Improving Care for Acute and Chronic Problems with Smart Forms and Quality Dashboards

Background and Purpose

Electronic health record (EHR) use and clinical decision support effectiveness have been limited in ambulatory care because clinicians do not perceive value of these tools at the time of use. In addition, EHRs have been limited in their ability to provide feedback on population management and physician performance that could drive quality improvement. To improve the value of clinical decision support and improve population-based healthcare quality, we are designing, implementing, and evaluating an integrated, documentation-based clinical decision support system – Smart Forms – and a physician feedback system – Quality Dashboards.

Smart Forms

Smart Forms are problem-oriented, documentation-based clinical decision support systems that actively engage clinicians during patient visits. Smart Forms improve workflow through the integration of clinical information display, decision support, ordering, and documentation. Based upon an underlying rules-based system, Smart Forms generate problem-specific and patient-specific data review, documentation templates, and orders, including medications, tests, referrals, and patient education materials.

Quality Dashboards

Quality Dashboards provide clinician-specific performance reports regarding guideline compliance for various conditions. Quality Dashboard feedback is personalized and compares clinicians with their peers and national benchmarks. Clinicians can sort data about their patient population in various ways (e.g., all patients deficient in a certain quality measure). Group actions, such as patient letters, can then be generated automatically. Such population insight, coupled with the ability to act on individual patient care needs, is critical to providing value to clinicians.

Smart Form and Quality Dashboard Integration

Although Smart Forms are oriented towards individual care and Quality Dashboards are oriented towards population management, they are designed to work together to improve quality. Smart Forms capture structured information (such as contraindications to medications) that informs Quality Dashboards. Quality Dashboards allow clinicians to “drill down” from a population view to individual patient Smart Forms to take action to address quality deficiencies.

Management of Acute and Chronic Problems

We have designed Smart Forms and Quality Dashboards for archetypical acute and chronic problems: acute respiratory infections (ARIs) and coronary artery disease/diabetes mellitus (CAD/DM). We selected these problems because workflow and design challenges are very different between acute and chronic problems. In addition, ARIs allow us to address errors of commission (e.g., inappropriate antibiotic prescribing), while CAD/DM allows us to address errors of omission (e.g., not prescribing aspirin).

Evaluation

To develop, deploy, and evaluate the ARI and CAD/DM Smart Forms and Quality Dashboards, we are sequentially performing prototyping, usability testing, pilot testing, and randomized controlled trials in primary care clinics. We have completed prototyping, usability testing, and pilot testing for the ARI Smart Form and are conducting a randomized controlled trial of the ARI Smart Form use during the 2005–2006 cold and influenza season. We have completed prototyping of the CAD/DM Smart Form and are conducting usability and pilot testing. The randomized controlled trial for the CAD/DM Smart Form begins Spring 2006. We are presently prototyping both the ARI and CAD/DM Quality Dashboards.

Conclusion

Smart Forms and Quality Dashboards are designed to address quality deficiencies by delivering actionable decision support to the point of care with a rigorous attention to clinician workflow. These novel tools are designed to work together to increase the self-evident value of EHRs to clinicians and improve the quality of medical care.