“The future is already here; it's just not very evenly distributed.”
-- Author William Gibson
We are regularly reminded that Stage 3 of meaningful use will shift the focus from EHR deployment and data exchange to the health outcomes improvement the technology is designed to enable. But of course some organizations are already past the implementation phase and are working on realizing those outcome improvements. That Stage 3 future is already here; it’s just not evenly distributed. (That’s one reason the Health IT Policy Committee is trying to come up with a way for providers to “deem” that they are meaningful users on the basis of health quality improvements.)
During an Aug. 29 webinar, leaders of several organizations that have received grant funding from the federal Agency for Healthcare Research and Quality (AHRQ) described some of their efforts to identify the best ways to use the availability of electronic data to offer better quality care for patients.
One of those involved the project that brought Farzad Mostashari, M.D., to national prominence, the Primary Care Information Project (PCIP) of the New York City Department of Health and Mental Hygiene. One of PCIP’s goals is to expand the number of NYC residents whose care it can measurably improve through the use of EHRs. It has worked with 30,000 providers in the city, including more than 1,000 small practices and 63 community health centers and outpatient clinics.
Amanda Parsons, M.D., M.B.A., the department’s deputy commissioner for health care access and improvement, gave an inspiring talk about moving from implementation to improvement. She said once practices got stabilized on their new EHRs, PCIP offered them quality improvement consulting help that included dashboards to provide regular feedback. PCMH preparation. “We helped with work flow redesign, patient portal training, registries, quality measures, and interoperability.
In designing dashboard measures, PCIP focused on the leading causes of mortality in New York City: Heart disease, lung cancer, pneumonia, and diabetes.
• “Do we see improvement in quality of care? Absolutely,” Parsons said. Introduction of dashboards led to overall improvement across the measures displayed. Following 600 physicians over two years in areas such as blood pressure control, hemoglobin A1c testing, and smoking cessation, Parsons said she is excited to see rates of improvement higher than the national average.
• Do providers respond well to performance feedback in the form of dashboards with monthly quality measures? “Yes,” Parsons said, “although it is important to be nonjudgmental. Make the practice feel like you are their coach.” Getting information back can lead to a helpful dialog, she added. Often they are willing to work on their performance but haven’t had the tools. With some attention to areas of focus they can eke out significant quality gains.
• Does pay for performance lead to quality improvement? Yes, she said, for many providers it does improve quality of care. PCIP has used private funding from the Robin Hood Foundation to pay providers bonuses for doing the right thing, and the bonus is doubled for Medicaid patients or those with co-morbidities. PCIP has found practices with monetary incentives reporting greater improvement, but the doubling of the bonuses to work with Medicaid patients or those with co-morbidities didn’t work.
• Does patient-centered medical home certification mean higher quality of care? Parsons said the patient-centered medical homes in New York City tend to provide higher quality of care, but they also started out at a higher level. PCIP works with 332 PCMH practices, and 168 of those have achieved the more intensive level 2 or 3 recognition.
The other presenters during the AHRQ webinar were equally impressive. Elizabeth Alpern, M.D., M.S.C.E., director of the section of research and emergency medicine at the Children’s Hospital of Philadelphia, gavean overview of a project under way to collect and report quality measures from EHRs for the Pediatric Emergency Care Applied Research Network (PECARN). Lynne Nemeth, Ph.D., R.N., an associate professor at the Medical University of South Carolina, described the work of PPRNet,a practice-based learning and research organization. PPRNet involves 172 small to medium size primary care practices in 39 states. It pools data from primary care practices all over the country for the purpose of quality improvement and research. The network offers its members quarterly Practice Level Performance Reports to aid in practice quality improvement initiatives. “We can engage in research regarding what is needed to develop high-performing primary care teams and how practices make improvement using health IT,” Nemeth said.The practices use feedback from performance reports to reset the vision and priorities for improvement. Projects have been focused on improving cardiovascular disease outcomes, colorectal cancer screening, medication safety, and alcohol screening.