Using Pre-Visit Planning and Electronic Health Record Messaging to Improve Liver Function Monitoring in the Pediatric Cystic Fibrosis Clinic

From the 2021 HVPAA National Conference

Shruti Paranjape (Johns Hopkins University School of Medicine)


Quarterly liver function tests (LFT) are required for people with cystic fibrosis (pwCF) newly started on highly effective modulator (HEM) therapy, which can cause liver toxicity. Compared to 2019 registry data, our clinic noted a sharp decrease in LFT monitoring from 90% to 75% in 2020. We examined causes of decreased lab monitoring frequency separate from causes related to the COVID-19 pandemic in an effort to improve our center’s LFT and annual lab monitoring data.

The objective of this quality improvement (QI) work is to utilize pre-visit electronic health record (EHR) messaging and improve the median percentage of pwCF beginning HEM therapy with required quarterly and annual LFT above the respective center and national registry medians by 12/31/21.


Root cause analysis (process mapping, Ishikawa cause and effect fishbone, Pareto charts) detected pre-visit planning and communication with CF individuals and their families/caregivers as causes of decreased lab monitoring frequency apart from decreased frequency of CF clinic visits in 2020. Using QI strategies, our team optimized processes for pre-visit chart review to identify pwCF due for labwork, communicated with pwCF and caregivers regarding the clinic visit plan via EHR messaging, and tracked completion of labs. The key metric is to track the rates of EHR message delivery and receipt along with the weekly percentage of labs completed ±1 month of visit date from 1/1/21-12/31/21. We are presently designing processes to track labs completed after the clinic visit and to communicate results and recommendations with pwCF and caregivers.


For the first quarter of 2021 (2021 Q1), completion of required LFT is nearly at target (22%). Quarterly LFT have been measured in 60% of pwCF newly started on HEM in 2019-2020. However, on average, 70% of ordered LFT were obtained each week in 2021 Q1. Process metric tracking showed that pre-visit EHR messages sent by physicians increased from 64% to 75%, but messages read by pwCF and caregivers decreased from 86% to 72% in 2021 Q1.


Weekly clinic review and physician communication via direct EHR messaging regarding pre-visit plans is effective for completion of ordered labs but presently remains slightly below target. Variation in completion of labs may be related to causes that affect: 1) clinic scheduling and census; 2) appointment time; 3) insurance requirements for labwork; and 4) receipt of the EHR message by the pwCF/caregiver. Design of further processes will utilize coproduction to target improving communication between the physician and pwCF/caregiver regarding messaging of the clinic plan, completion of required labs, and communicating lab results.

Clinical Implications

Timely LFT monitoring is critical given that children 6-11 years of age will soon be started on HEM therapy (FDA approval anticipated ~June 2021), increasing our percentage of pwCF on HEM from 42% to 69%.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog