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  • The Gap in Our Attention to the Gaps in Care

    While gaps in care can be defined in many ways, we are defining it as the difference between well-known national standards for care and what is actually happening. We have identified some important remedies that can be effected quickly and with demonstrable success, such as medication fulfillment, adherence and patients gaining a better understanding of their treatments. One of our recent surveys (n=606) revealed what is missing and how to address it. It all comes down to communication—in the right way and through the channels that support clinical decisions.

    When physicians prescribe for a patient, we provide an automated prompt or reminder via our network within the workflow of the connected EHR. The prompt about potential gaps in care is informed by the data available in the patient record with the patient's healthcare payer, and sent on behalf of the payer. For example:

    • Age-based or seasonally based reminders for screenings or vaccinations (e.g., colorectal screening for a patient aged 50 or over; pneumococcal conjugate vaccination for a patient aged 65 or over).
    • Suggestions to review a prescribed medication that might not be appropriate for a patient based on evidence-based guidelines (e.g., glyburide for an elderly diabetic patient, benztropine for an elderly patient with Parkinson's).
    • Suggestions to consider adding a medication to meet evidence-based guidelines (e.g., suggest adding an ACEI/ARB for a patient taking a diabetes medication and a diuretic).

    In our recent study, we looked specifically at how to identify the gaps in care and whether in-workflow reminders through the use of EHRs would make a difference, particularly among prescribers who have value-based contracts or value-based care (pay for performance, outcomes/quality goals, shared savings and similar value-based guidelines). The short answer is yes. Although many practices still tend to rely a great deal on paper files, healthcare providers themselves have become much more oriented toward electronic means of communication. Our study gathered info from physicians in family care, cardiology, endocrinology, internal medicine, psychiatry and neurology, and we discovered some important statistics.

    Why Gaps in Care Letters Are Less Effective

    Today, identification of gaps in care is largely done through patient discussions and manual review of the patient record. This includes gaps in care letters from payers, but those letters often do not get the attention they require. Over 64% of physicians recalled receiving a gap in care letter, but only 24% of practices systematically processed the information into the patient file. The reasons behind this, according to physicians, could be that the reports may be too general, include multiple patients, be based on outdated information, be considered clinically insignificant, or even be because the reports may be on paper, which is undesirable in most circumstances. Some physicians selectively process gaps in care, prioritizing notifications that indicate patients may not have filled a script for a chronic medication, may be due for chronic condition monitoring, or may be on the wrong medication or need additional medication. These are all good reasons for attention and prompt follow-up.

    This led to the question of whether healthcare providers would be likely to consider an EHR reminder for notifications that require prompt attention when with a patient. The most impactful in-workflow reminders are described below:

    • Notifications of potential adherence-related issues were welcomed: 85% of physicians would be likely to consider a notification that a patient had not filled a prescription, and 90% would consider a notification of a significantly overdue refill.
    • Reminders to consider appropriate vaccinations are also useful: 83% of surveyed physicians said they would be likely to consider an EHR reminder to vaccinate a patient, for instance, one aged 65 or over with pneumococcal conjugate.
    • Similarly, physicians welcome reminders to monitor a patient or provide a screening: When asked about a reminder to monitor a patient, such as for a colorectal screening, the number went to 82%.
    • Surveyed physicians were even open to notifications that sensitively requested they review their prescribing: 70% said they would consider an EHR suggestion to review a medication that may not be appropriate for a patient, and 74% would consider an EHR suggestion to add a medication to meet evidence-based guidelines.
    • Many welcomed in-message links to further information.

    These are not insignificant numbers. They tell that manual processes and gaps in care letters, while useful, are often insufficient and can be improved. The physicians we surveyed reported a much higher likelihood—over 75%—of responding to EHR reminders of gaps in care, and indicated they were especially open to those referencing therapy adherence issues.

    There are many reasons for this, but two stand out. One, of course, is that healthcare providers are more focused on digital communication today. The other is that EHR reminders happen while physicians are with the patient, so they are prompted to act in the moment.

    One caveat, though: The EHR is just as subject as the letters are to overuse, inaccuracy and lack of application. So, we are paying attention to the specific requests of physicians for information to be succinct, easy to act on, clear, accurate and appropriately targeted. Physicians today are aware the EHR notifications are much more customizable, to address highly specialized needs of individual patients—just the kind of capability the digital revolution has offered us.