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Physician EHRs: Make patient data work for you

Managing the data deluge an electronic health system provides can be a seemingly onerous task, but corralling the information will improve your practice.

By — Posted June 24, 2013

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Thanks to electronic health records and requirements that doctors use those systems to collect and share data, physician practices have easy access to information they never had before. The data, experts say, hold a lot of power. They can transform the way physicians treat patients and run their practices.

Since the rise of EHRs, much of the talk about patient data has been geared toward so-called big data used by insurance companies, researchers and large health systems to conduct large-scale research projects, guide best practices and determine population-based health statistics. But the data that go into those repositories originate inside physician practices. Experts say that in addition to sending the data along for outside projects, the information collected within a practice's four walls can be used for its own data projects.

Practices already are collecting and reporting certain data measurements to meet requirements of the meaningful use incentive program. But many have not used the data beyond submitting the required reports, because they probably don't know where to start.

Bill O'Byrne, executive director of the New Jersey Health Information Technology Extension Center, the state's regional extension center, said his organization has been working with practices to help them understand what they can do with the patient data they collect.

Regional extension centers were created under the 2009 Health Information Technology for Economic and Clinical Health Act to help physicians select and adopt EHR systems to meet meaningful use requirements. Now that the RECs have helped get EHRs into doctors' offices and assisted physicians in achieving meaningful use, O'Bryne said most practices are at the point of learning how to get the most out of EHRs. He said he is surprised by the new ways EHRs and the data they produce are being used every day.

Data can provide practices with information needed to implement changes in the way care is delivered. Data also can help practices identify improvements on the business side and open up opportunities for physicians to participate in new payment models, including shared savings or bundled payment plans. Deciding what data to use and analyze is a three-step process: identify goals, measure accomplishments and change operations.

“Data is great, and you can do all kinds of cool things with data and create all of these reports and say, 'Wow, look at all of this stuff,' ” said Bob Dupuis, director of technical and managed services for Arcadia Solutions, a health care consulting firm in Burlington, Mass. “But where the rubber meets the road is actually implementing changes in how you do things.”

Identify goals

“We can't overlook the fact that all patients need preventive care,” said Beth Shindele, director of improving health for populations and communities for Quality Insights of Delaware. Quality Insights is a Medicare quality improvement organization that runs the state's REC program, of which Shindele is executive director. EHRs can match patients to needed preventive care, track whether they've received it and monitor the outcomes. EHRs also can help doctors manage chronic care cases. So as physicians attempt to start managing their practices in data-driven ways, preventive and chronic care management are good places to begin, experts say.

Conducting a full practice profile is the first step in identifying areas for improved management, Shindele said. Most EHR systems allow users to run queries on certain patient populations to generate reports.

The profile could include lists of patients with certain chronic conditions and a count of how many are being treated for the condition or need interventions, as well as lists of patients who fall within certain age and gender demographics and how many have received preventive services that apply to that demographic.

When a profile has been made, the practice can hone in on specific diseases or patient populations and the measurements that need improvement.

For example, a large percentage of a practice's patients might be diabetic and struggling to keep A1c levels under control. That could be an area to target. Another practice may identify a large group of hypertensive patients who could benefit from weight-loss interventions.

Physicians also can use meaningful use as a guide, said Kathy Rivard, practice coordinator for the Quality Insights of Delaware REC.

Stage 2 of the meaningful use program has 64 measures that physicians can track. Reviewing those measurements might suggest to physicians what to focus on in their practices. When the measurements are decided, a baseline report is crucial so that the practice knows its starting point. Finally, the practice should set goals with specific targets. If reducing A1c levels is the goal, the practice should decide on the percentage of patients they want to have reduced levels within a set period, Dupuis said.

Measure accomplishments

Before EHRs, measuring progress was limited to data collected through claims data. The advantage of an EHR is that it can provide a snapshot of what is going on at a specific point, whether it's a year ago or now.

Practices should view the progress toward changes they want to implement as a marathon, not a sprint, Dupuis cautioned. A good way to keep staff motivated and everyone committed to the goal is to break up the marathon into a series of sprints.

“Create checkpoints of success,” he said, and keep everyone informed on the progress. When the first goal is met, the bar can be raised to the next level of success. “If people are constantly achieving goals, they get excited when they see the work they are doing is having an impact,” he said.

Shindele said one goal she worked on with a practice was to increase the number of colorectal cancer screenings. She taught the practice how to pull from its EHR the list of patients who, based on age, should have had a colonoscopy but had not. Those patients were sent a postcard encouraging them to schedule the procedure. Some of these patients followed through with an appointment, and for several, polyps were discovered and removed during the exam. This proved that data analysis can be potentially lifesaving, she said.

Change operations

Managing the health of patients can be done in a more organized fashion with EHRs. So can the financial health of a practice, especially when data from the EHR are combined with information from the practice management system. Physicians can use data to measure productivity or the rate of follow-up care. EHR data also can identify redundant care and other waste, which is especially important if the practice plans to participate in a shared-savings payment model. Acting on this uncovered data can change the way a practice is run daily.

O'Byrne said a physician client used patient data to re-create the way appointments are handled. He used problem list data to assign a level of acuity to each patient. Level one is assigned to healthy patients. Their appointments are generally for annual exams or minor illnesses. These patients have the least priority for same-day appointments. Level two is for patients with chronic diseases who are given priority if they call with certain symptoms or complaints. Level three are patients who have the most severe illnesses and need the most attention.

Patient data can identify possible business opportunities or additional services to offer patients. For example, if a large number of patients are obese, the practice might consider hiring a nutritionist or implementing other weight-loss services, Rivard said.

Using data can lead physicians toward participation in an accountable care organization, O'Byrne said. The first step is creating a patient-centered medical home environment. The practice is able to coordinate care more rapidly and efficiently than would be possible without the ability to exchange information electronically with all the members of a patient's care team. The next step is using the data to determine what is working and what is not — the basis for an ACO/shared savings model.

Data can help guide physicians to the most effective treatments, O'Byrne said. Most doctors recognize within 30 days if there has been a change in a patient's status, he said. “If the problem has not been solved in 30 days, it's useless to continue down the same path.” An EHR system can organize the data in an effective way, he said. For example, a bar chart can show how a patient's body is reacting to a specific treatment. That information can be used to look for trends in how patients meeting certain characteristics or demographics react to a certain treatment.

O'Byrne said he and the practices he works with are discovering new ways to use data every day. As long as data are being collected, how they are used will continue to evolve, he said.

“There's a lot of those 'aha' moments with doctors when they realize, 'Oh my God. I didn't know [my EHR] could do that,' ” O'Byrne said. “The light comes on in their faces, and they'll say they had no idea they had all that ability at their fingertips.”

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8 recommended clinical quality measures

Beginning in 2014, all eligible professionals participating in the meaningful use incentive program must report clinical quality measures to the Centers for Medicare & Medicaid Services using the 2014 edition of those standards. The edition includes a list of 64 standards from which physicians can choose to focus. CMS recommends the following eight for adult treatment:

  1. Controlling hypertension: Measures the percentage of patients 18 to 85 years old with a diagnosis of hypertension and whose blood pressure was controlled adequately.
  2. Use of high-risk medications in the elderly: Measures the percentage of patients 66 and older who were prescribed at least one high-risk medication and those prescribed at least two high-risk medications.
  3. Preventive care and screening, tobacco use screening and cessation intervention: Measures the percentage of patients 18 and older who were screened for tobacco use one or more times within 24 months and who received cessation counseling intervention.
  4. Use of imaging studies for low back pain: Measures the percentage of patients 18 to 50 years old with a diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis.
  5. Preventive care and screening, screening for clinical depression and follow-up plan: Measures the percentage of patients 12 and older screened for clinical depression on the date of the encounter using an age-appropriate standardized depression screening tool and, if positive, a follow-up plan is documented on the date of the positive screen.
  6. Documentation of current medications in the medical record: Measures the percentage of patients for whom the physicians documented all of the current medications (over-the-counter, prescription, herbal and vitamin/mineral dietary) and dosage, frequency and route of administration.
  7. Preventive care and screening, body mass index screening and follow-up: Measures the percentage of patients 18 and older with a BMI documented during the encounter and the previous six months. If outside normal parameters, a follow-up plan is documented.
  8. Closing the referral loop, receipt of specialist report: Measures the percentage of patients with referrals for which the referring physician receives a report from the physician to whom the patient was referred.

Source: Recommended core measures for meaningful use, Centers for Medicare & Medicaid Services (link)

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How to use data for quality improvement

Practices can implement many quality improvement plans based on data physicians were required to collect for stage 1 of meaningful use. Data collection also can help guide practices toward services they can add or to which they can refer patients.

Data Improvement plans/practice changes
Blood pressure Reduction in hypertension rates
BMI charts Weight-loss programs, nutritional counseling
Smoking status Smoking-cessation programs
Condition lists Outreach reminders, preventive/follow-up care
Immunization records Outreach reminders
Family history Outreach reminders, preventive care/testing

Source: Centers for Medicare & Medicaid Services list of meaningful use core and menu objectives

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