title: Exceptions to outpatient quality measures for coronary artery disease in electronic health records.
abstract: BACKGROUND
  Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments.
  
  
  OBJECTIVE
  To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions.
  
  
  METHODS
  Cross-sectional observational study.
  
  
  METHODS
  5 internal medicine or cardiology practices.
  
  
  METHODS
  47,075 patients with coronary artery disease between 2006 and 2007.
  
  
  METHODS
  Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records.
  
  
  RESULTS
  3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure.
  
  
  CONCLUSIONS
  The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives.
  
  
  CONCLUSIONS
  Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information.
  
  
  BACKGROUND
  Agency for Healthcare Research and Quality.
authors.affiliation: American Medical Association, Chicago, Illinois 60654, USA. karen.kmetik@ama-assn.org
authors.forename: Karen S
authors.initials: KS
authors.lastname: Kmetik
authors.forename: Michael F
authors.initials: MF
authors.lastname: O'Toole
authors.forename: Heidi
authors.initials: H
authors.lastname: Bossley
authors.forename: Carmen A
authors.initials: CA
authors.lastname: Brutico
authors.forename: Gary
authors.initials: G
authors.lastname: Fischer
authors.forename: Sherry L
authors.initials: SL
authors.lastname: Grund
authors.forename: Bridget M
authors.initials: BM
authors.lastname: Gulotta
authors.forename: Mark
authors.initials: M
authors.lastname: Hennessey
authors.forename: Stasia
authors.initials: S
authors.lastname: Kahn
authors.forename: Karen M
authors.initials: KM
authors.lastname: Murphy
authors.forename: Ted
authors.initials: T
authors.lastname: Pacheco
authors.forename: L Greg
authors.initials: LG
authors.lastname: Pawlson
authors.forename: John
authors.initials: J
authors.lastname: Schaeffer
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Schwamberger
authors.forename: Sarah H
authors.initials: SH
authors.lastname: Scholle
authors.forename: Gregory
authors.initials: G
authors.lastname: Wozniak
mesh_terms: D000368:Aged; D059019:Clinical Coding / Q000592:standards; D003324:Coronary Artery Disease / Q000188:drug therapy*; D003430:Cross-Sectional Studies; D011307:Drug Prescriptions / Q000592:standards; D057286:Electronic Health Records / Q000592:standards*; D006801:Humans; D008297:Male; D019370:Observation; D010045:Outpatients; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D015203:Reproducibility of Results