Eric Newman, MD, chief of the rheumatology department at Geisinger Health System in Danville, Pa., was curious about how practical it is to get useful information from an electronic health record (EHR) at the time of a patient visit.
To find out, he and his colleagues examined the EHRs of 50 typical RA patients and assembled a “minimal mental dashboard”—basic information needed for a productive office visit that tells the doctor how the patient has been faring on their current treatments and their present health status.
It was not a speedy undertaking, Dr. Newman found.
“It took an average of 17 minutes—that’s almost the entire clinic visit,” he says. “What it tells us is, in real life, doctors are not looking at the information they need to look at because they simply cannot get it out of the existing EHR. That’s because the information they need is scattered throughout the electronic health record, or not visible in a way that’s helpful to manage patients with complex chronic disease.”
But he thinks he may have an answer.
What is RheumPACER?
He and a team at Geisinger have developed a system called RheumPACER that has been in use for about two and a half years at two Geisinger rheumatology departments. It’s a system that synthesizes information from several sources that are usually scattered, and presents physicians with an easy-to-access guide to a patient with up-to-the-minute information. The web-based system easily connects to the departments’ EHR with a hyperlink.
RheumPACER (PACER stands for Patient Centric Electronic Redesign) synthesizes information from a patient questionnaire that is filled out on a touch screen upon arrival at the doctor’s office. It includes questions about function levels, pain, fatigue, stiffness, social situation, events since the last visit, and other criteria. That information is calculated into disease activity scores, stored, compared to previous values, and sent to the system for immediate viewing by the physician.
RheumPACER also synthesizes information from nurses, the physician, and the EHR.
The information is viewable in a series of tabs, for general information, review of outcome trends, documentation for physician and patient, and quality analysis and reporting.
All of this, Dr. Newman says, saves the doctor and the patient time during office visits and lets treatment decisions be made based on the most current data, so that treatments dovetail with the status of the patient.
“I will have a really good idea about if you’re doing well or not doing well in a quantitative fashion, so that you and I can do problem solving when I walk in the room, instead of interrogating you for the first 10 minutes of a visit to see how you’ve been doing,” he says. “I walk into the room at 30 miles an hour instead of at zero.”
Dr. Newman traces the seeds of RheumPACER back to 1988, when he developed a paper-based questionnaire and outcomes database. But he had to wait for the right technology—and the right colleagues—to make a system like RheumPACER possible.
He and his team received a grant to fund the project from the Agency for Healthcare Research and Quality three years ago.
“That was the final piece that could get the momentum going,” Dr. Newman says.
A review found that after two years, 6,275 return patients had completed 19,876 touch-screen questionnaires. Eighty-six percent of RA patients had completed a Routine Assessment of Patient Index Data 3 (RAPID3); a Clinical Disease Activity Index (CDAI) had been completed for 61% of patients.
RheumPACER is being used by 12 of 14 doctors in the two Geisinger departments where it is available.
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Physician and Patient Feedback
Virginia Lerch, MPH, a research development manager at Geisinger’s Henry Hood Center for Health Research and the RheumPACER project manager, said the reaction from doctors has been mainly positive.
“All in all, they’ve been a really supportive group,” she says. “They’ve really embraced the innovation. They’ve provided a lot of the changes that we’re doing. This next round of revisions has come from their feedback.”
William Ayoub, MD, director of rheumatology at the Geisinger location in State College, Pa., who works at a site that uses the system as well as one that doesn’t, says it involves extra work for the patient and the doctor. But, he believes that it’s work that pays off.
“The advantage is we’re able to objectively measure how well the patient may be doing,” he says. “I would say that little extra work is probably well worth it. It makes us better able to document the patient’s status, enter it into the medical record, and follow it in time.”
He said that a “distinct minority” of patients is “computer phobic” and is reluctant to do the questionnaire, but most grow accustomed to it.
“If we explain to the patient how this helps us to care for them, and if we show them some of the nice graphs that PACER generates, they’re able to say, ‘Oh, this is important,’ and the patients are very willing to complete the PACER questionnaire,” he notes.
The two-year review didn’t find significant decreases in median chart review time or median progress note completion time, although there were improvements in those areas. But there were significant improvements in productivity, measured in relative value units, and revenue per patient visit.
That doctors are using RheumPACER routinely is a sign of its value, Dr. Newman says.
“Introducing a tool like this is a huge change in the existing system of care,” he says. “One of the most important measures of success is that you’ve been able to introduce a new tool that allows reliable capture of information from patients as part of their clinic process and reliable use by the people that need to use it.”
What’s next for RheumPACER?
The system is in a constant process of refinement. It is now only compatible with the EPIC EHR system, but changes are being developed so that it will no longer be “hard-wired” to that system and can be compatible with other EHRs.
“The holy grail, obviously, is a universal interface,” Dr. Newman says.
Lerch says the key is creating a kind of midsection to the system that can be altered depending on the EHR system.
“An approach that we’re taking is to have an abstracted middle layer that is agnostic to the underlying data source,” she says. “If you move from one system to the next, the changes would occur at that middle-layer level.”
Dr. Newman says he hopes for wider availability of RheumPACER by early next year and hopes others can see the impact that quick data formulation can have on patient care.
“How does it help you if you capture this information and then two or three days later you calculate the results?” he says. “The patient’s gone. You missed the opportunity to actually have that discussion with them during that visit. Real-time results help drive patient-centered care.” the rheumatologist
Thomas Collins is a freelance medical writer based in Florida.
