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Hammam N, Izadi Z, Li J, Evans M, Kay J, Shiboski S, Schmajuk G, Yazdany J. The Relationship Between Electronic Health Record System and Performance on Quality Measures in the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) Registry: Observational Study. JMIR Med Inform 2021; 9:e31186. [PMID: 34766910 PMCID: PMC8727049 DOI: 10.2196/31186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Routine collection of disease activity (DA) and patient-reported outcomes (PROs) in rheumatoid arthritis (RA) are nationally endorsed quality measures and critical components of a treat-to-target approach. However, little is known about the role electronic health record (EHR) systems play in facilitating performance on these measures. OBJECTIVE Using the American College Rheumatology's (ACR's) RISE registry, we analyzed the relationship between EHR system and performance on DA and functional status (FS) quality measures. METHODS We analyzed data collected in 2018 from practices enrolled in RISE. We assessed practice-level performance on quality measures that require DA and FS documentation. Multivariable linear regression and zero-inflated negative binomial models were used to examine the independent effect of EHR system on practice-level quality measure performance, adjusting for practice characteristics and patient case-mix. RESULTS In total, 220 included practices cared for 314,793 patients with RA. NextGen was the most commonly used EHR system (34.1%). We found wide variation in performance on DA and FS quality measures by EHR system (median 30.1, IQR 0-74.8, and median 9.0, IQR 0-74.2), respectively). Even after adjustment, NextGen practices performed significantly better than Allscripts on the DA measure (51.4% vs 5.0%; P<.05) and significantly better than eClinicalWorks and eMDs on the FS measure (49.3% vs 29.0% and 10.9%; P<.05). CONCLUSIONS Performance on national RA quality measures was associated with the EHR system, even after adjusting for practice and patient characteristics. These findings suggest that future efforts to improve quality of care in RA should focus not only on provider performance reporting but also on developing and implementing rheumatology-specific standards across EHRs.
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Affiliation(s)
- Nevin Hammam
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
| | - Zara Izadi
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
| | - Jing Li
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
| | - Michael Evans
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
| | - Julia Kay
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States.,Philip R Lee Institute for Health Policy Research, San Francisco, CA, United States.,San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, CA, United States
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Gandrup J, Li J, Izadi Z, Gianfrancesco M, Ellingsen T, Yazdany J, Schmajuk G. Three Quality Improvement Initiatives and Performance of Rheumatoid Arthritis Disease Activity Measures in Electronic Health Records: Results From an Interrupted Time Series Study. Arthritis Care Res (Hoboken) 2020; 72:283-291. [PMID: 30740931 PMCID: PMC6689446 DOI: 10.1002/acr.23848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/05/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Applying treat-to-target strategies in the care of patients with rheumatoid arthritis (RA) is critical for improving outcomes, yet electronic health records (EHRs) have few features to facilitate this goal. We undertook this study to evaluate the effect of 3 health information technology (health-IT) initiatives on the performance of RA disease activity measures and outcomes in an academic rheumatology clinic. METHODS We implemented the 3 following initiatives designed to facilitate performance of the Clinical Disease Activity Index (CDAI): an EHR flowsheet to input scores, peer performance reports, and an EHR SmartForm including a CDAI calculator. We performed an interrupted time-series trial to assess effects on the proportion of RA visits with a documented CDAI. Mean CDAI scores before and after the last initiative were compared using t-tests. Additionally, we measured physician satisfaction with the initiatives. RESULTS We included data from 995 patients with 8,040 encounters between 2012 and 2017. Over this period, electronic capture of CDAI scores increased from 0% to 64%. Performance remained stable after peer reporting and the SmartForm were introduced. We observed no meaningful changes in disease activity levels. However, physician satisfaction increased after SmartForm implementation. CONCLUSION Modifications to the EHR, provider culture, and clinical workflows effectively improved capture of RA disease activity scores and physician satisfaction, but parallel gains in disease activity levels were missing. This study illustrates how a series of health-IT initiatives can evolve to enable sustained changes in practice. However, capture of RA outcomes alone may not be sufficient to improve levels of disease activity without a comprehensive treat-to-target program.
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Affiliation(s)
| | - Jing Li
- University of California, San Francisco
| | | | | | | | | | - Gabriela Schmajuk
- University of California and the Veterans Affairs Medical Center, San Francisco
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Gandrup J, Yazdany J. Using Health Information Technology to Support Use of Patient-Reported Outcomes in Rheumatology. Rheum Dis Clin North Am 2019; 45:257-273. [PMID: 30952397 DOI: 10.1016/j.rdc.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Technology can help health care providers understand their patients' experience of illness in a way that was previously impossible. Experience in using health information technology (IT) to capture this information through PROs within rheumatology suggests that careful attention to human centered design, including detailed workflow planning, consideration of patient and physician burden, integration into the health IT ecosystem, and delivering information to the right person at the right time are all important. Technology applications must be tested in diverse health systems and populations to ensure they are simple to interpret, useful for clinical decision making and effective in impacting outcomes.
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Affiliation(s)
- Julie Gandrup
- Division of Rheumatology, University of California, San Francisco, San Francisco, CA, USA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, San Francisco, CA, USA.
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Carroll RJ, Eyler AE, Denny JC. Intelligent use and clinical benefits of electronic health records in rheumatoid arthritis. Expert Rev Clin Immunol 2015; 11:329-37. [PMID: 25660652 DOI: 10.1586/1744666x.2015.1009895] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the past 10 years, electronic health records (EHRs) have had growing impact in clinical care. EHRs efficiently capture and reuse clinical information, which can directly benefit patient care by guiding treatments and providing effective reminders for best practices. The increased adoption has also lead to more complex implementations, including robust, disease-specific tools, such as for rheumatoid arthritis (RA). In addition, the data collected through normal clinical care is also used in secondary research, helping to refine patient treatment for the future. Although few studies have directly demonstrated benefits for direct clinical care of RA, the opposite is true for EHR-based research - RA has been a particularly fertile ground for clinical and genomic research that have leveraged typically advanced informatics methods to accurately define RA populations. We discuss the clinical impact of EHRs in RA treatment and their impact on secondary research, and provide recommendations for improved utility in future EHR installations.
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Affiliation(s)
- Robert J Carroll
- Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
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Arvikar SL, Collier DS, Fisher MC, Unizony S, Cohen GL, McHugh G, Kawai T, Strle K, Steere AC. Clinical correlations with Porphyromonas gingivalis antibody responses in patients with early rheumatoid arthritis. Arthritis Res Ther 2014; 15:R109. [PMID: 24017968 PMCID: PMC3978628 DOI: 10.1186/ar4289] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 07/11/2013] [Accepted: 09/09/2013] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Prior studies have demonstrated an increased frequency of antibodies to Porphyromonas gingivalis (Pg), a leading agent of periodontal disease, in rheumatoid arthritis (RA) patients. However, these patients generally had long-standing disease, and clinical associations with these antibodies were inconsistent. Our goal was to examine Pg antibody responses and their clinical associations in patients with early RA prior to and after disease-modifying antirheumatic drug (DMARD) therapy. METHODS Serum samples from 50 DMARD-naïve RA patients were tested using an enzyme-linked immunosorbent assay with whole-Pg sonicate. For comparison, serum samples were tested from patients with late RA, patients with other connective tissue diseases (CTDs), age-similar healthy hospital personnel and blood bank donors. Pg antibody responses in early RA patients were correlated with standard RA biomarkers, measures of disease activity and function. RESULTS At the time of enrollment, 17 (34%) of the 50 patients with early RA had positive immunoglobulin G (IgG) antibody responses to Pg, as did 13 (30%) of the 43 patients with late RA. RA patients had significantly higher Pg antibody responses than healthy hospital personnel and blood bank donors (P < 0.0001). Additionally, RA patients tended to have higher Pg antibody reactivity than patients with other CTDs (P = 0.1), and CTD patients tended to have higher Pg responses than healthy participants (P = 0.07). Compared with Pg antibody-negative patients, early RA patients with positive Pg responses more often had anti-cyclic citrullinated peptide (anti-CCP) antibody reactivity, their anti-CCP levels were significantly higher (P = 0.03) and the levels of anti-Pg antibodies correlated directly with anti-CCP levels (P < 0.01). Furthermore, at the time of study entry, the Pg-positive antibody group had greater rheumatoid factor values (P = 0.04) and higher inflammatory markers (erythrocyte sedimentation rate, or ESR) (P = 0.05), and they tended to have higher disease activity scores (Disease Activity Score based on 28-joint count (DAS28)-ESR and Clinical Disease Activity Index) and more functional impairment (Health Assessment Questionnaire). In Pg-positive patients, greater disease activity was still apparent after 12 months of DMARD therapy. CONCLUSIONS A subset of early RA patients had positive Pg antibody responses. The responses correlated with anti-CCP antibody reactivity and to a lesser degree with ESR values. There was a trend toward greater disease activity in Pg-positive patients, and this trend remained after 12 months of DMARD therapy. These findings are consistent with a role for Pg in disease pathogenesis in a subset of RA patients.
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Desai SP, Liu CC, Tory H, Norton T, Frits M, Lillegraven S, Weinblatt M, Coblyn J, Yazdany J, Shadick N, Solomon DH. Rheumatoid arthritis quality measures and radiographic progression. Semin Arthritis Rheum 2014; 44:9-13. [PMID: 24560878 PMCID: PMC4111785 DOI: 10.1016/j.semarthrit.2014.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 01/07/2014] [Accepted: 01/21/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Documentation of quality measures (QMs) in rheumatoid arthritis (RA) is used as a surrogate for measure of quality of care, but the association of this documentation with radiographic outcomes is uncertain. We examined documentation of RA QMs, for disease activity and functional status and the association with radiographic outcomes. METHODS Data were analyzed for 438 RA patients in a longitudinal cohort with complete data on van der Heijde-modified Total Sharp Score (TSS). All rheumatologist (N = 18) notes in the electronic medical record during a 24-month period were reviewed for RA QMs. Any mention of disease activity categorized as low, moderate, or high was considered documentation of the QM for disease activity. Functional status QM documentation included any mention of the impact of RA on function. Change in TSS was quantified with progression defined as ≥1 unit per year. We compared percent of visits with an RA QM documented and mean change in TSS. RESULTS The mean age in the cohort was 56.9 years, disease duration was 10.8 years, baseline DAS28 score was 3.8 (±1.6), 67.7% were seropositive, and 33.9% used a biologic DMARD. Radiographic progression was observed in 28.5%. Disease activity was documented for 29.0% of patient visits and functional status in 74.7%; neither had any significant relationship to mean TSS change (both P > 0.10). CONCLUSION The documentation of RA QMs was infrequent and not associated with radiographic outcomes over 24 months.
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Affiliation(s)
- Sonali P Desai
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115.
| | - Chih-Chin Liu
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Heather Tory
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Tabatha Norton
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Michelle Frits
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Siri Lillegraven
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Michael Weinblatt
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Jonathan Coblyn
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of San Francisco, San Francisco, CA
| | - Nancy Shadick
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115
| | - Daniel H Solomon
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham & Women's Hospital, 75 Francis St, PBB-B3, Boston, MA 02115; Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA
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Desai SP, Yazdany J. Quality measurement and improvement in rheumatology: rheumatoid arthritis as a case study. ACTA ACUST UNITED AC 2012; 63:3649-60. [PMID: 22127687 DOI: 10.1002/art.30605] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sonali P Desai
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 75 Francis Street, PBB-B3, Boston, MA 02115, USA.
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Leveraging human genetics to develop future therapeutic strategies in rheumatoid arthritis. Rheum Dis Clin North Am 2010; 36:259-70. [PMID: 20510233 DOI: 10.1016/j.rdc.2010.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The purpose of this article is to place these genetic discoveries in the context of current and future therapeutic strategies for patients with RA. More specifically, this article focuses on (1) a brief overview of genetic studies, (2) human genetics as an approach to identify the Achilles heel of disease pathways, (3) humans as the model organism for functional studies of human mutations, (4) pharmacogenetic studies to gain insight into the mechanism of action of drugs, and (5) next-generation patient registries to enable large-scale genotype-phenotype studies.
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MALAVIYA AN, GOGIA SB. Development, implementation and benefits of a rheumatology-specific electronic medical record application with automated display of outcome measures. Int J Rheum Dis 2010; 13:347-60. [DOI: 10.1111/j.1756-185x.2010.01551.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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How to improve DAS28 use in daily clinical practice?--a pilot study of a nurse-led intervention. Rheumatology (Oxford) 2010; 49:741-8. [DOI: 10.1093/rheumatology/kep407] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Collier DS, Grant RW, Estey G, Surrao D, Chueh HC, Kay J. Physician ability to assess rheumatoid arthritis disease activity using an electronic medical record-based disease activity calculator. ACTA ACUST UNITED AC 2009; 61:495-500. [DOI: 10.1002/art.24335] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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