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Monday, September 19, 2011

Quality is not only in the domain of the EHR

One of the challenges with quality measures that I've mentioned previously on this blog is fitting it into the provider workflow.  The example used in the illustration previously has to do with aspirin and heart attack.  Other challenges have to do with quality measures around Venous Thromboembolism (VTE) and Stroke.

The problem that EHRs run into is that in order to measure quality, you need to know about certain condition specific data. Yet this data is often very hard to codify in an EHR.  I delve into some discussion on contraindications and exclusions in Quality Improvement Never Ends that I wrote last week.  And I also tweeted a statement someone made at the CDC Public Health conference.  Farzad Mostashari asked for some details in a response to that tweet, so here they are.

I'll first go back to some of the work that HITSP did on VTE and Stroke.  There are some key data elements used in exclusions for these measures:
  • Comfort Measures Only
  • Elective Carotid Intervention
  • VTE Prophylaxis
  • Reasons for No VTE Prophylaxis
Where would you find these data elements in an EHR?  We were challenged to find a code for comfort measures in SNOMED CT.  You might find a procedure code for Carotid Intervention, but would you find whether that was elective or medically required?  Whose definition of elective would you be using?  An insurers?  Someone's guideline?  If so, from where? Next up: VTE Prophylaxis:  There are three types, medication based, device based, or compression stockings (arguably a device as well).  OK, how is this routinely coded in the EHR?  Medications certainly are coded using RxNORM, but looking through ICD-9-CM (Procedure codes used in a hospital setting), I have trouble identifying codes for application/use of VTE prophylactic devices.

On reasons for no VTE prophylaxis, think about how the data would get there.  A provider very well versed in treatment of patients who are at risk for VTE but aware that prophylactic measures are contraindicated would have to take an extra step to indicate why the weren't indicated for a patient.  I'm not saying it shouldn't be done, but often workflow questions like these about "what didn't you do and why" don't get raised during the implementation of an EHR, and so the data doesn't get captured.  And it wouldn't necessarily be built in because in some settings, it might not even be needed.

Looking at the specific question of HAI, one of the components in the HAI report is the location of care.  This is documented as using the NHSNHealthcareServiceLocationCode code system.  This is a very detailed code system.  More detailed in fact, than is often used in patient registration systems.  Patient Registration systems, I also note, are not necessarily the same as the EHR, and while they may be connected, might contain information such as patient location type that isn't accessible through EHR capabilities.

Another example is in the "Infection Condition Observation".  In this case, the type of infection being reported also has detailed coding.  Some of the condition codes include superficial/deep primary/secondary surgical site infections.  Note that there are not even SNOMED codes at this level of detail, and it often wouldn't be captured in the EHR.  Instead, this information would be captured by the infection control officer in a separate Health IT system devoted to the capture of detailed information for HAI reporting.

So, there may be a system that is able to capture data at this level, but it is a system that is used by one or two specialists within the entire facility, and I would be hard pressed to call this an EHR system.  Thus, I quoted the speakers statement:  Data needed for HAI reporting are not typically captured in an EHR.

Personally, I might amend that statement if I weren't quoting someone else to clarify that "Some data" needed for HAI reporting ..., but for the most part, it is a true statement.  The EHR doesn't solve every healthcare problem.  The EHR is but one component of an ultra-large-scale system.  We need to be aware that there are other components in this system beyond the EHR, and that the EHR will not solve every single Healthcare IT problem by itself.  In fact, the HAI specifications produced by HL7 were specifically created for systems used by infection control officers.

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