Implementation of a Peer Review Process to Improve Documentation Consistency of Care Process Indicators in the EMR in a Primary Care Setting

BACKGROUND: Kaiser Permanente Colorado is a group model nonprofit HMO that provides health care services to more than 500,000 members. The Primary Care Clinical Pharmacy Services (PCCPS) department consists of 33 clinical pharmacy specialists (CPS), who are located in 19 primary care clinics. OBJECTIVES: To develop and implement a peer review process to (a) improve the consistency of documentation of process indicators in the electronic medical record (EMR), (b) ensure compliance with existing standards, and (c) share best practices among PCCPS with varying geographical locations and practice styles. METHODS: A committee was formed to undertake the peer review process. An audit tool consisting of yes/no questions was created to assess chart documentation by PCCPS and to provide feedback for improvement. Four sections were included in the evaluation tool: (a) content, (b) collaborative drug therapy management, (c) nonformulary reviews, and (d) pharmacy system documentation. Peer reviews occurred quarterly, and all CPS participated. Copies of reviews were distributed to PCCPS clinicians and their supervisors. Questions and inconsistencies regarding the process were identified by the peer review committee to provide feedback to the group to optimize reviews. After completion of each quarter’s reviews, error rates were calculated by dividing the total number of “no” answers by the total number of PCCPS notes reviewed that quarter. A 2-tailed Fisher’s exact test was used to compare the error rate at the last quarter of each year (2007 to 2010) with baseline (2007 Q1). RESULTS: A total of 1,856 reviews were conducted between 2007 Q1 and 2010 Q2. Significant improvements in documentation were demonstrated over the first 12 months and sustained for the next 2.5 years. From 2007 Q1 to 2010 Q2, the rate of noncompliant elements decreased from 14.1% to 2.5% (P = 0.001) in the content section and decreased from 31.3% to 8.3% (P less than 0.001) across all sections. CONCLUSIONS: Over 3 years of follow-up, the peer review process was successful in improving the consistency of documentation by PCCPS and compliance with existing standards. The process was well received by participants. The peer review document is easily adaptable and can be updated to address changes in drug therapy management protocols and nonformulary medication reviews as needed. This process also allows for sharing of best practices among high-functioning PCCPS practitioners who otherwise could remain isolated.