Two-year trends of 151 independent practices showed significant gains on 4 key quality measures: antithrombotic therapy, BP control, HbA1c testing, and smoking cessation intervention. Our findings suggest that independent SPs and CHCs, with assistance from a community EHR extension program such as PCIP, can achieve clinical quality gains similar to those observed in larger, well-resourced integrated delivery systems (2
). Our findings are relevant to independent practices serving resource-challenged urban areas.
Several reports in the literature indicated that practice size is associated with higher quality of care (23
), so we also conducted analyses to ascertain whether the level of improvement differed across practice characteristics, such as whether CHCs experienced greater improvements than SPs. Of the practice characteristics we analyzed, none accounted for consistent differences in the increases observed with the exception of duration using an EHR.
Previous reports from this population suggest that short-term improvements are possible (25
); in this study, we observed increases of several percentage points per year, suggesting that long-term improvement can also occur. This continued progress supports the idea that urban independent practices can drive long-term improvements in population health, a finding that is promising for inner-city independent practices like those served by PCIP, because they see an above-average number of patients who are uninsured and who have more severe health issues (17
). At the same time, policy makers or stakeholders looking for instant quality gains should be cautious to expect early returns post-EHR implementation, because the larger increases in improvement were seen in the latter time period — between October 2010 and 2011 — when practices had been using the EHR for 25 months or more.
Our study has limitations. It was limited to the 151 practices where we received consistent quality measurement data over the 2-year period and therefore did not include all practices that joined PCIP and received similar support. Practices included in the study were generally earlier adopters of EHR, and we could not infer whether the performance trend would be similar or dissimilar to that of practices who were later adopters. We did not include specialties or other facilities that may interact with patients.
Providers working with PCIP represent a group of EHR users who have received varied assistance from PCIP staff, including training and guidance on quality improvement strategies, technical support on EHR software (upgrades, patches, and configuration), and connection for health information exchange. This type of support has been shown to positively affect the transition to an EHR system (27
). A separate study using claims-based data suggests that improvement on quality measures can be achieved for practices that have used technical assistance (29
). By the end of the analysis period in 2011, practices had been exposed to several environmental changes that were not measured or tested in this study. These include the introduction of the Centers for Medicaid and Medicare Services Meaningful Use incentives, New York State Medicaid incentives for practices achieving recognition for patient-centered medical homes, and monthly dashboards from PCIP for trending performance on selected EHR use and quality measures. Whether the introduction of these programs had an affect on the observed quality trends is unknown.
Improvement resulting from better documentation alone in the EHR was not tested in this study. However, we are aware that documentation and work-flow variability can result in underreporting of practice performance for some measures and not others (30
). For example, HbA1c testing in patients with diabetes requires laboratory values to be returned through an electronic interface or manually entered into the patient’s record by the provider or practice staff. Practice rates on laboratory tests in which an electronic laboratory interface was not available and the practice does not routinely enter results into the patient’s record will be underreported, because EHR quality measurement programming will not detect information in scanned documents or faxes. Smoking cessation intervention is subject to appropriate documentation of counseling or prescription of smoking cessation aids; providers may not have instituted appropriate workflows to capture counseling conversations in the appropriate section of the EHR, thus underreporting the delivery of cessation intervention. In the example of antithrombotic therapy, gains in performance may be explained by improved documentation of over-the-counter medications (eg, aspirin) while continued trends represent better attention to this preventive service.
Broad adoption of EHR systems, along with technological advances and more experience with measurement using data from electronic records, may further drive improvements in primary care. However, it is promising to note that in our study, performance among independent practices was similar to or in some cases, exceeded, that of larger integrated systems. For instance, in 2011, PCIP averaged 64% on the BP control measure. For that measure in the same year, NCQA reported that nationally, commercial health maintenance organizations were averaging 65% and commercial and Medicare PPOs and Medicaid HMOs were averaging 58% to 60% (2
). Both providers and policy makers should be encouraged by this indicator that independent primary care physicians can keep pace with their peers who work in integrated systems and can continue to improve, post-EHR adoption.
In our experience, the amount of support providers need to realize quality gains varies widely. Practices may require anywhere from 2 to 10 onsite visits in a year from a midlevel clinical quality specialist (29
). These resources could be further sustained through local programs or through stakeholder support, such as payers or employer-based initiatives. Continued federal incentives and new payment models from Centers for Medicare and Medicaid Services may help stimulate independent primary care practices to get the most from health IT as an investment to improve health care and focus on patient-centered, outcomes-driven care and coordination.