Background/Purpose: Cardiovascular disease (CVD) is a major cause of morbidity and mortality in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Guidelines for the management of both SLE and RA recommend evaluation of and intervention for known cardiovascular risk factors, including dysplipidemia. However, studies suggest that screening rates remain suboptimal. Quality improvement methodology offers a practical approach to bridge this gap in care. The fellowship training setting is an ideal environment in which to pilot such a project, as the American College of Graduate Medical Education requires that fellows demonstrate the ability to continuously improve patient care. Our aim was to improve the rate of recording lipid panel results in patients with SLE or RA to over 50% in a one month period.

Methods: In our busy outpatient rheumatology clinic in a county hospital setting, we examined patient, provider, and health system factors that could be barriers to providing routine cardiovascular risk assessment for our patients. For our first Plan-Do-Act-Check (PDCA) cycle, we examined the frequency with which physicians recorded lipid panel results in clinic notes during routine visits. We obtained baseline data for all RA or SLE patient visits for each of our six clinical fellows one month period. Our hospital district utilizes the EPIC electronic medical record (EMR); thus we devised a simple “dotphrase” to assist providers in ascertaining the date and results of a patient’s most recent lipid panel with just a few keystrokes. We then organized an educational session for our providers to inform them about the initiative, the collective baseline data and applying the “dotphrase”.  Each clinical fellow also received an individual summary of their baseline screening rates. 

Results: We reviewed 91 patient visits during the pre-intervention period (69% RA, 31% SLE).  Patients were 46.7 years old (SD 14.7) and 83% female.  Forty-two percent of patients had a lipid panel sent within the past year. Lipid panels were ordered by primary care physicians (63%), rheumatologists (15%), and other physicians (22%). Twenty percent of patients were on statin therapy. Our providers documented lipid panel results, however, in only 12% of the visits. Following the implementation of the EMR “dotphrase”, we reviewed an additional 92 patient visits over a one month period. Baseline characteristics were similar to our pre-intervention group. Our providers augmented their lipid panel recording to a rate of 65% after the intervention.

Conclusion: In our hospital district setting with an integrated EMR, the use of a simple “dotphrase” was effective in improving provider documentation of lipid panel results in patients with RA and SLE.  Future PDCA cycles will focus on increasing rates of obtaining screening lipid panels and intervening in patients with documented dyslipidemia.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/using-the-electronic-medical-record-to-increase-rates-of-physician-assessment-of-lipids-in-patients-with-systemic-lupus-erythematosus-and-rheumatoid-arthritis-a-quality-improvement-initiative/