Leveraging electronic health records to develop measurements for processes of care.

Patient-Centered Medical Home (PCMH) is a promising model of care that aims to reinvent primary care, so that it is “accessible, continuous, comprehensive, and coordinated” (American Academy of Family Physicians et al. 2007; Blumenthal and Tavenner 2010) with an increased emphasis on team-based care (Peikes et al. 2012). Progress toward better quality, improved patient experience, and lower costs has been reported (Peikes et al. 2012). While it has been recognized that at the center of integrated health care delivery is a high-performing primary care provider (PCP) who can serve as a medical home for patients (Meyers et al. 2010), the focus of current PCMH recognition measures is largely on practice-level characteristics (National Committee for Quality Assurance 2011a). If delivery systems broadly implement uniform changes, for example, installing electronic health records, implementing advanced access (Friedberg, Lai et al. 2009), however, such practice-level measures will have limited value in discerning the causes of heterogeneities in processes and outcomes of care across practices. While implementing electronic health records (EHRs) at the organization level makes it less of a distinguishing feature about primary care transformation among its component clinics, the EHR can potentially offer measures of process of care that are consistent with some component standards for patient-centered medical homes (Friedberg, Lai et al. 2009). Therefore, the growing spread of EHRs provides valuable opportunities to health care organizations to routinely measure physician practice in an unobtrusive way. Indeed, some organizations already regularly take advantage of practice-based data (e.g., same-day access, e-message turn-around time) for operations purposes. There is strong interest in leveraging delivery organizations' capacities to use performance indicators to assess physicians and other professionals (Robinson et al. 2008; Mechanic 2010). Researchers can use these existing data to construct clinician-level measurements of patient-centeredness in clinical processes to potentially fill a gap in PCMH measurement tools. We explored several EHR-generated PCP-level process of care measures following the key structural domains of the PCMH identified in the literature: enhanced access and continuity, informed care management, care coordination (Abrams, Schor, and Schoenbaum 2010; Rosenthal et al. 2010), and increasing opportunities for patients to participate in the care process (Bergeson and Dean 2006). These domains correspond to both the broad functional domains (e.g., care coordination capabilities) of the National Committee on Quality Assurance Physician Practice Connection-Patient Centered Medical Home (NCQA PPC-PCMH) assessment tool, and the core elements outlined in the Joint Principles of the Patient-Centered Medical Home (Rosenthal et al. 2010). We compared the process of care constructs in the literature with routinely collected EpicCare EHR data to examine: (1) if information in the EHR can be reliably used to operationalize constructs of process of care related to the aforementioned three domains of patient-centered care (Rosenthal et al. 2010) and (2) the relationship between these EHR-based measures and health outcomes among patients with chronic diseases. Because type II diabetes (DM) and hypertension are two of the most common chronic conditions, we chose to analyze clinical outcomes of patients with either of these conditions. Because blood pressure (BP), LDL, and A1C control are the most important management goals for patients with DM, we chose them as examples to test the clinical relevancy of the PCP-level patient-centeredness measures (Barr 2008; Peikes et al. 2012). We also analyzed BP control for patients with hypertension (Peikes et al. 2012; Rosenthal, Abrams, and Bitton 2012). Furthermore, we examined whether the level of NCQA recognition for patient-centered care, at the clinic level, was associated with clinical outcomes among patients with diabetes or hypertension for clinics within the group practice. We hypothesized that some of the variables representing processes of care in the above-mentioned domains may be highly correlated and reflective of underlying latent characteristics of PCPs' propensity to practice patient-centered care. We further hypothesized that these highly correlated variables, if they indeed cluster with each other, would form factor scales that can be consistent with the domains of patient-centered processes of care practices. In addition, we hypothesized that these factor scales, if emerged, would be correlated with clinical outcomes. However, there may be stand-alone process of care variables at the PCP level—also available from the EHR or administrative data—that could be correlated with clinical outcomes. Lastly, we hypothesize that patients with diabetes or hypertension would be more likely to have better clinical outcomes if they were served by PCPs in clinics with higher levels of NCQA recognition for patient-centered care (described below).