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Improving Patient Care |

Quality Improvement with an Electronic Health Record: Achievable, but Not Automatic

Richard J. Baron, MD
[+] Article, Author, and Disclosure Information

From Greenhouse Internists, Philadelphia, Pennsylvania.

Acknowledgments: The author thanks the outstanding team of support staff at Greenhouse Internists, who did most of the work described in this article, and the Greenhouse physicians, Drs. Elizabeth Fabens, Melissa Schiffman, and Erica Wolf, who have been wonderful improvement partners in our EHR adventure. Finally, the author thanks Dr. Eric Holmboe for his helpful and thoughtful input on earlier drafts of this manuscript.

Potential Financial Conflicts of Interest: Consultancies: R.J. Baron (Mercer Human Resource Consulting). Grants received: R.J. Baron (Physicians Foundation for Health Systems Excellence).

Requests for Single Reprints: Richard J. Baron, MD, Greenhouse Internists, PC, 345 East Mt. Airy Avenue, Philadelphia, PA 19119; e-mail, rbaron@greenhouseinternists.com.

Ann Intern Med. 2007;147(8):549-552. doi:10.7326/0003-4819-147-8-200710160-00007
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As physicians in small offices increasingly adopt electronic health records (EHRs), there are high expectations for how such records might be used to improve quality. Eighteen months after implementing a full-featured EHR in our 4-physician general internal medicine practice, we used it to support a project to improve mammography rates. We achieved a 10% absolute improvement at a modest but unreimbursed cost. Nonetheless, we encountered some barriers, including the complexity of acquiring structured data, difficulty in measuring our baseline rate, and the absence of support resources both within and outside our practice. Although we are only 1 small practice using 1 EHR product, our experience may inform other physicians implementing EHRs and those who seek improved health system performance.

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Grahic Jump Location
Figure 1.
Algorithm for entering mammography data into an electronic health record.

Algorithm showing the number of mouse clicks required for signing in a mammogram versus recording the data in a structured format.

Grahic Jump Location




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More meaningful Electronic health record system
Posted on October 27, 2007
Dr Robert James
Christian Medical College and Hospital, Ldh, Pb, India
Conflict of Interest: None Declared

Electronic health record system is now being used in hospitals in India also. Though the progress is slow, yet it is there.

The only thing is information stored is accessible to a few limited systems wired together. So to check a simple report you have still to go to ward and punch in patient unit no and check the reports. You can't access the same while you are out of the ward, even in hospital corridors. I think once our hospital goes wifi, information will be more readily accessible and even on personal laptops. Then we would be able to access vital patient information even when on the move. The latter can help save a lot of time, that can be used to treat the patient..

Another addition that needs to be made to electronic health record system is to, allow access to patient information on mobile phone systems/PDAs, so that it storing patient information becomes even more meaningful and useful.

It would be very convenient if an intern can collect CBC of a patient by just sending patients unit no as a SMS to a dedicated SMS hospital no, or better if the cardiologist can get to see old and new ECGs of a patient in a MMS and make some important changes in patient management while the patient is on hold over the phone.

Imagine if you can get an alert through a text message on your phone, that your patient has acetone positive or life threatening hyperkalemia. It could help you intervene a few hours earlier. Or you could compare your patient's ECG with his / her old ECG in your hospital electronic database and change the medication for better.

I think electronic health record system will undergo much more needed changes world wide to integrate data, and also to make it more accessible.

Conflict of Interest:

None declared

Electronic Health Records - Getting There, But Not Quite There Yet
Posted on November 4, 2007
Yul D Ejnes
Coastal Medical, Inc.
Conflict of Interest: None Declared

In his description of the challenges of conducting quality improvement activities in his practice using an electronic health record (EHR), Baron (1) reminds us that installing electronic records in physicians' offices is only one step in the process of transforming health care delivery using health information technology. My experience as a user of an electronic record for thirteen months confirms Baron's observations. Unlike the cooker sold on Sunday morning infomercials, EHR adoption is not "set it and forget it."

EHR adoption is an oft-cited goal of politicians and policy-makers, more so this election season. As they describe it, EHR's will improve quality, reduce cost, and increase efficiency. Those potential benefits will not be realized without addressing the lack of interoperability among information systems, a deficiency that forces Baron and many others, including me, to have to manually input data into their ostensibly automated information systems in order for it to be searchable and available for analysis. Decision support and ease of use also have a long way to go, for that matter.

Without question, there are immediate benefits from EHR adoption, including access to patient information anywhere and anytime, integration with electronic prescribing, and easy location of data within the patient record. However, the bigger payoffs will have to wait until regional health information exchanges are established, interfaces among systems are affordable, and EHR applications evolve to match more closely how physicians take care of patients.


1. Baron RJ, Quality Improvement with an Electronic Health Record: Achievable, but Not Automatic, Ann Intern Med. 2007;147:549-552.

Conflict of Interest:

Member, Board of Regents, ACP

Response to Quality Imporvement with An EHR: Achievable, but Not Automatic
Posted on November 16, 2007
Elder Granger
Department of Defense, TRICARE Management Activity
Conflict of Interest: None Declared

In his article, Dr. Baron illustrates the importance of using structured data in an EHR to support population health management. Eighteen months after implementing a full- featured EHR in his 4-physician general internal medicine practice; he used it to support a project to improve mammography rates. Dr. Baron suggests that his project results should "encourage those who believe that modest investments in primary care "“ beginning with EHRs and extending to resources needed to follow up on the information they provide"”is worthwhile"¦" He concludes that an EHR may not be sufficient, but based on his experience it will be necessary.

The Military Health System, a global enterprise with approximately 20,000 health care providers, shares Dr. Baron's experiences and concurs with his conclusions. The MHS EHR, called AHTLA, uses structured data to allow for clinical analyses, population health management, medical surveillance, development of evidence-based clinical practice guidelines, and outcomes research. With structured data in the EHR, the continuity of care is improved and makes the encounter documentation accessible in unambiguous, easily understood, and comprehensive terms.

A key design principle of AHLTA is to capture discrete data once, enabling its reuse for multiple purposes. AHLTA uses the Problem- Oriented, Subjective, Objective, Assessment, Plan (SOAP) note format with a standard lexicon of defined clinical terms mapped to standard codes. These provide the basis for the AHLTA clinical narrative note and for subsequent clinical analyses. With AHLTA, providers enter symptom information using structured text, and this enables the establishment of computable links among clinical data; coding; and information on health behaviors, environmental conditions and other risk factors. Data from AHLTA allows providers to query empanelled members to determine who requires screening study (e.g., mammogram, colonoscopy, etc.). In addition, AHLTA has a reminder capability to call attention to a patient's requirements for screening studies and will soon be able to enroll individual patients into rosters of Clinical Practice Guidelines directed at surveillance and management. Either approach provides a proactive means for providers to encourage prevention and wellness behaviors.

With standardized nomenclatures and computable structured text, our MHS EHR data can be searched, aggregated, analyzed and shared; providing a powerful source of information for medical surveillance, clinical research, preventive measures, clinical outcomes, disease management, clinical predictive modeling, patient safety, and business analytical purposes.

Elder Granger, Major General, MD, USA Deputy Director TRICARE Management Activity 5111 Leesburg Pike, Skyline 5, Suite 810 Falls Church,VA 22041

Potential Financial Conflicts of Interest: None disclosed.

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