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Original Research |

Exceptions to Outpatient Quality Measures for Coronary Artery Disease in Electronic Health Records

Karen S. Kmetik, PhD; Michael F. O'Toole, MD; Heidi Bossley, MSN, MBA; Carmen A. Brutico, MD, MBA; Gary Fischer, MD; Sherry L. Grund, RN; Bridget M. Gulotta, MSN, MBA; Mark Hennessey, MBA; Stasia Kahn, MD; Karen M. Murphy, RN, PhD; Ted Pacheco, MD; L. Greg Pawlson, MD, MPH; John Schaeffer, MD; Patricia A. Schwamberger, RHIA; Sarah H. Scholle, MPH, DrPh; and Gregory Wozniak, PhD
[+] Article and Author Information

From the American Medical Association, Chicago, Illinois; Midwest Heart Specialists, Lombard, Illinois; Physicians Health Alliance, Scranton, Pennsylvania; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Iowa Foundation for Medical Care, Des Moines, Iowa; Fox Prairie Medical Group, St. Charles, Illinois; North Ohio Heart Center, Avon, Ohio; and National Committee for Quality Assurance, Washington, DC.


Acknowledgment: The authors thank the information technology experts who enabled the reporting of data from each practice site: John Carroll, Marsha Dunlap, Patricia Gallacher, David Pietrzyk, and Vikram Sheshadri. They also thank Erin Kaleba for her contributions to the project; Vince Bufalino for helpful discussions; Rachel Connolly for assistance with data analysis; Joan Roberson and Sandy Pennington for conducting manual data abstraction; and Tim and Becky Kresowik for their critical review of a draft of the manuscript.

Grant Support: By the Agency for Healthcare Research and Quality (R18 HS 017160).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2184.

Reproducible Research Statement:Study protocol: Available from Dr. Kmetik on written request and with written agreement. Statistical code: Portions available from Dr. Kmetik on written request and with written agreement. Data set: Not available.

Requests for Single Reprints: Karen S. Kmetik, PhD, American Medical Association, 515 North State Street, Chicago, IL 60654; e-mail, karen.kmetik@ama-assn.org.

Current Author Addresses: Drs. Kmetik and Wozniak, Ms. Bossley, and Ms. Gulotta: American Medical Association, 515 North State Street, Chicago, IL 60654.

Dr. O'Toole and Ms. Schwamberger: Midwest Heart Specialists, 1919 South Highland Avenue, B203, Lombard, IL 60148.

Drs. Brutico and Murphy: Physicians Health Alliance, 700 Quincy Avenue, Scranton, PA 18510.

Dr. Fischer: University of Pittsburgh Medical Center, 933W-MUH, 200 Lothrop Street, Pittsburgh, PA 15261.

Ms. Grund and Mr. Hennessey: Iowa Foundation for Medical Care, 1776 West Lakes Parkway, Des Moines, IA 50266.

Dr. Kahn: Fox Prairie Medical Group, 2560 Foxfield Road, Suite 160, St. Charles, IL 60174.

Drs. Pacheco and Schaeffer: North Ohio Heart Center, 1220 Moore Road, Avon, OH 44011.

Drs. Pawlson and Scholle: National Committee for Quality Assurance, 1100 13th Street Northwest, Suite 1000, Washington, DC 20005.

Author Contributions: Conception and design: K.S. Kmetik, M.F. O'Toole, G. Fischer, M. Hennessey, L.G. Pawlson, J. Schaeffer, P.A. Schwamberger, S.H. Scholle, G. Wozniak.

Analysis and interpretation of the data: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, G. Fischer, S.L. Grund, B.M. Gulotta, M. Hennessey, S. Kahn, K.M. Murphy, T. Pacheco, L.G. Pawlson, J. Schaeffer, P.A. Schwamberger, S.H. Scholle, G. Wozniak.

Drafting of the article: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, S.L. Grund, B.M. Gulotta, M. Hennessey, S. Kahn, K.M. Murphy, T. Pacheco, L.G. Pawlson, J. Schaeffer, P.A. Schwamberger, S.H. Scholle, G. Wozniak.

Critical revision of the article for important intellectual content: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, G. Fischer, S.L. Grund, B.M. Gulotta, S. Kahn, K.M. Murphy, T. Pacheco, L.G. Pawlson, P.A. Schwamberger, S.H. Scholle, G. Wozniak.

Final approval of the article: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, G. Fischer, S.L. Grund, B.M. Gulotta, S. Kahn, K.M. Murphy, T. Pacheco, J. Schaeffer, P.A. Schwamberger, S.H. Scholle, G. Wozniak.

Provision of study materials or patients: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, G. Fischer, S.L. Grund, B.M. Gulotta, S. Kahn, K.M. Murphy, T. Pacheco, J. Schaeffer, P.A. Schwamberger.

Statistical expertise: K.S. Kmetik, S.L. Grund, M. Hennessey, G. Wozniak.

Obtaining of funding: K.S. Kmetik.

Administrative, technical, or logistic support: K.S. Kmetik, M.F. O'Toole, H. Bossley, C.A. Brutico, G. Fischer, S.L. Grund, B.M. Gulotta, M. Hennessey, S. Kahn, K.M. Murphy, T. Pacheco, L.G. Pawlson, J. Schaeffer, P.A. Schwamberger, S.H. Scholle.

Collection and assembly of data: M.F. O'Toole, H. Bossley, C.A. Brutico, S.L. Grund, B.M. Gulotta, M. Hennessey, S. Kahn, K.M. Murphy, T. Pacheco, J. Schaeffer, P.A. Schwamberger, G. Wozniak.


Ann Intern Med. 2011;154(4):227-234. doi:10.7326/0003-4819-154-4-201102150-00003
Text Size: A A A

Background: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments.

Objective: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions.

Design: Cross-sectional observational study.

Setting: 5 internal medicine or cardiology practices.

Participants: 47 075 patients with coronary artery disease between 2006 and 2007.

Measurements: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records.

Results: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure.

Limitation: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives.

Conclusion: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information.

Primary Funding Source: Agency for Healthcare Research and Quality.

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