ACC Corner | Bridging the Gap with EHRs: A Private Practice Perspective

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 - Vincent Bufalino
VIncent Bufalino, MD, FACC

At Midwest Heart Specialists, implementing quality improvement and investing in EHRs go hand in hand. Its EHR system has allowed Midwest Heart to design and meet internal benchmarks and participate in quality-focused federal incentive programs that offset some of the costs of EHRs. Most importantly, EHRs have helped Midwest Heart caregivers effectively serve patients.

Implementing quality improvement is all about process change. At Midwest Heart Specialists—which includes 50 cardiologists in suburban Chicago—this change started in 1997 with the installation of a new IT infrastructure and the development of in-house EHRs and continues to this day.

EHRs are crucial to quality improvement efforts. While the investment in system upgrades and workflow processes is large, the gains in care coordination and patient outcomes outweigh the costs. Federal initiatives like the Physician Quality Reporting System (PQRS), e-prescribing and EHR incentive programs provide opportunities to recoup losses.

As of today, Midwest Heart's EHR provides a digital integrated cardiac record that serves as longitudinal and comprehensive data collection. Data from the clinic, office, hospital, cardiac cath lab and patient's home are integrated in one place, allowing for point-of-care alerts, disease management modules and the ability to benchmark and identify areas for quality improvement.

It doesn't happen all at once. Between 2000 and 2003, we developed virtual lipid, heart failure and hypertension specialty clinics and integrated with local hospitals. In 2004, we upgraded our EHRs to include data field modifications that allow for physician and patient-specific reasons for medication decisions, smoking cessation and functional class. As of 2005, point-of-care alerts addressing medications, LDL and ejection fractions were added to the system.

The integration of performance measures into our EHRs also improved quality. Since 2004, we have seen significant enhancements, including with medication adherence. Between 2004 and 2010, the percentage of CAD patients with prior MI on beta blockers went from 77.3 percent to 92.2 percent, documentation of ejection fraction increased from 52.5 percent to 97 percent and diabetes screening for non-diabetes patients improved from 61.8 percent to 97 percent.

As a result, we have qualified for pay-for-performance bonuses and "monetized our file cabinet." We have been participating in PQRS since 2007, the e-prescribing incentive program since 2009 and meaningful use since 2011.

We struggled the first year of PQRS to retrofit our performance measures to comply with the program's claims submission requirements until CMS decided to allow registry reporting. We now extract data using the same data warehouse as our internal performance measures. To date, we have received full bonus monies.

E-prescribing required a workflow redesign to comply with the claims submission process, which took three months. However, we have since been able to receive the full incentive payments.

In January, we upgraded to a certified EHR version to participate in meaningful use. We have met 14 of the 15 required measures and five of 10 optional measures. We consequently were able to demonstrate 90 days continuous use of a certified EHR and meet requirements for the incentive bonus.

We define efficacy as outcomes associated with an intervention under ideal circumstances. Until recently, we, as healthcare providers, relied on clinical trials and benchmarks to guide treatment of patients.

With the advent of electronic systems, we increasingly have the opportunity to take the ideal to inform our decisions in the real-world, so that we are effective regardless of setting, or where in the care continuum a patient falls.

Does building a bridge between efficacy and effectiveness pose challenges? Yes. However, Midwest Heart is proof that it's not only possible, but rewarding for both patients and practices.

Dr. Bufalino is chair and CEO at Midwest Heart Specialists.