In the Clinic

EHRs Prompt Better Uptake of Preventive Services, Help Track Patients' Progress

April 01, 2011 07:00 pm David Mitchell

When it comes down to it, the chief motivation behind the health care industry's move to adopt health information technology, or health IT, is really very simple: patients. Give them better, safer care that they can afford to access.

So when family physician V. Paula Messmore-Arn, M.D., decided to take the health IT plunge, patients were her central focus. Specifically, she wanted to improve the quality of care in her practice and "make a difference in patients' lives." Messmore-Arn knew she was seeing as many as 100 patients with diabetes each month, but until her Kansas City, Mo., practice implemented an electronic health record, or EHR, system in 2009, there was no easy method for tracking those patients.

"I had no way to pull that information and see who they were and who needed help," Messmore-Arn told AAFP News Now. "Now, my office manager is able to pull that, and we're able to get a report once a month to see where our progress is, or not, and target that."

In addition to hemoglobin A1c test results, Messmore-Arn's EHR allows her to track other clinical and preventive measures data, such as lipid profiles, blood pressure readings and information about tobacco use.

"It has helped us with our quality of care," she said, "and we expect that we'll get even better because we can identify deficiencies. We can identify which patients are outliers, get them in and try to get them resources to get their diabetes under control if it's not."

Academy Resource Helps EHR Users Tackle Tobacco Use

The AAFP has developed a two-page guide(2 page PDF) for integrating a focus on tobacco cessation directly into electronic health record, or EHR, systems.

The guide stresses the need for a system that prompts clinicians or staff to collect and record information about tobacco use, secondhand smoke exposure, cessation interest and past quit attempts. The EHR also should include prompts that remind clinicians to

  • encourage quitting,
  • advise about smoke-free environments, and
  • connect patients and families to cessation resources and materials.

In addition, the guide outlines EHR features required to meet CMS' meaningful use criteria and provides the elements that should be included in a tobacco cessation template, including tobacco status and history, previous quit attempts and medications used in those attempts, readiness to quit, type of counseling and pharmacotherapy provided, and plan for follow-up.

Also noted are specific objectives and measures included in tobacco-related meaningful use criteria, such as recording the smoking status of more than 50 percent of all patients 13 years or older and providing relevant, patient-specific resources to more than 10 percent of patients.

Jason Mitchell, M.D., assistant director of the AAFP's Center for Health IT, suggested treating smoking status as a vital sign.

"Make sure that when a nurse checks weight and height, they ask about smoking status and document that," Mitchell said. "Every time you see someone, you ask, 'What's going on with your tobacco use?'"

Ed Bujold, M.D., is working to achieve patient-centered medical home recognition from the National Committee for Quality Assurance at his practice in Granite Falls, N.C. He told AAFP News Now that one of the results of that process has been improved screening rates for health issues such as tobacco use.

"There are a lot of things that are required in regard to those kinds of questions, which we hadn't been asking before, but we are now," said Bujold. "The EHR has helped with that. Every time a patient comes in, we ask about smoking status and if they're interested in quitting. We weren't doing it before we had an EHR because the question wasn't sitting there for the nurse to ask every time. It prompts you to ask the question."

Like Bujold, Sarah Mullins, M.D., said her practice in Wilmington, Del., is focusing on tobacco use. Mullins' practice is participating in the AAFP's Office Champions tobacco cessation pilot program.

"What my staff is focusing on is that when vital signs are taken, every patient who comes into the office is asked about smoking status," said Mullins. "The staff identifies smokers in their charts, which alerts the physician that, 'This patient has been identified as a smoker. Is this something you want to discuss during this cough, heart disease or diabetes visit?'"

She told AAFP News Now that the EHR system she uses in her practice has pop-up windows for reminders about particular patient issues, including smoking status, that she reviews before she enters an exam room.

"I like the reminder systems because I can't dig through (the patient's) chart when I'm in an encounter," Mullins said. "If you can have it upfront, that's one of the things that is most helpful. You're trying to remember mammograms and colonoscopies and everything else every time you see someone, so having an electronic reminder will always help me to remember to ask someone about smoking.

"I'll even tell my patients, 'Your chart just reminded me you're a smoker. Are you still smoking a pack a day? Have you cut down from that?' They know I'm still on the agenda to help them with the reason they're there, but their chart is actively reminding me that this is something we need to talk about each visit."

Mullins did a small study during her residency at Christiana Care Health System in Wilmington, which was then in the process of implementing the AAFP's Ask and Act tobacco cessation program. She documented the number of patients who were designated as smokers before and after the implementation of Ask and Act. The intervention revealed an increase in reporting and a decrease in smoking rates.

"I think the 'baby step' toward getting an effective smoking cessation program in your practice is to get people asking about tobacco first," Mullins said. "That's where a lot of the effort is. You can't help your smokers unless you identify them first, and you can use your EHR to identify them."

Studies have shown that simply being asked about tobacco improves a smoker's chances of eventually quitting, said Mullins.

"I love that, because how many times are you going to ask someone if they say, "No, I can't quit'? But if you know just the action of asking is going to improve their chances, I'm going to ask a hundred times," she said. "There's no harm in asking."