Three Quality Improvement Initiatives and Performance of Rheumatoid Arthritis Disease Activity Measures in Electronic Health Records: Results From an Interrupted Time Series Study

Abstract

Objective: Applying treat-to-target strategies in the care of patients with rheumatoid arthritis (RA) is critical for improving outcomes, yet electronic health records (EHRs) have few features to facilitate this goal. We undertook this study to evaluate the effect of 3 health information technology (health-IT) initiatives on the performance of RA disease activity measures and outcomes in an academic rheumatology clinic.

Methods: We implemented the 3 following initiatives designed to facilitate performance of the Clinical Disease Activity Index (CDAI): an EHR flowsheet to input scores, peer performance reports, and an EHR SmartForm including a CDAI calculator. We performed an interrupted time-series trial to assess effects on the proportion of RA visits with a documented CDAI. Mean CDAI scores before and after the last initiative were compared using t-tests. Additionally, we measured physician satisfaction with the initiatives.

Results: We included data from 995 patients with 8,040 encounters between 2012 and 2017. Over this period, electronic capture of CDAI scores increased from 0% to 64%. Performance remained stable after peer reporting and the SmartForm were introduced. We observed no meaningful changes in disease activity levels. However, physician satisfaction increased after SmartForm implementation.

Conclusion: Modifications to the EHR, provider culture, and clinical workflows effectively improved capture of RA disease activity scores and physician satisfaction, but parallel gains in disease activity levels were missing. This study illustrates how a series of health-IT initiatives can evolve to enable sustained changes in practice. However, capture of RA outcomes alone may not be sufficient to improve levels of disease activity without a comprehensive treat-to-target program.

Figure 1.

P-charts showing A) the proportion of visits per month with a clinical disease activity index (CDAI) score documented in the electronic health record and B) the proportion of the documented CDAI scores in remission/low categories per month, during implementation of three quality improvement initiatives in an academic rheumatology clinic. CDAI: Clinical Disease Activity Index Vertical lines: Indicate onset of initiatives

Figure 2.

Interrupted time series (ITS) analysis with mean proportion of CDAI scores recorded in the EHR in biweekly time periods after implementation of three quality improvement initiatives. UC: Upper confidence limit, LC: Lower confidence limit. P-bar: Overall mean of monthly proportion. CDAI: Clinical Disease Activity Index. Vertical lines: Indicate onset of initiatives