Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

Background: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments.

Objective: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions.

Design: Cross-sectional observational study.

Setting: 5 internal medicine or cardiology practices.

Participants: 47,075 patients with coronary artery disease between 2006 and 2007.

Measurements: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records.

Results: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure.

Limitation: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives.

Conclusion: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information.

Primary Funding Source: Agency for Healthcare Research and Quality.