious-illness care programs. The use of electronic health records have demonstrated several challenges to operationalizing, collecting, and reporting these measures in palliative care environments [11]. If community-based serious-illness care programs are to demonstrate value and ensure accountability in the care of vulnerable patients, further assessment needs to be done [12,13].…”