The promise of reaping the rewards of data aggregation and analysis on a national scale is just one of the many factors behind the health information technology movement that continues to gain ground across the U.S. health care system. And the Distributed Ambulatory Research in Therapeutics Network, or DARTNet(www.dartnet.info) -- of which the AAFP National Research Network, or AAFP NRN, is a founding partner -- is on the verge of realizing that promise.
DARTNet -- which collects data from multiple commercial electronic health records, or EHRs, for practice-based research and quality improvement -- already can access, with appropriate permission from practices, data from 1,700 physicians in 345 practices who care for more than 4 million patients.
And now, DARTNet is looking to add even more physicians, practices and patients to its growing network.
"The bigger the sample size, the more questions we can answer," said Elias Brandt, research systems analyst for the AAFP NRN. "Diversity is always a big thing in any data pull. The wider selection of clinics that we can choose from, the more powerful our research will be."
The Distributed Ambulatory Research in Therapeutics Network, or DARTNet(www.dartnet.info), is a network of electronic health record, or EHR, data drawn from multiple organizations. DARTNet facilitates data collection and aggregation and seeks to explore how available EHR data can be used to supplement data from other sources in answering questions about the safety and effectiveness of medications, medical devices and medical care, while improving the quality of care provided by DARTNet member organizations.
The network has four goals:
- support the patient-centered medical home,
- enhance the state-of-the-art in effectiveness research,
- advance practice-based research capabilities and
- enhance the use of health information technology in ambulatory care.
DARTNet was founded in 2007 at the behest of the Agency for Healthcare Research and Quality. In addition to the AAFP NRN, DARTNet's partners are the University of Colorado Department of Family Medicine and School of Pharmacy; the Robert Graham Policy Center; the University of Utah's Center for High Performance Computing; and QED Clinical Inc. d.b.a. CINA.
Family physicians who are members of DARTNet told AAFP News Now that joining the network has allowed them to participate in research that benefits the specialty while improving the quality of care they provide in their practices and yielding financial benefits. Moreover, some DARTNet members say, participation in the network has permitted them to connect with colleagues in ways they never could before.
"It is a painless way to participate in practice-based research," said Robert Eidus, M.D., of Cranford, N.J. "The projects actually improve care. You get to benchmark your performance to other (physicians' performance)."
"Some of the studies involve a point-of-care aspect," Brandt said, "but some are straight data pulls, so the physicians don't have to do anything."
Cynthia Croy, M.D., of Joplin, Mo., said her private practice, which includes one other physician and a nurse practitioner, has received $1,000 to $2,000 for each of the half a dozen studies in which the practice has participated during the past two years.
"It adds a little bit of margin to the finances," she said.
According to Brandt, some DARTNet studies pay practices even more in direct stipends and also cover costs associated with clinical decision support.
Croy said her practice has increased its rates of immunizations and preventive screenings, such as mammograms and lipids testing, since joining DARTNet. Many DARTNet sites, including Croy's practice, use the CINA Point of Care Clinical Decision Support tool to incorporate specific screening tests into routine care.
For example, Ed Bujold, M.D., of Granite Falls, N.C., said integrating the nine-item Patient Health Questionnaire(www.depression-primarycare.org), or PHQ-9, into the clinical decision support system led to diagnosing patients whose depression otherwise might have gone unnoticed.
"Patients would fill those out, and I had not even known they had depression because that's not something they want to talk about," he said. "It allowed us to open a discussion about the topic, and then there was treatment for it. It also allowed me to gauge whether someone was getting better and augment their therapy if they weren't."
That's because the tool automatically generated a new PHQ-9 whenever a patient previously diagnosed with depression came into Bujold's office so he could reassess the patient's response to treatment.
DARTNet members also receive benchmarking reports that compare a practice's performance to that of other clinics in the system in areas such as diabetes measures, cholesterol levels and blood pressure.
"The big issue is aggregating your own performance, so you know how you are doing on things such as the percentage of patients with hypertension whose blood pressure is under control, and you get to see how you are doing in comparison to others," said Eidus. "I have learned primarily that there are others that are doing a better job in some areas than I am, so I have to re-examine my own processes. Based on the benchmarks, we are enhancing our patient outreach activities, identifying patients with gaps in care and proactively reaching out to them."
Bujold said the benchmarking reports alerted him to the fact that some of his patients who should have had their cholesterol tested had not been tested.
"There's room to improve," he said. "We can go back to our staff and say, 'We need to do better on this.' The one that sticks out is measuring LDL. Some people are not getting screened. We're going to look at patients who haven't had LDLs and see if we can get them in for the test and see if they're at risk."
Bujold also uses the CINA Point of Care Clinical Decision Support tool, which allows him to compare his patient data with nationally recognized guidelines to produce patient-specific recommendations during office visits.
"If you're trying to do more management of diseases, you're bringing people in more often," he said. "I've heard several people say the CINA software pays for itself the first couple days of the month just because you're bringing people in for physical exams and more checks related to blood pressure, diabetes and things like that. It helps us bring in more revenue, which helps us pay for things like EHRs."
DARTNet members don't have to use CINA, but they do have to have a system that allows them to pull their data. They don't have to use a certain type of EHR, either. Network members are using a dozen different types of EHRs.
In addition to improved care, Croy said participating in DARTNet has connected her with other network members. Thanks to DARTNet, she is serving on an advisory board for a study on lipids that meets once a month via conference call.
"It's interesting," she said. "It improves your feeling that you're doing something useful and being connected to the larger family practice community. We get pretty isolated in our little offices. You get to interact with physicians from all over the country."
DARTNet started in 2007 with a diabetes study that included eight health care organizations with access to 674,000 patients. A depression study initiated in 2009 expanded the network to 20 organizations and 3.5 million patients.
Researchers also have used the network to study topics such as cardiovascular disease, community-associated methicillin-resistant Staphylococcus aureus, CME effectiveness, chronic kidney disease and proper prescribing of antibiotics.
Currently, DARTNet members span 15 states. According to Brandt, expanding nationwide would allow researchers to answer regional questions. Having a larger patient pool also would provide the researchers a better sample size to answer questions regarding minorities and certain subpopulations.
But it's really the ability to readily share data that DARTNet members' EHRs provide that is key to DARTNet's success.
"The research capabilities of DARTNet go beyond what we can do in a study that did not involve EHRs because the access to outcomes data is incredible," said Debbie Graham, DARTNet COO and associate research director for the AAFP NRN. "Almost all of our studies involve improving the care that our docs provide because we integrate clinical decision support. The information and support they receive is invaluable."
Graham said physicians who participate are helping improve family medicine as a whole.
"It allows an organization to improve the level of care it provides to patients through quality improvement programs, through benchmarking reports and through the best practices they learn," she said. "The research itself will help to improve the discipline by increasing knowledge about the topic being studied."
Physicians interested in participating in DARTNet may contact Graham by e-mail.