title: Implementation of EHR-based strategies to improve outpatient CAD care.
abstract: To evaluate the effects of a multifaceted quality improvement intervention during 2 time periods on 4 coronary artery disease [CAD] measures in 4 primary care practices. During the first phase, electronic reminders prompted physicians to order indicated medications or record contraindications and refusals (exceptions). In the second phase, physicians also received reports about their performance (including lists of patients not satisfying these measures), and financial incentives were announced.
  
  
  
  Time series analysis.
  
  
  
  Adult CAD patients seen within the preceding 18 months were included. The primary outcome was the performance on each measure (proportion of eligible patients satisfying each measure after removing those with exceptions). Secondary outcomes were the proportion with the medication on their medication list, and the proportion with exceptions.
  
  
  
  Median performance at baseline was 78.8% for antiplatelet treatment, 85.1% for statin treatment, 77.0% for beta-blocker after myocardial infarction (MI), and 67.1% for angiotensinconverting enzyme inhibitor or angiotensin receptor blocker after MI. Performance improved slightly for 3 measures during the first phase and improved more substantially for all 4 measures during the second phase. For 3 of 4 measures, however, documentation of exceptions increased but not medication prescribing. Most exceptions were judged to be appropriate by peer review.
  
  
  
  Physicians responded more to the combination of feedback and financial incentives than they had to electronic reminders alone. High performance was only achieved for 1 of 4 measures and recording of exceptions rather than increases in medication prescribing accounted for most of the observed improvements.
authors.affiliation: Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA. spersell@nmff.org
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Persell
authors.forename: Janardan
authors.initials: J
authors.lastname: Khandekar
authors.forename: Thomas
authors.initials: T
authors.lastname: Gavagan
authors.forename: Nancy C
authors.initials: NC
authors.lastname: Dolan
authors.forename: Sue
authors.initials: S
authors.lastname: Levi
authors.forename: Darren
authors.initials: D
authors.lastname: Kaiser
authors.forename: Elisha M
authors.initials: EM
authors.lastname: Friesema
authors.forename: Ji Young
authors.initials: JY
authors.lastname: Lee
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D003324:Coronary Artery Disease / Q000188:drug therapy / Q000628:therapy*; D003661:Decision Support Techniques; D057286:Electronic Health Records; D005246:Feedback; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy; D010818:Practice Patterns, Physicians'; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012052:Reimbursement, Incentive; D017010:Reminder Systems
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors