Focus Shifts to Improving Physician Performance

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Medical Education Feature – October 2010


Tex Med. 2010;106(10):27-29.

By Ken Ortolon
Senior Editor

Patients arriving at a Midland hospital's emergency department after suffering a stroke two years ago had no idea they were among the first to benefit from a new form of continuing medical education (CME).

The new CME replaces the traditional method of physicians earning credits by attending a lecture or case conference, watching a webinar, or reading a journal article with new requirements for a much greater level of physician involvement. It's called performance improvement (PI) CME and involves chart audits to measure current physician performance, followed by an intervention to change physician behavior. Performance is then remeasured to gauge the level of improvement.

In May 2008, Midland Memorial Hospital launched a project to use the new CME to improve stroke outcomes. Robyn Kedzie, director of quality management at the 320-bed community-based hospital, says officials asked all physicians who had admitted patients with a stroke to participate. The participants met to review the American Heart Association's Get With the Guidelines for Stroke and evaluate the hospital's compliance with guidelines for perfect care. They also reviewed the hospital's stroke mortality data.

In the second stage of the program, the hospital developed screening criteria for its emergency department to diagnose stroke victims faster, as well as order sets for both ischemic and hemorrhagic stroke, Ms. Kedzie says. Officials also implemented other measures, including reducing turnaround times for obtaining head computed tomography scans to 45 minutes.

"Then the PI CME group championed these action plans with the intent of changing the practice of our physicians and nursing staff. We recollected the data associated with the Get With the Guidelines criteria and found that we improved significantly," Ms. Kedzie said. "Not only did our compliance with the criteria increase, but our Texas Health Care Information Council stroke risk-adjusted mortality decreased, and our perfect care – which means we complied with all the criteria – went from 11 percent in 2008 to 75 percent in 2009."

Rehabilitation medicine specialist Mark Fredrickson, MD, was a member of the PI CME committee that developed the program. He says only between six and eight of physicians on the hospital staff were totally involved in the project and received the full 20 credits, but several other physicians got at least partial CME credit for their participation.

Dr. Fredrickson is enthusiastic about this new approach to CME.

"My experience with it is that it's a good approach for problem solving," he said. "It's a team-based approach, and you produce an actual product, that being algorithms with approaches for treating a particular problem – in our case, a stroke."

Ms. Kedzie says reaction among other physicians was mixed.

"You always have a core group of physicians interested in the project and those who prefer not to change," she said.

While only a handful of physicians on staff received CME credit for the project, the vast majority of staff doctors are using the new screening criteria and order sets even though they were not formally involved in the CME program, she says.

"The real payoff is seen when the physicians embrace the changes in their practice," she added. "We're meeting the guidelines, but the real benefit is to the patient when we see a decrease in our mortality rate associated with stroke."


5 + 5 + 5 = 20

For at least the past five years, CME activities have increasingly focused on improving physician performance. In fact, the Accreditation Council for Continuing Medical Education (ACCME) adopted updated accreditation criteria in 2006 that require CME to be designed to change physician competence, physician performance, or patient outcomes.

Under the ACCME model for PI CME, there are three stages of activity – learning by assessment of current practice performance, applying performance improvement interventions to patient care, and evaluating the performance improvement effort. Physicians who participate in PI CME projects may earn 5 AMA PRA Category I Credits™ for each stage, plus 5 credits if they complete all three stages, for a total of 20 credits.

Texas Medical Association President Susan Rudd Bailey, MD, a former member of the ACCME Board of Directors, says many factors are coming together "to encourage physicians to look at their CME as much more of a lifelong learning and continuous improvement process as opposed to just checking your boxes to get your credits to renew your license every year."

But Dr. Bailey and others say some physicians likely will resist PI CME because of the amount of time involved, the need for an electronic medical record system to produce measurable data, and a relative lack of formal programs.

"Busy doctors aren't going to be able to sit down and design a performance improvement project for their office where they can find the problem, document the extent of the problem, come up with a solution, implement the solution, and document the change and its effect on patient care," she said. "That's just not something that, A, we have time to do or, B, we could do easily without an electronic medical record."


Driving the Improvement Bus

San Antonio psychiatrist Martha Medrano, MD, immediate past chair of TMA's Committee on Continuing Education, says new maintenance of certification requirements implemented by the various medical specialty boards are the primary drivers of the transition to PI CME.

Over the past several years, all 24 medical specialty boards the American Board of Medical Specialties (ABMS) recognizes adopted new policies that require periodic recertification of their board-certified physicians, and all have included PI CME as a requirement for that recertification.

"For example, in the very near future as a psychiatrist, even to apply for board recertification, you will need to demonstrate performance improvement projects in order to qualify to even sit for the exam," Dr. Medrano said.

The American Medical Association first approved PI CME as a category eligible for AMA PRA Category 1 Credit™ in 2005. Since then, at least 15 national medical specialty societies created PI CME projects, according to Norman B. Kahn Jr., MD, executive vice president and chief executive officer of the Council of Medical Specialty Societies. Dr. Kahn spoke at a conference for CME providers in Austin in June sponsored by TMA and the Texas Alliance for Continuing Medical Education.

At that conference, he said the traditional CME message of "Trust me, I'm keeping up" has been supplanted by a new message that physicians are continually assessing the care they deliver, measuring that care against national benchmarks, comparing themselves to their peers, learning evidence-based practice, changing practice behaviors, and documenting improvement over time.

Dr. Kahn says patients used to judge their physicians based on what he calls physicians' "pedigree" – where they went to medical school, whether they are board certified, their membership in specialty societies, and other factors. Now, patients increasingly want to judge their physicians on performance. Participation in performance improvement activities and documentation of that participation is one way performance can be measured, he says.

"So we're having a cultural evolution from pedigree to performance," Dr. Kahn said. "This is facilitating a culture of performance improvement in medical practice."

In addition to the specialty society programs, a number of hospitals and other organizations across the country have developed PI CME projects, including a handful here in Texas.

TMA also developed two such programs focused on practice management issues such as billing and collections assessment and operations improvement. TMA's Physician Oncology Education Program also offers a PI CME project related to breast cancer. (See "TMA, POEP Offer Performance Improvement CME.")


Partners in Quality

Billie Dalrymple, director of TMA's Continuing Medical Education Department, says the transition to performance improvement has made CME a "big time" partner in quality initiatives. It also means those who develop and accredit CME activities have to retool their operations.

"The CME of old involved asking doctors what they wanted to hear about, bringing in a speaker, and getting a drug company to pay for it," she said. "We don't do it that way anymore. And in the hospitals that we accredit, it's what are the challenges in your day-to-day work? What education do you need to support that? And, we also want to know how you know that. For example, are there CMS [Centers for Medicare & Medicaid Services] measures that you're trying to meet in the hospital? Are there standards with your own specialty that you need to meet? And then CME is designed around that."

Dr. Bailey says that, overall, CME is moving in the right direction. But it's having some "growing pains," she says.

"It's really, really difficult to document that any educational intervention is going to measurably change a doctor's quality of care," she said. "And, until electronic medical records are more integrated into everyday practice and the process can become more seamless, performance improvement CME is going to be in its infancy."

In addition to those concerns, both Dr. Bailey and Dr. Medrano say physicians are concerned about who will provide needed CME opportunities. Dr. Medrano says part of that concern is the reduction in the number of CME activities supported by commercial interests.

"The biggest concerns for physicians are, first, how is this going to happen, is there someone who is going to facilitate making sure that physicians have opportunities for performance improvement projects, and, second, the cost."

According to Dr. Kahn, a PI CME sponsor might have to pay $1,000 to $3,000 to get its project approved for maintenance of certification credit by an ABMS board, but the cost of participating in such projects for individual physicians should be no more than that for traditional CME.

Dr. Bailey says an added concern is that documentation requirements for the new CME activities likely will drive some smaller CME providers out of the business.

Still, she says, PI CME will be good for patient care in the long run.

"I would much rather go to a doctor whose continuing education is really a reflection of his or her practice, as opposed to a random set of lectures that may not have anything to do with my medical condition at all. It will make CME more relevant. I think it will make CME more effective.  We just have to keep it from making CME too complicated to participate in."

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon.


RELATED STORY

TMA, POEP Offer Performance Improvement CME

Are you looking for opportunities to gain performance improvement continuing medical education (PI CME) credits? Well, look no further than the Texas Medical Association.

 TMA Practice Consulting and the TMA Physician Oncology Education Program (POEP) offer three PI CME courses that can each earn you 20 AMA PRA Category 1 Credits™.

POEP's Breast Cancer Screening CME Performance Improvement Activity is designed to help physicians increase appropriate use of mammography screening.

In stage 1, physicians earn credits by completing a chart review of 20 randomly selected women eligible for mammography and determining if a mammogram is recommended. In stage 2, physicians institute systems in their office to increase mammography recommendations, and, in stage 3, physicians complete a second chart review to determine if their efforts were successful in improving their mammography screening rates.

Primary care physicians and obstetrician-gynecologists are the target audience. Physicians can earn 5 credits for each stage of the activity, plus 5 credits for completing all three stages.

For more information, call Laura Wells, POEP program coordinator, at (800) 880-1300, ext. 1673, or (512) 370-1673, or e-mail Laura Wells.

TMA Practice Consulting offers two PI CME activities. The first is a billing and collections assessment. A TMA consultant evaluates a practice's billing and collections procedures, front office processes, staff competencies, workflow, and financial reports. The consultant analyzes the data and offers written recommendations for improvement.

Information from the assessment will enable physicians to understand the practice's billing and collections processes, recognize the implications and outcomes of those processes, and create a plan to address practice deficiencies.

The second activity involves operations improvement planning. TMA consultants interview physicians and staff and analyze current practice operations, including financial management, human resources, billing and collections, clinical services, medical records management, and governance. The physicians confer with the consultant to determine a plan to address any deficiencies identified and evaluate the results of that plan.

Both TMA Practice Consulting activities offer up to 20 AMA PRA Category 1 Credits™ for completion of all three stages of each activity.

For more information on the PI CME activities offered by TMA Practice Consulting, call Laura Palmer at (800) 880-1300, ext. 1408, or (512) 370-1408, or e-mail Laura Palmer.

In addition, you can take the revised TMA Patient Safety and Medical Errors CME course on the TMA website. The TMA Subcommittee for Academic Physicians designed the course to help physicians enhance their patient safety skills.

The course is available for viewing at no cost; however, there is a $25 CME processing fee for physicians who would like to receive CME credit.

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