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Steven Ornstein, M.D.
Director, Practice Partner Research Network (PPRNet)
Professor of Family Medicine
Medical University of South Carolina, Charleston S.C.
Since the first tentative steps toward the creation of electronic health records (EHR), the emphasis on converting paper records to searchable electronic files has been largely driven by the desire for greater efficiency and the hope for enhancing routine care. Yet, their use by primary care physicians in group or solo practices in the U.S. has lagged far behind large groups (still only 30%) and their European counterparts. And for those that did embrace these solutions, there were no EHR-based clinical benchmarking tools or services that readily could be used by the independent primary care practice.
Providing a Physician Network to Benchmark Care
In 1995, the Practice Partner Research Network (PPRNet) was formed to provide physicians with tools to improve patient care. A joint effort between the Department of Family Medicine at the Medical University of South Carolina (MUSC) and Practice Partner®, a developer of electronic health records in Seattle, Wash. (acquired by McKesson in 2007), PPRNet has become a groundbreaking concept in practice-based quality improvement and research.
Our idea was to form a network of primary care physicians, all using this same system. By extracting data from their patient records, we could produce a longitudinal patient database and begin the first effort to create benchmarks for clinical care among small independent practices or individual groups within a large practice.
We chose Practice Partner Patient Records as the EHR for the research network, in part because we were familiar with it (we were using it at the MUSC Family Practice Residency), as well as for its popularity among primary care practices. Andy Ury, M.D., Practice Partner founder and now VP and general manager for McKesson, also shared our strong belief that EHRs could be key to improving quality of care and was instrumental in starting and supporting the network.
On a day-to-day basis, PPRNet provides management of the network, designs and implements research projects and works directly with participating practices. The practices provide de-identified patient data to PPRNet monthly by running a simple utility program, which extracts clinical data from their Practice Partner EHR software. To facilitate longitudinal analysis, an encrypted patient identifier is assigned by the extract program prior to receipt by PPRNet. In exchange, the participating practices receive quarterly reports, measuring their performance against more than 80 clinical benchmarks based on performance across the entire network.
Today PPRNet includes more than 700 providers and data from more than 1.8 million patients in 38 states. By connecting these care providers, we are able to provide a clear path to improving patient care through consistent benchmarks for the treatment of specific clinical conditions.
Changing Perceptions of EHRs
The prevailing model in ambulatory care has long been to treat specific conditions when patients choose to visit the office. PPRNet changes that paradigm. Using treatment benchmarks and the encrypted patient identifier, the physician can determine which patients require specific screenings and treatments. The practice can then become proactive in reaching out to those that need care, but may not be following recommended treatment plans.
For example, at one practice, the PPRNet quarterly report showed one physician that only half of all his eligible patients are up to date on colorectal cancer screening. In comparison with other groups, the achievable benchmark was 66 percent. Seeing these comparisons creates a goal that may not have been apparent without empirical data.
Yet, from the very beginning we realized that it is not enough to just provide data. Practices need strategies to help them meet treatment targets. To do that, we visit physicians and their staffs to develop specific improvement methods. We also host annual network meetings where physicians can share best practices.
Knowledge Empowers Improvement
As one physician told me, "Before I got these reports, I just assumed my patients were getting excellent care. When I got the reports, I could target those areas that needed improvement. In other words, you think you've followed recommended tests on everyone because you are well trained and well intentioned, but until you see the data you just don't know where you really stand."
Dr. Steven Ornstein is a researcher and Family Medicine practitioner in Charleston, S.C. He joined the faculty of the Department of Family Medicine at the Medical University of South Carolina in 1985 and is one of the founders of PPRNet and currently serves as director.
This sample PPRNet report shows over time the percentage of the practice's diabetes mellitus patients with their most recent Triglyceride reading at less than 150. The graph also shows the median and benchmark (approximately top 10th percentile) of PPRNet member practices.
This sample report shows the PPRNet SQUID™ (Summary Quality Indicator), which helps quantify improvements in the practice quality-of-performance indicators. The report reflects the average proportion of quality processes and outcomes that are up-to-date and under control among patients in the practice.
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