Embedding “Smart” Disease Coding Within Routine Electronic Medical Record Workflow: Prospective Single-Arm Trial

Abstract

Background Electronic medical record (EMR) chronic disease measurement can help direct primary care prevention and treatment strategies and plan health services resource management. Incomplete data and poor consistency of coded disease values within EMR problem lists are widespread issues that limit primary and secondary uses of these data. These issues were shared by the McMaster University Sentinel and Information Collaboration (MUSIC), a primary care practice-based research network (PBRN) located in Hamilton, Ontario, Canada. Objective We sought to develop and evaluate the effectiveness of new EMR interface tools aimed at improving the quantity and the consistency of disease codes recorded within the disease registry across the MUSIC PBRN. Methods We used a single-arm prospective trial design with preintervention and postintervention data analysis to assess the effect of the intervention on disease recording volume and quality. The MUSIC network holds data on over 75,080 patients, 37,212 currently rostered. There were 4 MUSIC network clinician champions involved in gap analysis of the disease coding process and in the iterative design of new interface tools. We leveraged terminology standards and factored EMR workflow and usability into a new interface solution that aimed to optimize code selection volume and quality while minimizing physician time burden. The intervention was integrated as part of usual clinical workflow during routine billing activities. Results After implementation of the new interface (June 25, 2017), we assessed the disease registry codes at 3 and 6 months (intervention period) to compare their volume and quality to preintervention levels (baseline period). A total of 17,496 International Classification of Diseases, 9th Revision (ICD9) code values were recorded in the disease registry during the 11.5-year (2006 to mid-2017) baseline period. A large gain in disease recording occurred in the intervention period (8516/17,496, 48.67% over baseline), resulting in a total of 26,774 codes. The coding rate increased by a factor of 11.2, averaging 1419 codes per month over the baseline average rate of 127 codes per month. The proportion of preferred ICD9 codes increased by 17.03% in the intervention period (11,007/17,496, 62.91% vs 7417/9278, 79.94%; χ21=819.4; P<.001). A total of 45.03% (4178/9278) of disease codes were entered by way of the new screen prompt tools, with significant increases between quarters (Jul-Sep: 2507/6140, 40.83% vs Oct-Dec: 1671/3148, 53.08%; χ21=126.2; P<.001). Conclusions The introduction of clinician co-designed, workflow-embedded disease coding tools is a very effective solution to the issues of poor disease coding and quality in EMRs. The substantial effectiveness in a routine care environment demonstrates usability, and the intervention detail described here should be generalizable to any setting. Significant improvements in problem list coding within primary care EMRs can be realized with minimal disruption to routine clinical workflow.

Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care: a cross-sectional study using practice-based research network data

“…The usability of the CFS in primary care was evidenced in our study with frailty scores completed for 77% of eligible patients. This directly collected data was a strength of the study, as was the study setting within a PBRN where disease coding in the EMR has been strengthened through previous initiatives 25. We attribute the high scoring completion rate to a combination of factors: clinicians were engaged prior to deciding to go forward with the study; the study aligned with physicians’ interests in supporting frail patients as well as effective leadership and clinical championing of this study and its data collection requirements.…”

“…There are 55 family physicians associated with the MUSIC Network. This study was based on a subset of the 37 physicians in the MUSIC PBRN, and their previously described 38 000 patients represent a broad cross section of patients 25 26…”

“…Coded conditions include disorders such as chronic obstructive pulmonary disease (COPD) and heart failure as well as risk factors such as hypertension and dyslipidaemia. Previous work that improved the quantity and the consistency of chronic disease codes recorded within the MUSIC PBRN EMR featured quick-pick lists of ‘preferred terms’ for common and discrete primary care conditions such as unipolar depression (311) and bipolar depression (296), both with distinct codes 25. For this study, certain conditions considered to be similar (ie, variations of the same base condition) were grouped, for example, dementia (ICD-9 290) and Alzheimer’s disease (ICD-9 331.0), in order to form meaningful groupings for frequency analysis.…”

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling

“…Clinicians involved in patient care developed our smart tools, resulting in an EPT algorithm that was complementary to clinical workflow. Prior studies have demonstrated that longevity in EMR smart tools can be attributed to clinician involvement with the design and training for the workflow 21 …”

“…Prior studies have demonstrated that longevity in EMR smart tools can be attributed to clinician involvement with the design and training for the workflow. 21 STIs include trichomonas (n = 24), syphilis (n = 1), hepatitis b (n = 3), hepatitis C (n = 1), and HIV (n = 0). ¶ EPT was not known to be accepted or declined in n = 7 encounters before the intervention and n = 3 cases after the intervention because of unclear documentation and no evidence of prescription in the patient or partner's chart.…”