Progress in using the electronic health record to improve primary care

The seminal work in the 1970s by Geoffrey Rose on population-based strategies for prevention 1 and Julian Tudor Hart on evidence-based anticipatory care 2,3 had a profound influence on primary care and were actively supported by the Royal College of General Practitioners.In 1985 in the East London borough of Tower Hamlets, five GP practices collaborated as the Healthy Eastenders Project to support a basic electronic health record (EHR) system, employing nurses for preventive activities and providing comparative audits of their care.By 1992, with the first wave of general practice computerisation, a single EHR system, Egton Medical Information Systems (EMIS), was deployed across all practices in Tower Hamlets with the neighbouring boroughs of City and Hackney and Newham following closely.The Clinical Effectiveness Group (CEG) began to form a supportive network for implementing and evaluating work on preventive care across the locality.4 The early system required 'floppy disks' to extract data using Morbidity Information Query and Export Syntax (MIQUEST) with manual transport, usually by bicycle, to the CEG office to collate information from each practice.Although cumbersome, the results were transformative, and for the first time practices could see their own performance and share comparable information with their peers.[4][5][6] In the early days, the theoretical framework used by the CEG team to translate evidencebased innovation into routine clinical practice was necessarily pragmatic.With increasing experience, two complementary strategies framed the process of change.The first included elements of change management described by Kotter.7 These included: building the case for change, forming a coalition that includes both clinicians and managers, empowering others to act on the programme by the provision of education, comparative performance data, and quality improvement tools, creating early wins for the programme, and consolidating the new approach into work-as-usual to ensure sustainability.An early example of this approach was engaging all practices to code self-reported ethnicity in the early 1990s.Working in an area where 50% of registered patients are from ethnic minority groups, the importance of understanding inequalities in access to health services and clinical management by ethnicity was clear to all, but practices needed tools and support to do the work.Embedding ethnicity recording into new patient checks and chronic disease management data entry templates provided a simple tool, and population ethnicity recording rose rapidly to >80%.8,9 This was consolidated by local commissioners providing financial support for health advocacy and translation services where they were most needed.The second theoretical approach drew on Michie's behaviour change wheel.10 Interventions are characterised by and linked to a core behaviour framework that includes: Progress in using the electronic health record to improve primary care Debate & Analysis British Journal of General Practice, March 2020 e215 Box 1. Core components of the CEG approach to data-enabled improvement a Prioritisation: agreement with local cliniciansGuidelines: the CEG publishes local guidelines and managers on areas to target.for target conditions, to achieve consensus Based on evidence, ability to make change, on standards.These are evidence based and alignment of financial incentives, locally trusted.measurability, and overall value.Education: at CCG and local networks events, Clinical data entry templates: these standardise the CEG contributes to teaching on the content of clinical coding for common chronic disorders, and agreed local guidelines.support performance measurement.Designed by the CEG team and embedded within the EHR system.Computerised clinical prompts: a range of 'in Analytics and dashboards: data are pulled centrally consultation' and 'back office' searches and from practice systems to the CEG.Interactive prompts.These increase guideline adherence by dashboards show comparative performance, which reminding clinicians of best practice and providing is benchmarked locally, regionally, and nationally.lists of patients for review.Practice facilitation: serves to align CEG functions across practices.Facilitators get to know a group of practices and support data management and use of quality improvement tools.This role also provides feedback to the CEG for continuous improvement.a Based on Sharing to Improve, Health Foundation briefing, May 2018.11 CCG = clinical commissioning group.