Qual-IT - October 2005 | Archived

Financial barriers to physician adoption of HIT, particularly for those in small or solo practices, have made up a large part of the discussion in the numerous community-level initiatives now under way.  While the underlying assumption is that HIT can provide tools to facilitate quality measurement and reporting, and to improve health care quality and safety, payers have been reluctant to provide direct subsidies for HIT acquisition without demonstrable benefit.  With little information available about the quality of care delivered by individual physicians, there is not much of a baseline against which to assess the gap between actual and desired performance—although a recent Rand study found that physicians provided only about 50 percent of recommended primary and preventive services (McGlynn 2003).

Part of the problem may be the difficulty of accessing patient information that could give physicians a clearer picture of the care they provide, and guide their clinical decisions.  In a recently completed Commonwealth Fund national physician survey (Audet 2005), which focused on physician use of and participation in quality measurement and improvement activities, many physicians reported that they do not have access to basic information such as patient lists and diagnoses, and most said they cannot readily access information such as lab results and medication records.  Only one-third of all surveyed physicians reported getting feedback on their performance, with those in larger groups and primary care practices somewhat more likely to receive such information.  A similar distribution of physicians reported that they participated in performance improvement efforts.

Several initiatives have provided some limited evidence that HIT can improve the quality of care provided by physicians.  HIT is one of the central components in the Chronic Care Model, which was developed by experts at Washington State's Group Health Cooperative of Puget Sound and has been implemented in physician practices and community health centers throughout the country.  A JAMA article on the project (Bodenheimer 2002) describes HIT functions that can improve chronic care management and outcomes, including disease- and population-based registries, reminder systems and decision support, and physician performance feedback.  The article provides specific examples, from various physician practice and clinic sites, of effective chronic care improvement practices, including the use of information systems.

Physician use of  “organized care management processes” to improve quality of care, again with a focus on chronic care management and outcomes, is examined in another JAMA article (Casalino 2002) based on a national survey.  The authors documented a direct correlation between the use of HIT and external incentives, such as pay for performance, and physician improvements in care management.

A small but growing number of initiatives around the country are trying to fill the gap between physicians' limited access to information and the HIT tools that could supply vital care management and quality data.   They are doing so by advancing the collection and public reporting of physician quality measurements, with more or less explicit linkages to the use of health information technology.  Among them are:

Integrated Health Care Association. IHA is a large multi-stakeholder organization dedicated to improving the quality and efficiency of health care throughout California.  Between 2000 and 2002, the Association convened a working group to design a physician pay-for-performance initiative, selected and specified measures for the project, sent the draft measurement set to all participating California physician groups for review and comment, and adopted clinical and patient satisfaction measures to launch the first year of the program; by the end of 2002, several major health plans in the state announced their participation.  Based on the first year of data collection and reporting, health plans made approximately $50 million in performance-related payments to participating physician groups in 2004.

The IHA measures weigh patient satisfaction, preventive care, chronic care management, and HIT investment and use.  The initial set of measures included four patient satisfaction domains—doctor-patient communication, specialty care, timeliness of care and service, and an overall rating of care—and six clinical elements, including mammograms, pap smears, childhood immunizations, and asthma, diabetes, and coronary artery disease management scores.  Performance on the clinical measures comprised 50 percent of the overall score, patient satisfaction accounted for 40 percent, and HIT adoption was weighted at 10 percent.  IHA evaluates the measures and weighting formula annually; additional measures and changes in weighting have been introduced each year after vetting by IHA's stakeholders. 

Massachusetts Health Quality Partnership.  MHQP was established as a collaborative effort among health care stakeholders in Massachusetts to advance coordinated quality measurement, reporting, and improvement activities.  In 2003, MHQP launched a consensus process to advance public reporting of standardized quality measures (based on HEDIS specifications) at the physician-group level.  The first public report card was published in 2004.  There is no specific tie-in to physician use of HIT, but a number of Massachusetts health plans have sponsored and participate in other initiatives to promote HIT use, and many of the state's physician groups already have access to and utilize these tools.

National Committee for Quality Assurance. NCQA is widely known for developing and maintaining the HEDIS measurement set for managed care plan performance monitoring and improvement, and for publishing an annual scorecard based on plan-reported data.  Some organizations (such as the Massachusetts Health Quality Partnership) have adapted the existing HEDIS measurement system to produce valid measures at the physician or physician-group level.  NCQA itself has developed an additional category of physician recognition focused on performance in three broad areas: care management and outcomes for diabetes and for heart disease, and practice site HIT capabilities.

Draft standards for the next generation of the physician HIT component, Physician Practice Connections, were made available for public review and comment in September 2005.  Organized into three categories, or levels, the standards provide a detailed and comprehensive vision for quality measurement and reporting, and for physician HIT functions directly supporting optimal patient care management:

·         Basic elements assess the use of evidence-based standards of care and maintenance of registries to identify and monitor individual “at-risk” patients;

·         Intermediate elements include use of electronic health records, decision support, and order entry for lab tests and prescriptions;

·         Advanced elements focus on physicians' HIT interoperability with other health information systems, for purposes of information exchange, as well as use of nationally accepted data standards.

Bridges to Excellence.  BTE is a multi-site, multi-stakeholder organization committed to improving physician quality of care through technical assistance, consumer information, and reimbursement strategies designed to reward physician investment in and results from performance improvement practices.  Physicians who quality for recognition under one or more of the three NCQA categories (physician office HIT capabilities, and diabetes and cardiac care) receive incentives including bonus payments and a partial offset of the fees paid to NCQA.  New York's Albany-Rensselaer-Schenectady region is one of four areas in the country where local employers and health plans are implementing the BTE model.

As described above, small but important steps, including performance incentives, are being taken to advance measurement, reporting, and quality improvement strategies among physicians.   In some of these efforts, the extent of HIT adoption is an integral part of these physician assessments.

A further step was taken when, in 2004, the National Quality Forum (NQF) established a steering committee, issued a call for measures focused on ambulatory care, and then, in 2005, approved a final set of measures that included many previously developed by the American Medical Association's Physician Consortium for Performance Improvement, reflecting consensus among a cross-section of medical specialty organizations (e.g., family practice, internal medicine, pediatrics).  This convergence of standards will be further reinforced if payers utilize the measures for  reporting requirements and incentives.  It also provides a starting point for vendors to incorporate standardized measurement specifications into physician HIT systems; the measures could then be translated into decision support tied to evidence-based practice standards, as well as be used to streamline data collection and reporting.

How is the issue of quality measurement and reporting through physician use of HIT playing out in New York?  Here, too, a number of innovative projects are under way.

The Taconic Health Information Network Community (THINC) has identified physician quality measurement and reporting as a primary function of its data exchange initiative.  A work group on clinical metrics is discussing principles and measurement issues.  THINC is also exploring opportunities for coordination and convergence in measurement among NCQA, Bridges to Excellence, the Centers for Medicare & Medicaid Services, and other organizations and agencies.

The New York State Department of Health has convened a pay-for-performance advisory group pursuant to legislation enacted in 2005.  The group is charged with selecting standardized clinical measures for use in demonstration programs to be selected through a competitive process in 2006.

IPRO and the Medical Society of the State of New York—two key statewide health care organizations, the former using federal funds and the latter state grant funds—are providing technical assistance to physician practices to promote HIT adoption and use, with quality measurement and reporting as a primary focus.

These and other efforts will undoubtedly yield increasing amounts of data about the quality and safety of health care provided by physicians in New York and across the country.  The future challenge is to translate that data into relevant information for physicians, consumers, payers, and others who will be in a position—and expected—to take action to bridge the quality chasm.

Audet A-MJ, MM Doty, J Shamasdin, SC Schoenbaum.  2005. Measure, learn, and improve: Physicians' involvement in quality improvement.  Health Affairs 24(3):843-53.

Bodenheimer T, EH Wagner, K Grumbach.  2002.  Improving primary care for patients with chronic illness.  Journal of the American Medical Association 288(14):1775-79.

Bridges to Excellence, www.bridgestoexcellence.org

Casalino L, RR Gillies, SM Shortell, JA Schmittdiel, T Bodenheimer, JC Robinson, T Rundall, N Oswald, H Schauffler, MC Wang.   2003.  External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases.  Journal of the American Medical Association 289(4):434-41.

Integrated Health Care Association, www.iha.org

IPRO, http://providers.ipro.org/index/doqit

Massachusetts Health Quality Partnership, www.mhqp.org

McGlynn EA, SM Asch, J Adams, J Keesey, J Hicks, A DeCristofaro, EA Kerr.  2003. The quality of health care delivered to adults in the United States.  New England Journal of Medicine 348(26):2635-45.

Medical Society of the State of New York, www.mssny.org

National Committee for Quality Assurance, www.ncqa.org

National Quality Forum, www.qualityforum.org

Taconic Health Information Network Community, www.medallies.com

Update: New York State and Federal Activities