New Computer Program Helps Physicians Monitor Themselves
Public Health Feature -- May 2001
By Laurie Stoneham
You have a 58-year-old female patient who suffered an acute myocardial infarction six months ago. She underwent revascularization, and though she's stable, managing her care is complex.
A new electronic tool makes monitoring and measuring just how well you do care for her and all your other patients with cardiovascular disease (CVD) a great deal easier. It's part of the HeartCare Partnership (HCP), and this computer software program lets you look at and evaluate what kind of care you're providing. HCP is a partnership of the Texas Medical Association and the American Heart Association, Texas Affiliate, with funding from Merck & Company.
The tool provides HCP participants with an electronic means of collecting and reporting their cardiovascular disease management data. Are you monitoring and achieving good blood pressure levels? Are you placing patients on appropriate medications? Are you counseling patients to stop smoking? Are you caring for the particular CVD needs of your diabetic patients? These are the kinds of questions this tool lets you track and see in easy-to-read electronic chart form.
It has other advantages. The tool is easy to use, makes outcomes reporting immediately available, provides comparative aggregate reports, helps the participant meet Health Plan Employer Data and Information Set and other accreditation and regulatory requirements, and offers written justification for evaluation and management coding, says Jim Rohack, MD, TMA president and a practicing cardiologist in Temple.
The HCP tool was created when Dallas cardiologist Bob Hillert, MD, chair of the HCP subcommittee of the TMA Committee on Cardiovascular Diseases, asked the Texas Health Quality Institute (THQI) to create an electronic version of the paper audit tool. THQI is comprised of TMA, the Texas Medical Foundation , and the Texas Osteopathic Medical Association . The electronic version of the audit tool represents a new generation of outcomes data collection and analysis. It helps physicians measure the care they actually deliver, not the care they think they deliver.
Participants (physicians, hospitals, and physician assistants) audit patient charts to examine 32 items (e.g., the history and diagnosis of various conditions and the use of proven therapies such as statin drugs, ACE inhibitors, and beta blockers) to track how well they are performing in meeting national standards of care. The data reflect, monitor, and track practice patterns over time to enable hospitals and physicians to find ways to improve quality performance and outcomes.
"This is a pure outcomes measurement tool, which all the experts in the field agree is the only effective way of ensuring quality improvement over time," said John W. Meyer, MD, a family practitioner in Hondo and a THQI member.
"I think physicians will always improve their practices if they can have data on how well they're doing presented to them in graphic form. It's especially powerful if you can compare it to yourself over time," Dr. Rohack said.
This "e-tool" is the latest development of the HCP, which is designed to help physicians improve risk factor management for patients with CVD through education and practice management strategies. It's an interactive continuing medical education program that includes educational workshops, chart audits, and individual support.
"The program strives to affect long-term behavioral change through intense focus on practical patient management strategies in the practice setting," said Bridget Butler, TMA's cardiovascular program manager.
Doctors Hospital of Dallas has been participating in the partnership since 1998. Dr Hillert says the program has allowed physicians, administrators, and staff to work together on quality issues. He believes the HCP is one of the reasons USA Today recently ranked Doctors Hospital among the top 100 intensive care units in the country, based on Medicare outcomes data.
To date, 108 physicians in group and solo practice settings and 32 hospitals have participated in the program. Since its inception in late 1998, 13 workshops and presentations have been held throughout the state.
Future plans include conducting both two- and four-hour workshops and providing continuing medical education credit for ongoing HCP participation, according to Ms. Butler.
Following the educational component, the HCP participant performs a baseline chart audit, with repeat audits at 3, 6, and 12 months and then annually to ensure ongoing compliance. Hospital participants complete audits on a minimum of 50 charts at random, and all other participants review a minimum of 30 charts. These audits, which the software streamlines, help participants pinpoint strengths and weaknesses in their clinical processes.
TMA provides each user with a unique identification number that's similar to a credit card number so it's impossible to identify individual participants by name. Those using the software are shown how to select unique identifiers so that individual patient information can't be traced.
The audit data are sent to TMA's centralized database by e-mail or on a diskette for processing and aggregate analysis. All data transmitted to TMA are encrypted and protected.
"Publishing these outcomes, we believe, will encourage physicians to use this tool to track their performance in managing cardiovascular disease," said Tomas Garcia III, MD, chair of the TMA Committee on Cardiovascular Diseases.
Setting a standard
There's nothing homegrown about the look or feel of this new software. The graphics are clean and sharp, and the built-in "wizard" provides guidance for every function. The "Help File" provides the user with real-time assistance with the clinical data items as well as with understanding how the software actually works.
Any support staff person familiar with Microsoft products will find this software a breeze to work with, Ms. Butler says. Most of the items ask for "Yes" or "No" responses and require a simple click to complete.
Dr. Hillert is not just bragging when he says, "This is a kind of tool that can be used nationally. It also sets a standard for the way future management tools should be developed."
The tool allows for instant analysis. Six different reports can be generated to provide detailed information on how the practice is performing against national performance criteria. The historical performance report shows progress over time. This can be run in both text and bar chart form. Aggregate reports that show comparison data by specialty, hospital type, geographic region, or other descriptors are generated by TMA from the central database and shared with participants.
Dr. Hillert emphasizes that "whether it's a hospital or a group practice, the information is their own individual data. That individual hospital or practice owns the data, and only that hospital or physician can release the data to any other group."
Not just collecting data
Josie Williams, MD, medical director for the Texas Health Quality Alliance and chair of THQI, said, "Just collecting the data won't improve care. We have to make the information that we give to docs meaningful, and we have to convince them and show them it can improve patient care. Unless we are very much engaged in looking at systems and able to do so without our licenses being threatened, we're not going to get that done. It has to be a cultural change and there has to be an understanding of why it's important."
"Beyond meaningful, you have to have reliable data," added Dr. Rohack. "You have to have data that you feel comfortable with in making a change in your practice because you know where it came from and you know its validity. The key to quality improvement is not just data; it's translating that data into usable information, and that's what the tool allows one to do."
Gathering and documenting quality of care data are no longer auxiliary activities that can be ignored. The "Who has the time?" lament doesn't work anymore. Payers and regulatory and credentialing bodies aren't just looking at how well physicians are caring for patients; they're demanding that improvements be demonstrated and documented over time. Everything from managed care contracts to specialty certification is becoming increasingly tied to the kind of data that shows physicians are providing a level of care that meets national standards.
Dr. Rohack adds that the American Board of Medical Specialties is now expecting physicians to document how they are improving their practices to maintain specialty board certifications.
And this is not a tool just for cardiologists, Dr. Rohack points out. It's for any specialist who cares for patients with CVD, including family physicians and internists. "In fact, there are many obstetrician-gynecologists who serve as primary care doctors for women. That OB-Gyn is going to have to show that he or she is caring for that component, too, along with mammograms and Pap smears."
Taking back control
"We're trying to help the physicians focus on what high-quality medicine should include and to do it with the least interruption of their time and schedule at essentially a zero cost," said Dr. Hillert.
Dr. Hillert, who also chairs the Texas Department of Health Council on Cardiovascular Disease and Stroke, says physicians "should realize that so many things in medicine are out of their control because of economic issues and such. But the one thing they still control is the measurement of quality. And they need to identify what quality is and what quality medicine should be because this again meets their targeted goal of what is best for patients. This electronic tool really gives them a handle on what they're doing and where they can improve without having to be told by someone else what to do."
"I think so much of the time physicians are seen as whining because we don't have our own database to support what we know is good quality of care," Dr. Williams emphasized. "And until we develop and collect our data and have that data in aggregate, we have very little to stand on to define and defend quality of care."
Improving patient care
Dr. Hillert says that in his private practice he has customized the HCP program to zero in on improving the care of heart patients who also have diabetes. Each chart has a stamp that covers all the quality improvement measures he wants to provide.
"We're moving toward accepted standards of practice, both in academic studies and with guidelines from national and international groups, such as the American Heart Association, the American College of Cardiology, the American Diabetes Association, and the National Kidney Foundation," he said.
He says the tool also is important in giving Texas physicians a way to improve the care of the state's at-risk populations. These include Medicare-age people, who have the highest risk for CVD and stroke; African-Americans, who have an increased risk for hypertension; and Hispanics, who are at greater risk for diabetes.
In discussing the tool's applications and benefits, Dr. Garcia offered, "The first part is that patient care obviously can be improved. The second part is that it allows those physicians to document how they are improving care. When organizations start looking at performance, this tool provides an easy way to make the information available with no added effort. And it helps them in the marketplace. And the third issue, of course, is that it does save lives. It's a win-win-win situation all the way down the line."
For more information, call (800) 880-1300, ext. 1461, or (512) 370-1461.
HeartCare Partnership electronic tool at a glance
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