"I was very nervous" about revealing all the data, recalls Ramachandran, a former director of technical services at Epic, vendor of the Downers Grove, Ill.-based group's electronic health record. "I thought we would hear a lot of concerns."
Ramachandran's nerves were quickly soothed, however. No one raised serious objections, and if anything, the response was affirmative. "The physicians were pleased by the fact that we were mining the data ourselves, as opposed to an external entity mandating us to do this. The fact that we were looking inward to improve and do right by the health care dollar was a big part of the buy-in process." Since that fateful meeting, the practice has expanded its use of scorecards, delivering a growing array of performance based metrics to the members and building highly specialized scorecards, such as one devoted exclusively to tracking progress on meaningful use. Now, the practice ties physician compensation in part to progress on upholding various metrics. "We're ahead of health reform," Ramachandran says.
Not all provider organizations embrace physician scorecards with the zeal found at DuPage Medical Group. But they may as well get used to the concept. Physician scorecards are rapidly becoming a universal fixture in the industry. Spawned by payment reform and an ever-increasing demand for performance metrics by health plans, employer groups and regulatory agencies, scorecards can offer remarkable depth and clarity to heretofore hidden aspects of clinical practice.
The I.T. needed to create an electronic scorecard can vary widely depending on the setting and the goals. And meeting physician pushback, at least initially, is often more challenging than setting up the infrastructure. Health plans- sometimes dismissed as black holes of information-are even launching scorecards as part of their accountable care programs. But just as physicians might balk at being measured, their competitive nature often takes over in a scorecard-driven practice setting-and both clinical and financial improvements can result, often significantly.
Measuring up
Just how common are scorecards? "Everybody wants to measure physicians-payers, government, states, and even the lay press whether its Angie's List or U.S. News & World Report," says Brian Harte, M.D., medical director, enterprise business intelligence, at the Cleveland Clinic Health System. "Then there are clinical collaborations with other health systems and professional societies. It is overwhelming. If I am a physician, the number of things someone is measuring me on is extraordinary. The problem is everybody measures the same thing but in different ways."
Cleveland Clinic captures dozens of metrics on both its employed physician group of 3,000 and another similarly sized group of affiliated physicians, Harte says. The data spans everything from upholding protocols on chronic conditions to tracking physician publishing.
"We start with what is required from payers and government," Harte says. "And we have internal measures around productivity that are set at the senior executive level. Our department chairs help us filter out these dozens and dozens of measures. Trying to measure 11 things for diabetes is unmanageable, so we try to narrow it down."
Scorecard builders of all stripes say that winnowing down the sheer number of potential metrics is a key step in any quality program. Atrius Health, which spans six group practices and more than 1,000 physicians in central Massachusetts, maintains a "massive array" of clinical quality and safety indicators on its enterprise dashboard, says Joe Kimura, M.D., medical director of analytics.
"The field of quality measure evolved from what was available on the administrative side," he says. "Classic quality measures were based on available data which was not necessarily actionable."
Now, Atrius' scorecards-driven by its enterprise Epic EHR, which feeds an all-payer claims-based data warehouse-offer up data aggregated at the practice level, but also broken down to the individual physicians contributing to any given measure. An individual physician, for example, can see what portion of his diabetic patients have hemoglobin measures and blood pressures beyond acceptable thresholds. Physicians can drill down into the metrics and retrieve all the supporting detail. And the measures are not static, Kimura notes. "They change as populations change and disease focus changes. Some old NCQA measures are not clinically relevant anymore. We talk to physicians, determine what is clinically meaningful, and create measures around that."
Rainbow effect
The road to physician scorecards, however, is anything but smooth. Expect pushback, experts say. "Some physicians definitely react negatively when you start sharing their performance data," says Mark Neubecker, a senior advisor at I.T. consultancy Impact Advisors, Kansas City, Kan.
Neubecker is well-versed in Epic EHR installations, and praises the software's capacity to support physician reporting, even offering up color-coded dashboards-red, yellow, green-to visually portray where individuals stand on the reporting spectrum from non- to full compliance. In addition to crunching its indigenous data, Epic can ingest data from third parties, such as payers, he adds. And Epic offers many "out of the box" scorecards tied to common performance indicators, such as the number of charts awaiting closure by physicians before they can be billed.
Scorecard simplicity aside, Neubecker says provider organizations building them must proceed with caution before rolling out metrics to the medical staff. "If you go down this route, you need not only red-yellow-green data, you also need to back it up with thorough testing," Neubecker says. "Physicians are extremely competitive individuals and they want to know the data is tracked correctly. But once they believe the numbers, you can see them trend up."
