Quality Assurance (QA) for Protocols in an Urban STD Clinic Utilizing an Electronic Medical Record (EMR)

Background:  The Denver Metro Health Clinic is an urban STD Clinic.  The clinicians are RNs working under protocols, using an EMR, with physician consultation available.  QA was done with spot reviews of charts to identify departures from protocols.  We developed initial EMR-based QA measures for two protocols, to allow review of all charts.

Methods:  We identified all visits with trichomonads on wet prep (trich) and >= 3 WBC/HPF without gonorrhea on Gram stain (NGU), and identified the diagnosis and treatment given.  We also identified all visits with a diagnosis of trich or NGU and the lab results and treatment given.  To follow protocol, the lab results, diagnosis and treatment all needed to be consistent.  If a chart did not follow protocol, we hand reviewed to determine whether the note indicated a physician consult directing off-protocol diagnosis and treatment.

Results:  From 4/1/2012 – 3/31/2013, 2030 men had >= 3 WBC/HPF on Gram stain; 1960 had NGU correctly diagnosed and treated (97%, range by individual provider:  95–100%).  Chart review revealed that several reasons accounted for the other 3%, including failure to address the lab results, lack of a recurrent NGU diagnosis in the EMR, leading to use of “other” for the diagnosis, and decisions to treat only 2 WBC/HPF as NGU without documentation of an MD consult.  During that time, 2504 women had trichomonads on wet prep; 2486 had trich correctly diagnosed and treated (99%, range:  98–100%).  Rarely the lab result was not addressed, but we found that ambiguity in the EMR about how to chart the treatment explained most of the remaining 1%.

Conclusions:  EMR-based review allows more complete review of RN adherence to protocols, as well as individual feedback to RNs about performance. We were able to identify deficiencies in the EMR itself as a cause of some errors.