title: Learning from primary care meaningful use exemplars.
abstract: BACKGROUND
  Submission of clinical quality measures (CQMs) data are 1 of 3 major requirements for providers to receive meaningful use (MU) incentive payments under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act. Some argue that CQMs are the most important component of MU. Developing an evidence base for how practices can successfully use electronic health records (EHRs) to achieve improvement in CQMs is essential and may benefit from the study of exemplars who have successfully implemented EHRs and demonstrated high performance on CQMs.
  
  
  METHODS
  Conducted in PPRNet, a national primary care practice-based research network, this study used a multimethod approach combining an EHR-based CQM performance assessment, a provider survey, and focus groups among high CQM performers. Practices whose providers had attested for stage 1 MU were eligible for the study. Performance on 21 CQMs included in the 2014 MU CQM set and a summary measure was assessed as of October 1, 2013, through an automated data extract and standard analytic procedures. A web-based provider survey, conducted in November to December 2013, assessed provider agreement, staff education, use of EHR reminders, standing orders, and EHR-based patient education related to the 21 CQMs. The survey also had more general questions about the practices' use of EHR functionality and quality improvement (QI) strategies. Statistical analyses using general linear mixed models assessed the associations between responses to the survey and CQM performance, adjusted for several practice covariates. Three focus groups, held in early 2014, provided an opportunity for clinicians to provide their perspectives on the validity of the statistical analyses and to provide context-specific examples from their practice that supported their assessment.
  
  
  RESULTS
  Seventy-one practices completed the study, and 319 (92.1%) of their providers completed the survey. There was wide variability in performance on the 21 CQMs among the practices. Mean performance ranged from 89.8% for tobacco use screening and counseling to 12.9% for chlamydia screening. In bivariate analyses, more positive associations were found between CQM performance and staff education, use of standing orders, and EHR reminders than for provider agreement or EHR-based patient education. In multivariate analyses, EHR reminders were most frequently associated with individual CQM performance; several EHR, practice QI, and administrative variables were associated with the summary quality measure.
  
  
  CONCLUSIONS
  Purposeful use of EHR functionality coupled with staff education in a milieu where QI is valued and supported is associated with higher performance on CQM.
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston. ornstesm@musc.edu.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Ornstein
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston.
authors.forename: Lynne S
authors.initials: LS
authors.lastname: Nemeth
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Nietert
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston.
authors.forename: Ruth G
authors.initials: RG
authors.lastname: Jenkins
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Wessell
authors.affiliation: From the College of Nursing (SMO, LSN); the Department of Public Health Sciences (PJN); the Department of Family Medicine (RGJ, AMW); and the Division of General Internal Medicine and Geriatrics, Department of Medicine (CBL), Medical University of South Carolina, Charleston.
authors.forename: Cara B
authors.initials: CB
authors.lastname: Litvin
mesh_terms: D057286:Electronic Health Records / Q000458:organization & administration*; D017144:Focus Groups; D019538:Health Care Surveys; D006801:Humans; D016014:Linear Models; D062527:Meaningful Use; D011320:Primary Health Care / Q000458:organization & administration*; D011785:Quality Assurance, Health Care; D019984:Quality Indicators, Health Care; D014481:United States
keywords: Electronic Health Records; Quality Indicators