Bajaj Puneet, Kollipara Usha, Koganti Rama, Wang Dan Claire, Chennu Navreet, Bhat Deepa, Mutz Jacqueline, Willett Duwayne, Fish Jason, Karp David
University of Texas Southwestern Medical Center, Dallas.
Southwestern Health Resources, Dallas, Texas.
ACR Open Rheumatol. 2021 Mar;3(3):164-172. doi: 10.1002/acr2.11233. Epub 2021 Feb 11.
Rheumatoid arthritis (RA) disease activity assessment is critical for treatment decisions and treat to target (T2T) outcomes. Utilization of the electronic medical record (EMR) and techniques to improve the routine capture of disease activity measures in clinical practice are not well described. We leveraged a Lean Six Sigma (LSS) approach, a data-driven five-step process improvement and problem-solving methodology, coupled with EMR modifications to evaluate improvement in disease activity documentation and patient outcomes.
A RA registry was established, and structured fields for Routine Assessment of Patient Index Data (RAPID3) and Clinical Disease Activity Index (CDAI) were built in the EMR, along with a dashboard to display provider performance rates. An initial rapid-cycle improvement intervention was launched, and subsequent LSS improvement cycles helped in standardization of clinic workflow, modifying provider behaviors, and motivating better documentation practices. Trends related to CDAI score categories were compared over time using run charts.
Our project included 1322 patients with RA and 10 241 encounters between April 2016 and December 2019. Initially, RAPID3 completion rates increased from 16% to 50%, and CDAI from 15% to 44% from the RCI intervention. Post LSS intervention, the RAPID3 rate increased to more than 90% (sustained at 85%), and CDAI rate increased to more than 80% (sustained at 72%). The patients in the low disease/remission category increased from 54% to 66% (p < 0.001), and those in the high disease category decreased from 15% to 7% (p < 0.001), demonstrating improved T2T outcomes.
Combining EMR modifications with systems redesign utilizing LSS approach led to impressive and sustained improvement in disease activity documentation and T2T outcomes.
类风湿关节炎（RA）疾病活动度评估对于治疗决策和达标治疗（T2T）结局至关重要。电子病历（EMR）的利用以及改善临床实践中疾病活动度测量常规记录的技术尚未得到充分描述。我们采用了精益六西格玛（LSS）方法，这是一种数据驱动的五步流程改进和问题解决方法，并结合EMR修改来评估疾病活动度记录和患者结局的改善情况。
建立了一个RA登记系统，在EMR中构建了患者指数数据常规评估（RAPID3）和临床疾病活动指数（CDAI）的结构化字段，以及一个展示医疗服务提供者执行率的仪表盘。启动了初步的快速循环改进干预措施，随后的LSS改进循环有助于使诊所工作流程标准化、改变医疗服务提供者的行为并促进更好的记录实践。使用运行图比较了不同时间与CDAI评分类别相关的趋势。
我们的项目纳入了2016年4月至2019年12月期间的1322例RA患者和10241次就诊。最初，RAPID3完成率从16%提高到50%，CDAI完成率从15%提高到44%（来自快速循环改进干预）。LSS干预后，RAPID3率提高到90%以上（维持在85%），CDAI率提高到80%以上（维持在72%）。疾病程度低/缓解类别的患者从54%增加到66%（p<0.001），疾病程度高的患者从15%下降到7%（p<0.001），表明T2T结局得到改善。
将EMR修改与利用LSS方法进行的系统重新设计相结合，在疾病活动度记录和T2T结局方面带来了显著且持续的改善。
