The Value of Linking Electronic Health Records (EHR) and Registries: Demonstrating Value in Managing Chronic Venous Disorders (CVD)

Healthcare as we know it has changed. In a day where evidence-based medicine and patient outcomes are under focus for every specialty, phlebology has a definitive need for practice-based data and an opportunity like no other. There is a tremendous need for meaningful demographic, epidemiologic, treatment, and outcome-related data. The key to capturing data lies in implementing and linking specific EHR values that we capture with every procedure or evaluation to a sophisticated registry.

EHR facts

Approximately 50% of providers who treat CVD use no EHR. Of those who are using electronic health records, a significant number are unsatisfied with the performance of their respective system. EHR vendors are not created equal. Large vendors target hospitals and large groups, and are generally cumbersome for the end users to implement. Some vendors are vein specific, yet may not be certified or permit data sharing. Adopting EHR technology is inevitable and is already being tied to reimbursement. Electronic health records offer the only means to efficiently capture every patient seen, and their respective outcomes. Vendors of EHR offer different features, yet the means to build efficiency and enable registry participation involves three simple features.

When it comes to choosing an electronic health record system, there is no perfect system. Many EHRs focus on the output or ability to draw fancy maps. Are those features truly necessary? Will drawing the map on a computer speed you up? The most important part of enhancing efficiency of an EHR involves the data entry process. If this is cumbersome in anyway, team buy-in will be difficult at best. Form functions and simplicity are imperative for a system to become a true benefit to a practice. Excessive drop down boxes, popup buttons, and text fields take more time to complete, but they have a role when there is high variability of the potential content or a need for exactness. As you review different EHR vendors, keep in mind that input options vary widely. Though output is important, it has little importance vs. formatting the input to be efficient. In fact, once the input has been formatted in a means to enhance efficiency, you may define output to suit your needs.

Importance and validation of registry data

Outcome based reimbursement is upon us. There is no doubt that phlebology encompasses a diverse group of
providers, yet is it valid to question the quality of outcomes from those from nontraditional backgrounds? I will argue that participation in any registry requires both time and financial commitments. Practices committed to this process should not have their integrity questioned. The validation of data is an important concept, and it is imperative that we have an accurate reporting of complications, as well as successes. The concerns raised about the integrity of a provider type are ill founded, especially when a practice is capturing patient-reported outcomes through confidential kiosks or tablets. In fact, one could easily argue that any practice with an EHR tethered to a sophisticated registry and a means to confidentially query patients is exceeding any existing reporting requirements.

One additional meaningful measure to ensure accurate reporting is to align a registry with a patient safety organization (PSO). Patient safety organizations protect data generated for assessing work quality, keeping data confidential and free from legal discovery in state and federal court. Ultimately, registry participation will involve those dedicated to the field, with the integrity apparatus of employing tools to capture the patient’s perception of outcome.

What can truly come from collecting and sharing data?

Cancer registries have the most robust recognition. Legislation of 1992 titled, ‘The Cancer Registries Amendment Act’ began national initiatives to study geographic differences, stage, cell types, and outcomes for a variety of treatment options. How will this play a role in phlebology? A recent registry project from the Geisinger Medical Center studied the outcomes of percutaneous coronary interventions (PCIs) in potentially sleep-deprived interventional cardiologists compared to well-rested providers. Over a five year period, the only significant difference demonstrated a higher rate of excessive bleeding at the arterial access site in the wellrested group. What could studies like this mean for the field of chronic venous disorders?

Given the lack of epidemiology surrounding many venous disorders commonly seen, the burden of venous disease may be assessed from the patient’s perspective. There are many examples where patients with meaningful venous pathology are disenfranchised by an assortment of insurance carriers employing stringent medical necessity and therapeutic guidelines lacking significant evidence. The following is a list of questions that may be prospectively assessed through registry participation:

• A patient has pain and swelling with a refluxing GSV less than 5.5 mm in diameter and bulbous tributaries. Is there truly any correlation between vein diameter and quality of life?

• A patient has a normal terminal valve yet reflux is noted from the pre-terminal valve of the GSV to the ankle. Is there a difference in quality of life or outcomes for patients with refluxing saphenous veins but normal terminal valves?

• A patient has a dilated (12.4 mm) refluxing anterior accessory saphenous vein with junctional reflux and bulbous tributaries. Do patients suffering from reflux in this pattern have any different quality of life impairment to those with GSV disease and otherwise same presentation?

• Patients with identical pathology are treated by vascular surgeons, interventionalists, and phlebologists. Is there a difference in surrogate or patient perceived outcomes?

• A C6 patient with recurrent varices after surgery is denied coverage of incompetent perforator disease with chemical and thermal ablation. What treatment provides the greatest benefit for this segment of patients with CVD?

• Compression therapy is required for many conservative trials. Is there a difference in quality of life benefit from wearing compression for 2, 6, or 12 weeks?

All venous disease states may be more completely assessed when we capture rich demographic, epidemiologic, surrogate, and patient perceived outcomes. This process becomes greatly simplified when the EHR data is effortlessly shared in a sophisticated registry. Data is not to be collected for the purposes of just capturing data. Prospective evaluation of any question must be followed with disclosure in society meetings and peer-review publications. Sequential patient-reported outcomes may show an incredible benefit for a variety of chronic venous disorders.

What next?

Electronic health records are an integral part of medicine moving forward. Sophisticated registries and EHR offer an incredible opportunity for vein practitioners to address the many questions facing our specialty. Many board certification organizations now require registry participation as a means of maintenance of certification. Given governmental and societal pressures, practitioners have an obligation to report outcomes. Capturing the patient’s voice is simply the next cog in the wheel of medicine, yet incredibly important if we place any value on those we help.

by Marlin Schul, MD