As I said in the first post in this series,

“Ambulatory clinical quality improvement programs need to be driven by physicians and their staff members if maximum improvements are to be seen.”

If physician engagement is so important, why are some physicians reluctant to actively participate with a CQI program? Physician naysayers are usually rather vocal on this topic (shocking, I know), so let’s discuss some of the most important barriers we encounter and how you can help your physicians see the light:

“I don’t need to change.”

We hear this a lot, and it is arguably the most difficult to address, because a transformation in thinking and care delivery is needed.  As I said last week, a successful CQI program has both point-of-care and population management components.  Many physicians think that because they nail the point-of-care part they don’t need to think about their patients as a population.  If you take great care of each patient at every encounter, then your patient panel must be in fine shape, right?  Wrong.

You don’t really know how your patient population is doing until you peel back the covers and really look.  When they see the data, most physicians are surprised that their outcomes aren’t better.

The Solution:  Show your physicians their outcomes!  Make them see where improvements can be made and how they stack up against their peers.

“I don’t trust the data.”

Of course, the first reaction a physician will have when you show him or her a suboptimal outcomes report is, “Well, obviously the data is wrong.”  End of story.  Done.  Finished.  Thanks for stopping by.

The Solution:  Before you have the conversation about outcomes, make sure the data used to produce the outcomes reports are accurate, up-to-date, and complete.  This requires software that can aggregate and normalize data from disparate systems and a proactive data management program, which usually involves the electronic receipt of Actionable Data from various clinical and administrative sources.  More on data management in future posts.

“I don’t have time.”

Let’s face it.  Physicians are busy!  There are ever increasing demands on our time, especially for non-clinical activities that don’t seem to benefit anyone (Don’t get me started!).  Asking physicians to do one more thing is a tall order.

The Solution:  Design your program to engage office staff members to help with the CQI process.  Staff members can ensure gaps in care are filled at every patient encounter, including simple prescription refill phone calls, using standard protocols “blessed” by the physician.  A Quality Manager can help lead the charge and organize the process, and this all means less work for the physician as well as improved outcomes!  More on this later.

There are other barriers, of course, like not wanting to use technology, staffing concerns, impending retirement, etc., and some of these will be addressed in future posts.

The argument for physician engagement with CQI programs is really quite compelling, so hopefully the information in this post and previous posts has helped you know a little more about how to get your physicians on the bus!

Next Week’s Blog

In next week’s post, I’ll tackle barriers to staff member engagement in CQI programs and talk about how these barriers can be overcome.

What Do I Share?

At first blush it might seem sensible for health care providers to share all of the data available to them with other health care providers, but this can be a tall order and may be overkill depending upon the reason you are sharing information.  When the goal is improving clinical and financial outcomes, a good approach is to share only the information most useful for your clinical quality improvement (CQI) program.  Let me explain a little further.

I look at the delivery of healthcare in the ambulatory setting as having two broad components – 1) Episodic care and 2) Proactive CQI programs.  Episodic care means working-up a patient’s fever, managing a patient’s heart failure, or addressing the proverbial sore big toe – at the point of care, one patient at a time.  Proactive CQI means making sure your patients’ care meets acceptable standards, using a combination of point-of-care and population management approaches.  Episodic care requires access to a complete health care data set, and Proactive CQI requires access to Actionable Data.  Actionable Data is the most useful data to share in a healthcare community for CQI programs.

So, what kind of Actionable Data am I talking about?  Well, there are different types of information that can provide valuable insights and guide decision-making, such as:

• Basic demographics, like age and gender;
• Payer relationships for P4P program reporting;
• Medical history profiles, like diabetes and heart failure;
• Vital signs, like weights and blood pressures;
• Care items, like mammograms and colonoscopies;
• Immunizations; and
• Lab results, like HbA1C, GFR, and LDL.

Other Actionable Data can include information about Case Management program goals, Care Management Tracking of ordered tests or consults, or clinical or financial risk assessments.

How Do I Share?

Well, that’s a good question.  If you are like me, your patients are cared for by a wide variety of specialists, acute care hospitals, long-term acute care hospitals, nursing homes, home care agencies, and hospices in your community, and these providers and organizations likely use various EMRs and paper-based documentation systems.  The community-wide EMR model hasn’t worked out very well for many reasons, and EMRs aren’t so good at population management, patient outreach, care management, risk assessment, and reporting anyway, which are all critical components of an effective CQI program.

In my experience, the best way for stakeholders in a healthcare community to share data and collaborate is to use a system that “sits above” other electronic and paper-based solutions and ties them all together.  The beta-blocker prescribed by the cardiologist, the dilated retinal exam performed by the ophthalmologist, the flu shot given by the nephrologist, the mammogram completed at the hospital, and the HbA1C ordered by the primary care provider can all be acquired from electronic sources and stored in a single patient chart accessible to all appropriate health care providers in a community.  Manually acquired data like vital signs, diabetic foot exams, and tobacco use information can be shared as well.

Why Do I Care?

This is the real question, isn’t it?  What I outlined above takes a bit of effort and costs a little money, so why shouldn’t you just work in a dank, dark office with no windows and a cold steel door that only patients can pass through?  Overly dramatic?  Maybe, but if physicians and other health care providers in a community share Actionable Data, this will throw open the virtual doors and windows to your office and provide some valuable visibility into your patient population, which will have several practical benefits:

• Access to a more complete, accurate, and up-to-date data set.  The cardiologist sees the patient is overdue for a mammogram, so she orders it for the patient.
• Decreased workload.  You don’t have to collect all of the data you need.  You have help!  The ophthalmology billing system lets the primary care physician know that the dilated retinal exam was done last week.
• Better communication with your patients.  Patients can record medication changes, immunizations, blood pressures, blood sugars, etc., which can all be shared by the appropriate health care providers to help improve overall data quality and outcomes.
• Better compliance with standards of care.  More health care providers sharing more data helps us all make sure our patients get the right care at the right time.  The nephrologist sees that the patient hasn’t had his colon cancer screening yet, so a referral is made.
• Increased reimbursement for higher quality care.  Whether it is P4P, PCMH, or Accountable Care, you CAN get paid more for providing high-quality care – and proving it.
• Decreased number of duplicate tests and procedures.  The Pneumovax given during the patient’s last admission and the PSA ordered by the urologist are available for all to see.

To summarize the last couple of blog posts, sharing Actionable Data within a health care community helps enable care collaboration, decreases physician workload, and drives improvements in clinical and financial outcomes.  We’ll talk a little more about care collaboration and data sharing in future series and posts as well.

Next Week’s Blog

In next week’s blog post, I’ll discuss overcoming barriers to physician engagement in clinical quality improvement programs.  This is a key topic, so stay tuned!

Let’s face it. Physicians may work in care teams in certain situations, but most decisions made by physicians are not made in consultation with other physicians or care providers. Medical training and the current practice of medicine focus heavily on developing independent clinical impressions and treatment plans.

In addition, we physicians have so many people making so many demands for our time that taking a minute or two to proactively communicate or coordinate care with anyone who isn’t sitting right in front of us usually just doesn’t happen. The barriers to efficient communication of this kind can be significant without the right tools, which most health care communities are still lacking. Even though care coordination may not be on most physicians’ minds, it is a key component of a successful Clinical Quality Improvement (CQI) program, and it deserves a little air-time here.

So What Is Care Collaboration, Anyway?

Broadly speaking, care collaboration means communication and coordination of care between various patient care stakeholders. It can mean:

• Primary care and specialty care physicians proactively working together;
• Achieving successful transitions of care from one set of physicians in the inpatient setting to another set of physicians in the outpatient setting – and vice versa;
• Working with family members of very young or very old patients to ensure that care is being delivered appropriately and effectively;
• Physicians and case managers working together to improve the care of the sickest patients; and
• Engaging with “outsiders”, like physician organizations, health information exchanges, employer groups, case managers, and (putting on my Kevlar vest for this one) payers!

When Did Pigs Start Flying in Your World?

You might be thinking to yourself, “Sure, all these great things will happen… when pigs fly!  That sounds like a lot of work… what physician has time to do all that?”

We all know that it’s the Angry Birds that fly not the Pigs, but pigs don’t have to fly for you to efficiently and effectively communicate and collaborate with a broad range of individuals to help improve clinical and financial outcomes. A collaborative healthcare intelligence solution is like the Facebook of Medicine in a healthcare community. It’s the meeting place for physicians and other providers, patients, families, and a whole host of other stakeholders as well.

I’ll go into more detail about how care collaboration can become a reality later in this blog series as well as in other upcoming series.  I introduce the topic here partly for background and partly as a lead-in to next week’s post regarding sharing data, which is essential for effective communication and care coordination.

In our next post:

In the next post I’ll discuss the many benefits of sharing data within a collaborative health care community and talk a little about how that model works in individual physician office practices. Stay tuned!

Setting Realistic Goals

Now that you’ve decided that you want to lead the quality improvement charge, you should set some goals. Some of the goals should be for the physician, some for the staff, and some for the office as a team:

Physician Goals

1. Support the quality improvement work in the office. Don’t be the grumpy doctor who won’t change his or her ways. I’m a grumpy doctor sometimes too, so I can say that.
2. Empower your staff to actively participate in improving outcomes. Give them marching orders and cut them loose! They will appreciate the responsibility and believe in the work.
3. Use technology at the point-of-care at every patient encounter to identify gaps in care and act on them. Use the tools available to you to cure, heal, and stamp out disease.

Staff Goals

1. Support the quality improvement work in the office. Don’t be the grumpy staff member who won’t change his or her ways.
2. Use technology at the point-of-care at every patient encounter to identify gaps in care and act on them.

Office Goals

1. Meet all Pay for Performance benchmarks this year. Leave no money on the table.
2. Obtain PCMH certification for your office. Increase reimbursement with this certification.
3. Improve your rankings on any payer Websites. Go from 3 apples to 5 apples!
4. Participate with the PQRS program. Leverage the data you have. Don’t let the government keep your money!
5. Increase performance on various preventive care and chronic disease management outcomes by X% each quarter. Can you do better than your office partners? Then do it!
6. Meet Meaningful Use requirements. If you are going to get serious about this, then go get your reward from the government.

These are just some ideas to get you started. Whatever goals you choose, make sure they are meaningful, achievable, and measureable.

In the next post in this series, we’ll roll up our sleeves a little further and talk about Collaborating and Sharing Data.

Now, I realize that there are many companies out there hired by payers and employers to improve outcomes and cut healthcare costs, and they must be doing something of value.  But I think most of you will agree that patients want their own physicians to manage and coordinate their care, not some stranger at a company they have never heard of.  That’s certainly been my experience over the last 12 or 13 years, and I haven’t seen much benefit to my patients when outsiders are involved.

In fact, lately we’re hearing more and more from our payer partners that they are seeing suboptimal results from the CQI programs they administer.  We are also hearing that these same insurers are putting more emphasis on engaging the physician and his or her office staff in the CQI process.  Pay for Performance (P4P), Patient Centered Medical Home (PCMH), Medicare’s Physician Quality Reporting System (PQRS), Meaningful Use, Accountable Care, etc. are all payer-sponsored programs intended to financially reward physicians for providing higher quality care.

“So, what?  What’s in it for me?”

I hear this from physicians a lot.  We’ll discuss overcoming barriers to engagement in another post, but let’s look at a few of the benefits of higher quality care from the physician’s perspective:

1. Higher quality care.  Great!  But maybe not enough to transform the way you practice.  Let’s face it.  The fee-for-service model doesn’t really encourage a transformation to a population-based care model.
2. Professional standing and public perception.  Huh?  You’re a fantastic physician, right?  You always do the right thing, and your patients love you.  So, why are you not in the top 10% of physicians in your area but the physician in the suite next door is?  More and more payers publicly report outcomes, like the new Physician Compare Website sponsored by CMS.  You want to be at the top of every one of these lists to attract and retain patients.
3. Decreased workload.  Sorry?  That’s like something for nothing.  How can I see improvements in quality without adding work to my already hectic day?  Automation and staff empowerment is part of the answer.  Use technology to identify patients with gaps in their care, and then use that technology to automatically reach out to those patients to fill those gaps.  Empower your staff members to tackle these gaps at every patient encounter (even med refill calls).  Soon, care gaps will be filled, and you will have less to think about and less to do at each patient visit.
4. Higher reimbursement.  Now we’re talking.  Physicians are finding that more and more of their income is dependent on providing and documenting high-quality care.  The programs listed above all reward physicians in one way or another for focusing their energies and resources on improving clinical outcomes.  Payment reform is just getting started, and the physicians who provide the most VALUE will be the winners.  More on value in a future post.

As you can see, the perks of more quality-focused care are numerous for the physician, but that doesn’t answer the question of how you get there. This is something we’ll tackle in the next post, where I’ll outline specific goals you should reach in order to reap the benefits I’ve discussed here.

Physician Office Series

1. Quality Improvement Benefits
2. Quality Improvement Goals
3. Collaborating and Sharing Data
4. Overcoming Physician Barriers to Engagement
5. Overcoming Staff Barriers to Engagement
6. The Quality Manager
7. Physician and Staff Roles
8. Staff Empowerment
9. Alert Fatigue
10. Work Flow Strategies
11. Basic Care Management
12. Patient Outreach
13. Benefits of Un-blinded Reporting
14. Physician and Staff Incentives and Rewards

Physician Engagement Series

1. Pay for Performance
2. Patient Centered Medical Home
3. Medicare’s Physician Quality Reporting System
4. Accountable Care
5. Meaningful Use
6. Public Reporting of Physician Performance
7. Other Programs
8. Maintenance of Certification
9. Physicians with EMRs

Patient Engagement Series

1. Point-of-Care Benefits
2. Patient Outreach Strategies
3. The Patient Portal
4. Targeted Patient Education
5. Secure Messaging for Communication and Collaboration

Clinical Integration Series

1. Goals and Requirements
2. Collaborative Community Care
3. Clinical Integration HIT needs
4. Primary Care Clinical Integration
5. Specialty Care Clinical Integration
6. Documentation and Legal Review

Care Management Series

1. Gaps in Care
2. Population Management
3. Predictive Modeling/Risk Assessment
4. Case Management
5. Transitions of Care
6. Patient Outreach
7. Patient Education
8. Special Quality Improvement Initiatives
9. Cost and Utilization Reporting
10. Care Management Tracking

Data Management Series

1. Interfacing Basics
2. Developing an Integration and Interfacing Strategy
3. Data Aggregation
4. Data Normalization
5. Data Mapping
6. ICD-10
7. The Data Analyst
8. Data Management Reporting and Administration

Reporting Series

1. Patient-Physician Attribution
2. Identifying and Reconciling Duplicate Patient Records
3. Outcome Measure Reporting
4. Predictive Modeling and Risk Assessment
5. Cost and Utilization Reporting
6. Reporting Strategies at the Office, PO, and HIE Levels

Paul D. Taylor, M.D., WellCentive Chief Medical Information Officer

Welcome to the new Wellcentive blog.  Our goal is to provide valuable insights based on real-world experience that will help you and your organization improve your clinical and financial outcomes and better serve your patients and physicians.

Wellcentive’s solutions were developed to meet the practical, day-to-day needs of physicians like me and to enable healthcare organizations like mine to proactively and effectively implement and administer clinical quality programs.  Wellcentive is a noted innovator and leader in the maturing healthcare intelligence market space, and our staff members have deep and highly relevant experience helping our clients improve clinical quality and financial performance at the physician, physician group, physician organization, and community levels.

Our software was originally designed and built by healthcare providers for healthcare providers.  We have continued to listen carefully to our customers’ needs, and our solutions have evolved as our customers have tackled the ever-changing healthcare landscape head-on. Thousands of physicians use our software to care for tens of millions of patients and our interface platform exchanges millions of messages each week.  Our customers include some of the most prestigious physician groups and organizations, healthcare systems, health information exchanges, employer groups, professional organizations, and HIT vendors in the country.

As a practicing internal medicine physician and Chair of my own PHO’s Clinical Integration Committee, and as Wellcentive’s Chief Medical Information Officer I will be leading this effort, however we will have other members of our team participate as well.  You’ll also hear an occasional word from one of our customers or partners.

Through this blog, we will share some of our knowledge, best practices, and practical insights, which we hope will be beneficial for you and the patients you serve.  We realize that software and technology are only a part of the story.  It’s what you do with the software and how you use the technology that really matters.

Content will be updated frequently, so please keep an eye on the WellCentive Blog.  Share it with friends and colleagues, and don’t forget to jump in and share any comments or feedback you have as well.   We all need to collaborate in order to provide high-quality, cost-effective healthcare, and we are looking forward to helping build a real community and enabling an ongoing dialog with our readers.