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.
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a tool within the data warehouse that enables physicians and nurses to see which chronic disease patients are most out of date with required tests and services.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.
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