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Trying to Get I.T. to Pay Off in P4P Programs
Health Data Management Magazine, October 2007
Over the past 30 years, Marshfield (Wis.) Clinic has periodically tailored its homegrown electronic health records system and data warehouse to meet clinician workflow. But the impetus behind some recent modifications has been more about its bottom line.
About three years ago, the 725-physician group practice retooled the EHR to help it participate in the Medicare Physician Group Practice Demonstration, a pilot program that offers providers financial incentives for meeting specified clinical performance and cost benchmarks.
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Before the April 1, 2005, program start date, Marshfield's I.T. staff developed PreServ, an application within the EHR that pulls information from the data warehouse to show physicians at the point of care if a patient needs any preventive services. They also developed iList, a tool within the data warehouse that enables physicians and nurses to see which chronic disease patients are most out of date with required tests and services.
Additionally, the clinic created a clinical "storyboard" application for the data warehouse to enable the practice to show physicians how their decisions affect clinical outcomes.
Last July, Medicare determined the practice had achieved target or better performance on seven of the 10 clinical measures specified for the first year of the program. Further, it estimated that Marshfield reduced Medicare costs by $6.03 million, and as a result, awarded it a $4.56 million bonus contingent upon it continuing a similar performance level during the remaining two years of the program.
Only two of the 10 participating group practices received bonuses for the first year. All the groups had EHRs, but it was Marshfield's ability to customize its system specifically for the project that gave it an advantage, says Jeremy Meller, clinic division CIO.
"Just having an EHR didn't necessarily help us meet the quality standards. It was the tools and processes we created behind the scenes that made the difference," Meller says. "But it would have been difficult to do without one."
About 35% of health plans-including Medicare-now offer some kind of pay-for-performance program, according to a May survey by Framingham, Mass.-based Health Industry Insights, a wholly owned subsidiary of research firm IDC.
These programs offer bonus payments if providers achieve specified benchmarks for various clinical quality metrics. Some also review claims or require providers to submit other evidence of reduced spending during the program.
To help collect and manage the massive amounts of data required for P4P programs, providers are using EHRs, practice management systems, and other clinical or data mining tools. And payers are using Web portals, managed care information systems or other data mining tools to administer them.
"There are two layers of I.T. necessary for P4P," says Janice Young, program director at Health Industry Insights. "There's a certain amount that's needed to amass the data you need to collect, and another amount to actually improve outcomes."
No Mandate
While 70% of payers that offer P4P programs say they encourage participants to use automated systems, most stop short of mandating it, according to the Health Industry Insights survey.
But while using I.T. is not necessarily a requirement, indications are that it certainly helps. For example, a July study by Integrated Healthcare Association, an Oakland, Calif.-based organization that operates a P4P program, found that group practices using I.T., such as electronic prescribing, automated drug interaction checks and preventive and chronic care reminders, scored 18% better on its various P4P clinical quality measurements than those that didn't.
Marshfield Clinic, fresh off earning its multi-million dollar P4P bonus, continues to add new software and develop related processes during the third and final year of the Medicare demonstration program
It recently automated a form to help ensure physicians perform a comprehensive foot exam on diabetic patients-one of the chronic disease populations the Medicare demonstration targets-each time they have an appointment.
Physicians access the forms at the point of care via Tablet PCs from Fujitsu Computer Systems Corp., Sunnyvale, Calif.
Additionally, Marshfield has installed the InformaCare disease management system from Pfizer Health Solutions, New York, to manage its congestive heart failure patients, whose treatment has been analyzed during the second and third years of the Medicare P4P program. The system receives clinical and demographic data for CHF patients from Marshfield's data warehouse. Nurses then use the system to call the patients to better inform them about the condition as well as customize care plans.
The group practice also is developing a Web portal that patients can use to view some of their lab results and appointment reminders. Eventually, the practice will be able to use the portal to create personal health records, says Meller, the CIO. Marshfield also plans to use its Medicare bonus to fund the infrastructure required to develop and support additional applications and processes for performance improvement, he adds.
"We continue to look at what interventions we can put in place to improve care," says Marilyn Follen, R.N., administrator of quality improvement and care management at Marshfield. "But initially we thought putting information at the point of care would help providers leverage our EHR to ensure we are meeting quality measures and outcomes as well as ensure proper care is delivered at the same time."
Two Initiatives
Catawba Women's Center didn't have much time to customize a clinical documentation system before it began participating in a pay-for-performance program. It submitted data to the Washington-based Bridges to Excellence initiative in January-just four months after deploying the application, from SRS Software Inc., Montvale, N.J.
The tight timeframe made collecting P4P information a major project for the Hickory, N.C.-based OB/
GYN practice because it was still rolling out the software, says Amy Guyer, practice administrator. But it managed both initiatives well enough to receive a projected bonus of $265,200 that will be paid in increments of $88,400 after each year they participate in the three-year program.
Catawba's bonus was paid by its largest health plan business partner, Blue Cross and Blue Shield of North Carolina, Greensboro, which offers financial incentives for providers that participate in the program.
Bridges to Excellence is an industry collaborative that works with payers, employers, providers and others to create P4P programs to help improve care.
To participate, providers must submit performance data based on at least three of the program's clinical quality measurements, as well as indicate what type of software they use to gather and analyze the information.
Catawba already had decided to purchase a clinical documentation system before it was accepted into Bridges to Excellence. Executives concluded they could pull clinical data from the new system's patient flow sheets and charts and send it to the program. But when Guyer and other practice staff began auditing the information, they sometimes found that clinicians hadn't entered all the required data during patient visits.
"We relied on providers and nurses to put all the information there that they could," she says. "But you have to rate yourself on how you did, and if we had only 60% of flow sheets completed, we couldn't answer favorably."
Catawba's less than stellar submission resulted in a level 1 score from the Bridges to Excellence program - the lowest level to warrant a payment by its sponsoring payer organization. The Blues Plan has a tiered reimbursement schedule that gives more money to practices that achieve higher scores from the program.
The program, however, enables practices that don't achieve the highest level 3 rating for the first year to resubmit new data during the final two years of the program for a chance at improving their performance rating - and payout - during years two or three. Catawba will submit its second year performance information next January. The practice, however, first plans to make some changes to its processes-and software-to ensure the second year data is better.
Changing Workflow
One change was modifying workflow to help clinicians better record required data on flow sheets and in patient charts. On the technology side, Catawba requested that SRS Software add several enhancements, such as new data fields in the flow sheets for P4P data, to make it easier to enter and retrieve information required by the program. The practice expects the additions to be implemented before it submits its second-year P4P data, Guyer adds.
"It was unclear how we would collect this data when we first started," she says. "But a lot of the things we envisioned are implemented now."
Providers use different I.T. strategies to participate in P4P programs, but their efforts often share a common trait - they don't anticipate they need to implement sophisticated analysis tools to compile the required data and determine if they are adhering to target metrics, says Mike Paskavitz, senior principal in the public health care division at Noblis Inc., a Falls Church, Va.-based consulting firm.
"The resources that go into collecting and transmitting data for P4P are significant in comparison to the resources for supporting data that's used internally," he says. "Nurses now must collect this data in addition to other information. So it can take them 1.5 hours to do the paperwork to admit a patient. It's a lot of work."
To ease some of the burden of collecting P4P data, providers are pressuring health care I.T. vendors to embed data fields for P4P metrics in their systems, Paskavitz adds.
Over the past year, companies such as Misys Healthcare Systems, Picis Inc., PatientKeeper Inc. and 3M Health Information Systems have added P4P reporting modules or related data fields to their applications to better equip providers to collect specific data sets required by P4P initiatives.
A Web-based practice management system - from athenahealth Inc. - modified to support P4P enabled Virginia Cardiovascular Specialists to dive into a pay-for-performance initiative with minimal disruptions to its clinical and financial processes, says Mark Netherland, CFO.
The Richmond-based group practice had been using the software for about a year when the Watertown, Mass.-based vendor last March embedded optional data and coding rules that correspond with clinical measurements required for the new Medicare Physician Quality Reporting Initiative. The P4P program, which is open to all Medicare providers, began July 1.
Virginia Cardiovascular Specialists spent a few months creating and implementing processes to use the system to report data to the program. It also worked with the vendor to customize billing forms in the application, Netherland says.
The billing forms, which are printed at registration, now include additional data fields for Medicare patients. Clinicians write the required PQRI quality data in the additional data fields when documenting encounters. When billing staff members enter the information from the paper forms into the practice management system, the software scrubs the claims to check whether quality data is missing.
"We had about two weeks of training to help staff and nurses understand the rules and logic of what they needed to do," says Robin Scott, billing manager. "Now they know the information they need and how to get it from a chart or a physician's dictation."
Full Bonus Anticipated
Though the reporting period for the PQRI doesn't end until Dec. 31, Netherland expects Virginia Cardiovascular Specialists to achieve the full 1.5% of fee-for-service claims bonus payment the program offers for participants.
The PQRI program requires providers to report quality data, not their performance improvement. Virginia Cardiovascular Specialists isn't evaluating the data to determine if it has improved performance before submitting it to the program, though Netherland says the group practice likely would receive a high score if the initiative rated it on performance.
"We were cognizant of the effect that the reporting measures would have on our staff," he says. "We think we're doing pretty much what we are supposed to do. But we've looked at what some practices have had to do to participate in other P4P programs, and some of the processes they've had to develop are very complex and time consuming."
For their part, managed care organizations are recognizing that collecting, analyzing and submitting data for pay-for-performance programs can be a daunting task for providers. As a result, about 37% offer "active investment or sponsorship" of technology, such as electronic prescribing or electronic health records systems that will be used for P4P, according to the study by Health Industry Insights.
Some payers are making their own technologies available to providers that participate in their P4P initiatives. For example, before Peoria, Ill.-based OSF HealthPlans began a P4P program in 2004, it began training participating providers to use its Web-based decision support system to collect, analyze and submit the data the program requires.
The CareEnhance Resource Management system, from San Francisco-based McKesson Corp., offers analysis and reporting of HEDIS data, pharmacy claims, provider claims and other member information.
No Additional Paper
OSF HealthPlans concluded that enabling providers to use the technology would help them better integrate the program's performance metrics into their workflow as well as enable participation without any extra paper, says Ralph R. Velazquez, M.D., vice president and chief medical officer at the organization, which is a subsidiary of OSF HealthCare. OSF HealthCare also owns OSF Medical Group, a 210-physician practice that is taking part in the P4P program.
"Paper reporting for P4P wasn't very effective," he says. "So we wanted a P4P program that offered more timely reporting that could be done on the Internet. Our goal was to give physicians registries of their chronic disease patients so they could have that information at the point of care."
The software, which pulls claims data from OSF HealthPlans' managed care information system, from The Trizetto Group Inc., Newport Beach, Calif., as well as its pharmacy system from CVS/Caremark, Woonsocket, R.I., enables providers to analyze how they are meeting the quality, formulary utilization and safety measurement metrics required by the P4P program. The providers also submit the data to the payer via the Web-based system.
OSF HealthPlans then uses the software to validate the information. It also presents the performance data on a quarterly basis to group practice executives to show them how far they've come on performance goals.
But despite the vast availability of I.T. and support OSF HealthPlans has given to its P4P participants, the managed care organization has yet to pay out the full amount of bonuses it's committed to the program each year. The first year it gave the providers only about a third of the program's annual $1 million budget; the second year had a two-thirds payout. OSF HealthPlans expects to award about 70% of the total for the third year, Velazquez says. The program offers a tiered level of reimbursements based on providers meeting specified levels of performance.
After the first year, OSF Medical Group adopted Six Sigma quality metrics into its workflow to help it hit performance goals. OSF HealthPlan also decided to educate more of the practice's office staff about the program so they could help physicians improve their performance.
"The I.T. has enabled us some great success with our P4P program," Velazquez says. "But the challenge isn't training physicians and staff to use the system, but to get them to significantly change their workflow to be part of the program."
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The Search for P4P Standards
Even provider organizations that have customized information systems to participate in pay-for-performance initiatives are finding that collecting the required data can be a Herculean task.
The chart audits, analysis and process change management required to submit data for a single P4P initiative are taking their toll on clinicians-and patients-who often must wait while additional data is documented in their charts, says Amy MacNulty, senior principal in the public health care division at Noblis Inc., a Falls Church, Va.-based consulting firm. Some organizations even are hiring clinicians specifically to collect and manage P4P data, so that existing staff members aren't burdened with the task, she adds.
"Everyone's learning how to go through this process of how to get and send the required information," MacNulty says. "It's very time consuming."
Additionally, different P4P programs require different clinical data sets and have varying metrics on which they measure performance. So while many provider organizations are eligible for multiple P4P initiatives, participating in more than one is likely to be virtually unmanageable, says Janice Young, program director at Health Industry Insights, a wholly owned subsidiary of research firm IDC, Framingham, Mass.
"It would be a reporting nightmare," she says. "And it wouldn't create the improvement in outcomes that the P4P sponsors want."
There are, however, some P4P consolidation efforts in the works. For example, the Integrated Healthcare Association, Oakland, Calif., has a standard P4P initiative for providers across the state. And many payers are either participating in or borrowing quality metrics from the Washington-based Bridges to Excellence P4P program, an industry collaborative that works with payers, employers, providers and others. Further, Medicare, the nation's largest payer, has opened its own P4P program, the Physician Quality Reporting Initiative, to all contracted providers.
Regional consolidation for P4P initiatives also could be in the works, says MacNulty, at Noblis.
"It would contribute to a provider's overhead to participate in multiple P4P programs," she says. "So there's been some effort to come up with basic metrics and standards that sponsors can use."
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