The Health Information Technology for Economic and Clinical Health (HITECH) Act is double-edged and time urgent. With penalties beginning in 2016, hospitals at all stages of adoption must accelerate the timeline from product purchase to implementation. The key to success is early and ongoing engagement of physicians, as illustrated by the success at Concord Hospital.
Outpatient Case Presentation
In 2003, the CEO created dedicated positions for an internist and two family physicians to harness the Electronic Health Record’s (EHR) untapped potential to improve quality. As a first step, these three leaders queried the EHR to determine the percentage of patients with diabetes who were at national benchmarks for hemoglobin A1c, blood pressure, and low-density lipoprotein. They were surprised to discover that only 10 percent of Concord’s patients were at the benchmark for all three parameters.
The organization aspired to become the first medical group in New Hampshire to achieve National Committee for Quality Assurance (NCQA) diabetes recognition without adversely affecting provider workflow. Concord’s primary care physicians (PCPs), who devote considerable energy to diabetes improvement, found the NCQA benchmarks meaningful and motivational.
The team created the informatics tools needed to achieve its objectives:
- Point-of-care prompts for diabetes services due
- Monthly electronic diabetes registry reports individualized by provider and aggregated for the entire organization
- An EHR-generated diabetes scorecard for patients that explains diabetes metrics in lay terms and enlists them in their own care
- A provider quality dashboard displaying individual metrics that is shared across the organization to identify best individual and group practices
- Yearly quality bonuses for employed primary care physicians who achieve NCQA diabetes benchmarks
In September 2004, ten months after beginning the diabetes initiative, Concord became the first organization in New Hampshire to achieve NCQA recognition. All 40 of the organization’s participating primary care physicians qualified.
Over the next five years, the team added ten additional metrics to the primary care quality dashboard, including indicators for cardiovascular disease, smoking status/counseling, and colorectal cancer, and built informatics tools, similar to those for diabetes, to support these additional quality initiatives. In addition, hospital leaders increased the maximum quality bonus from $4,000 to $10,000 per year for its employed primary care physicians. This combination of approaches and incentives has prompted rapid improvements similar in magnitude to those achieved for diabetes. The best measure of success has been the continued improvement in each of these metrics over the years since they were introduced. While physicians and their teams initially viewed each quality benchmark as a discrete project, providers now see these benchmarks as integral parts of their daily workflows.
As an unanticipated benefit of these efforts, Concord Hospital is now well positioned to meet many of the HITECH Act’s outpatient criteria for meaningful use. In 2009, for the first time, Concord Hospital received payment for its quality achievements. The Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative paid the hospital $40,000 for the electronic submission of quality data with no additional data entry by our physicians.
An Inpatient Win
The first computerized physician order entry (CPOE) quality improvement initiative was aimed at improving inpatient prophylaxis rates for venous thromboembolism. While Concord’s pre-CPOE prophylaxis rates, 74 percent for medical patients and 92 percent for surgical patients, were above the national average, CPOE helped the organization achieve a rate of 100 percent for both groups, as measured by a one-day observational survey.
One indicator of an organization’s culture is what its members do when no one is looking. Rather than mandating that physicians use CPOE, Concord Hospital has chosen to draw on its physicians’ collective professionalism—their strong desire to do the right thing for their patients—especially when no one is looking. Physician engagement cannot be assumed nor mandated, but without it, the chances of achieving meaningful use are minimal. The key to success is to align the professional needs of physicians with those of the institution. Physicians are passionate about doing the right thing for their patients. Informatics leaders must configure and deploy Clinical Information Systems to help physicians.
As always, I welcome your input to improve healthcare collaboration and get it done.
Kenneth H. Cohn
© 2011, all rights reserved
Disclosure: I have not received any compensation for writing this content.