Exceptions to Outpatient Quality Measures for Coronary Artery Disease in Electronic Health Records

Study Questions:

Are outpatient quality measures for coronary artery disease (CAD) accurate based on electronic health records?


This was a cross-sectional observational study using medical records from five internal medicine or cardiology practices between 2006 and 2007. Reviews of records for adherence and exceptions to four quality measures were completed. These measures included use of antiplatelet therapy, use of beta-blocker therapy post-myocardial infarction, use of angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy, and use of lipid-lowering therapy. Both automated reports and manual reviews of the medical records were completed.


Of the 47,075 patients with CAD whose records were reviewed, 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed that drug. Of 538 records randomly selected, 92.6% of the exceptions automatically reported were confirmed exceptions by manual review. Most exceptions were clinical contraindications, drug allergies, or drug intolerances. In a separate sample of 592 randomly selected records, unreported exceptions or a drug prescription was observed in 74.6% of patients for whom automatic reporting had recorded a quality failure.


The investigators concluded that an exception to recommended therapy occurs infrequently and is usually valid. Physicians frequently prescribe drugs even when exceptions are present. Automated reports of quality failure often miss critical information.


These data highlight the limitations of automated quality measure assessment. Ongoing research regarding the evaluation of quality of care is needed.

Clinical Topics: Atherosclerotic Disease (CAD/PAD)

Keywords: Electronic Health Records, Coronary Artery Disease, Myocardial Infarction, Drug Hypersensitivity, Drug Prescriptions

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