John Tooker, MD FACP, MBA

1
ACP, AHQA, and QIOs A Synergistic
RelationshipImproving Quality through Health
Information Technology

• John Tooker, MD FACP, MBA
• American Health Quality Association Annual
  Meeting
• February 25, 2005

2
Objectives

• Describe ACP Advocacy Efforts Beneficial to QIOs
• Describe ACP Practice Management Experience
• Describe Efforts to Establish EHR Standards and
  Certification
• Describe Effort to Establish a Starter Set of
  Performance Measures
• Discuss the Role of Evidence-based Clinical
  Decision Support in Quality Improvement
• Discuss Next Steps in Working Together Toward
  Quality Improvement Through HIT

3
ACP Advocacy Efforts

• Urging Congress and Administration to Stabilize
  Medicare Payments
• Avert cuts of approximately 5 per year over the
  next decadecumulative 30 by 2013
• Fix the Un-Sustainable Growth Rate formula
• Scheduled Medicare payment cuts will make it
  nearly impossible for physicians to acquire HIT
  and participate in quality improvement
  projects--Payroll Not Paperless

4
Financial Incentives to Acquire and Use HIT to
Improve Quality

• Urging Congress to Enact National Health
  Information Incentive Act, Bipartisan Legislation
  Introduced by John McHugh (R-NY) and Charles
  Gonzalez (D-TX)
• Based on ACP Proposal
• Provides Financial Incentives to Address Barriers
  to HIT Acquisition and Use
• Initial Funding Provides incentives to small
  practices to help acquire HIT in the form of
• Grants
• Refundable tax credits
• Revolving loans

5
Financial Incentives to Acquire and Use HIT to
Improve Quality

• Sustained Funding Directs Medicare to provide
  reimbursement incentives to physicians who use
  HIT to improve quality through
• Add-on payment for visits
• Separate payment for e-mail consultations and/or
  
• Care management fee

6
Expand MMA Section 649

• ACP Continues to Support MMA Section 649
  Demonstration
• Urging Congress to Expand Small Practice Pay for
  Performance Demonstration Created by MMA Section
  649
• Expanded Program Would Include the Following
• Provide financial incentives to small physician
  practices that work with QIO to voluntary acquire
  HIT and agree to have performance assessed using
  evidence-based measures and reported
• Include more than the current 4 states than
  authorized by Section 649
• Include more physician practices in each state
• Allow all participating physicians to be eligible
  for financial incentives as opposed to study and
  control groups under current demonstration

7
ACP Practice Management Experience

• ACP Practice Management Center (PMC) is
  refocusing its programs on developing best
  practices on office redesign and supportive
  tools
• Working to link good business practices with
  clinical improvement
• Arkansas DOQ-IT and CCIP projects are giving ACP
  first hand experience in developing
  practice-based models
• Developing a proposal for external funding to
  support a Center for Practice Improvement

8
EHR Standards and Certification Goals

• Support system purchasers by providing
  information and tools that aid in determination
  of requirements and comparison of systems.
• Support system vendors by providing a clear
  roadmap to future functionality.
• Support payers by providing a yardstick with
  which to measure EHR implementation of incentive
  programs. 

9
EHR Standards and Certification Process

• Develop list of EHR functions - HL7 EHR
  Functional Model
• Completed Summer 2004.
• Develop minimum function set for ambulatory EHR -
  HL7 Ambulatory Minimum Function Set
• Completed February 2005
• Use the HL7 draft standards to develop
  certification criteria for ambulatory EHRs
• Effort being led by Certification Commission for
  HIT (CCHIT)
• Due Summer 2005
• Certify EHR systems

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EHR Standards and Certification Minimum Function
Set

• Essential EHR Functions for Given Care Setting,
  Population, Realm, or Application
• The function must be feasible to implement now or
  within 18 months.
• The function must also be critical or key to
  helping an EHR system address at least one of the
  following criteria
• Support Delivery of Effective Healthcare
• Improve Patient Safety
• Facilitate Chronic Care Management
• Improve Efficiency
• Facilitate Self-help Management

11
Certification Commission for Health Information
Technology (CCHIT)

• Mission is to accelerate the adoption of robust,
  interoperable HIT throughout the US healthcare
  system by creating an efficient, credible,
  sustainable mechanism for the certification of
  HIT products.
• To reduce the risk of HIT investment by providers
• To ensure interoperability of HIT products with
  emerging local and national health information
  infrastructures
• To enhance the availability of HIT incentives
  from public and private purchasers/payers
• To accelerate the adoption of robust,
  interoperable HIT throughout the US healthcare
  system

12
CCHIT (Continued)

• ACP Member Serves on
• Commission
• Functionality Workgroup
• Interoperability Workgroup

13
Consensus on Starter Set of Performance Measures

• ACP is a co-conveneralong with AHIP, AAFP, and
  AHRQof a Leadership Meeting to guide the
  selection of starter set of uniform
  evidence-based measures also allows us to
  influence views of purchasers on efficiency
  measures, data reporting and aggregation
• Leadership Meeting Objectives
• Reach consensus on core principles for selecting
  starter set of performance measures for
  ambulatory care
• Reach consensus on conditions covered in a
  starter set of measures for ambulatory care
• Review proposed starter set of measures and
  identify other measures for consideration

14
Performance Measure Starter Set

• Leadership Meeting Next Steps After Approving
  Core Principles and Conditions
• Develop a set of supra criteria by which to
  select the final list of criteria that defines
  the starter measure set.
• Apply the supra criteria to the strawman
  list of measures and propose a starter measure
  set to the full group.
• Propose to the full group a sustainable process
  to steward the starter-set into sub-sequent
  larger numbers of measurement sets over time, and
  transition from administrative to EHR-based
  measures as needed.

15
Performance Measure Starter Set

• Examples of Possible Supra Criteria
• Clinical / scientific issues clinical relevance
  impact demonstrated examples of improvability
  and good outcomes and dealing with low volume
  measures, etc
•  Implementation issues ease of implementation,
  particularly in smaller practices and those that
  do not have EHRs, e.g., validating administrative
  data bases, accessing clinical data bases,
  creating decision rules to prioritize preferred
  data from overlapping sources, etc
• Contextual issues to what degree is the measure
  of physician vs other system performance who is,
  could, or should be responsible for patients who
  are treated by multiple physicians

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Evidence-based Clinical Decision Support ACP
Physicians Information Education Resource (PIER)

• Content is Currently Comprised of 356 Modules
  Including
• Diseases
• Undifferentiated Symptoms (in preparation)
• Screening and Prevention
• Procedures
• Complementary-Alternative Medicine
• Legal/Ethical Issues
• Drug Resource

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PIER Architecture

• Uniform structure, format and style
• Drill down from the general to the specific
• Guidance statements
• Bulleted, single-sentence actionable
  recommendations
• Underlying rationale and evidence entries
• PubMed abstracts and full-text ACP resources
• Library of additional resources
• Discrete pieces of content every step of the way

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Different Uses of PIER in ACP Products

• PIER Website for members
• PIER PDA
• New reciprocal dedicated links to Annals and
  Journal Club
• Clinical features derived from PIER in Observer
• Website modifications Flattening

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Different Uses of PIER by Licensees

• Aggregated Medical Resources, e.g. Stat!Ref
• Integrated with other PDA applications, e.g.
  Skyscape
• Direct IP access of the website and PIER e-mail
  bulletins, e.g. LSU
• Integrated with a pharmacologic data base, e.g.
  Gold Standard Multimedia

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PIER Integration in an EHR

• Dynamic Digital Healthcare Systems, Inc.,
  Melbourne, Florida
• David P. Hurwitz, MD, President
• General internist in an internal medicine group
  practice
• ACP member and recipient of preceptor award in
  community-based teaching program
• Multi-featured EMR designed for informed
  evidence-based medical practice

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PIER Integration into an EHR

• Uniform PIER content pieces can be used anywhere
  in the EMR to inform clinical decision making
• Links are made through infobuttons or through
  PIER-derived order sets for key diseases
• EMR vendors can link to any page at any level in
  PIER, e.g. specific recommendations, tables, etc.
• PIER modules are updated at least every three
  months and provide reliable current information
• Performance measures can be embedded in PIER
  order sets, and the EMR can collect and collate
  data

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Advantages for PIER Users

• Users have access to updated clinical information
  at the point of care
• Information is presented in clear, uniform and
  easy to digest nuggets to save time and increase
  efficiency
• PIER order sets outline evidence-based quality
  care and embed performance measures that can be
  captured by the EMR to provide data for pay for
  performance.
• Navigation to Evidence and Additional Resources
  provide opportunities to get continuing medical
  education while taking care of patients

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Next Steps in Working Together Toward Quality
Improvement Through HIT Enhancing the
Synergistic Effect

• Building on Already Strong Relationships
• ACP works collaboratively with AHQA
• ACP leadership active in QIOs
• Working Together to Help Physicians with EHR
  Selection and Office Redesign to Improve Quality
• ACP collaboration with Arkansas Foundation
  provides an example
• Working Together to Prepare Physicians for
  Pay-for-Performance Environment

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Next Steps in Working Together Toward Quality
Improvement Through HIT

• Working Together With ACP State ChaptersAs
  Required in the CMS Draft QIO Proof of Capability
  Requirementsto Meet Challenges of the 8th SOW
• ACP is working to ensure state chapters are
  informed regarding HIT and pay-for-performance
• ACP Board of Regents discussed issue in January
  2005
• ACP state chapters are eager for information
• State chapters adopted resolution calling for ACP
  to furnish this information
• ACP is Available to Help QIOs Meet this
  Capability Requirement