Health Affairs

Editor’s note: The federal government’s Beacon Program provides funding to 17 communities that have already made inroads in the development of secure, private, and accurate systems of electronic health record (EHR) adoption and health information exchange. This is the first in a series of Health Affairs Blog posts in which leaders of several Beacon communities will discuss their experiences over the first year of the program. The Beacon program’s first year will also be the topic of a Washington D.C. event (registration closed but available via Webcast) tomorrow, May 17, sponsored by the Office of the National Coordinator for Health Information Technology (ONC) and the Engelberg Center for Health Care Reform at the Brookings Institution, and a live Twitter chat on Wednesday May 18 hosted by ONC’s  Aaron McKethan.

What’s the true value of health information exchange?  Some might say it’s simply the movement of data where and when it needs to be for a moment-in-time snapshot of a patient’s care.  Some might argue that the true value lies in what can be done with the data once it’s where it needs to be.

In Indiana, and specifically the Central Indiana Beacon Community, the latter is where we think health information exchange needs to move to have the most meaningful impact on patient care and support a much more efficient utilization of healthcare resources.

The organizing centerpiece of our Beacon Community is a program called Quality Health First (QHF), which aims to improve screening rates and to support the management of medical conditions such as diabetes, heart disease, asthma and breast cancer. The Community also encompasses other compelling initiatives, including:
.

• operating a remote patient monitoring pilot with over 1,500 at-risk CHF and COPD patients;
• working with payers to lower patient copayments for certain high-value services like diabetes medications;
• assessing clinical and economic outcomes for diabetes management provided by clinical pharmacists in physician office clinics; and
• implementing new “cost of care” measures to get a better handle on the variation and high costs of care for certain care episodes.

The Quality Health First Program

In 2007, the Indiana Health Information Exchange (IHIE) — the lead organization of the Central Indiana Beacon Community — developed the concept of QHF for addressing gaps in healthcare and providing information that supported early patient interventions, rather than just focusing on recent patient healthcare encounters.

This community program provides standardized quality measures used by physicians to care for their patients and payers to provide bonus payments to physicians based on care improvements.

What started out as a demonstration project in the Indianapolis metropolitan area with 915 primary care physicians (PCPs) providing care to approximately 650,000 patients has now grown to 1,700 PCPs in over 50 communities statewide providing care to over 1.1 million patients.  Over 240,000 patients with diabetes are being monitored through this program.

So how did we get here?

Overview

The Quality Health First Program reports are based on over three billion pieces of clinical information from our health information exchange, along with claims information from participating payers, including commercial carriers, Medicare and Medicaid.

These reports identify for physicians their patients who have chronic diseases.  They provide reminders of when patients are due – or are currently overdue –  for certain screenings.  For example, the report shows whether a diabetic patient has had a recent HbA1C test and the result of this test.  It identifies the date and location of the most recent test, and why that patient is being flagged in the report.

In addition to generating monthly summaries for providers to help support direct patient care, the program also provides:
.

• Physician peer comparisons at the community level,
• High level summaries for physician groups to support system-wide improvements,
• Summaries to payers to track progress, and
• Population-based reports for patients, providers, payers, employers, public health and other population segments.

Stakeholder Roles

Implementing a quality program into a health information exchange has been a case of trial and error for us in Indiana. We’ve learned a lot over the past four years.
.

• It’s important to involve a broad coalition. From the outset, our HIE already had significant participation from hospitals, physician groups, public health, payers and employers.  These stakeholders made considerable investments and provided other support to our efforts.  They also helped us tweak the quality program to serve a broad spectrum of stakeholders while keeping the patient care component of the program at the center.
• The Swiss Cheese Factor. While the data set we’re working with is robust, there will always be holes in the information presented.  IHIE instituted a point of care process wherein providers can supply data that did not otherwise come to IHIE in a claim or facility setting and a ‘reconciliation’ process that enables physicians to update the information, thereby filling in the ‘holes’ in the Swiss cheese.  So far, physician offices have returned over 500,000 discrete pieces of data that has made the reports as accurate as they can be.  In turn, they trust IHIE and the data used in the reports.
• There will be a provider learning curve. Provider engagement in the program has been challenging, both from enrollment and ongoing participation perspective.  We have had to overcome skepticism from providers, who have been inundated with other performance programs from payers.  It does take time, energy and staff resources to implement an efficient reconciliation process.
• Chicken or Egg? It’s been a challenge for the payers to identify appropriate bonus payments to physicians based on this quality program.  It takes the participation of payers to feed provider participation, and vice versa.  We have one payer that has paid out over $7 million over two years to participating physicians in the program.  But we need more payer bonus programs.

That being said, we are pleasantly surprised with our provider enrollment thus far during the Beacon Program.  The Central Indiana Beacon Community encompasses 46 counties and about 43% of Indiana’s 6.3 million people.  The majority of the growth of the program has been within this area.  Of the 1,700 PCPs who participate statewide today, nearly 1,400 are within the Beacon boundary.   Our goal by the end of the Beacon Program is to enroll 1,550 PCPs within the Beacon boundary.  Of the 1.1 million patients included in the program, over 994,000 are within the Beacon boundary.  We credit the Beacon Program for helping provide a rallying point and focus to our fledgling quality program.

Use in the Real World

There are wide variations among our physician population in how they use the reports, but we hear time and again how, regardless of health insurer bonus programs, this program is the right thing to do for their patients.

We recently surveyed a practice with 14 providers outside of the Indianapolis metro area.  When they first received their quality reports, the rate of conducting yearly LDL screenings for their diabetic patients stood at 49 percent.  After a year of participation, that increased to 84 percent.

A single provider practice in the Indianapolis-area had similar results.  Their first quality reports showed that only 63 percent of their diabetics received a yearly HbA1c test.  After one year, that jumped to nearly 80 percent.

Whether these improvements are due to better information (through reconciliation) or a better process to get these patients needed tests is a question that we are sorting through.  At a minimum, it gives the practice information that they previously might not have had before, which in itself can be a powerful tool.

Depending on workflow, some physician offices have started calling patients flagged in their monthly summaries who are overdue for certain testing.  Others mail reminders.  Some practices do both.  We are currently testing with one practice the direct delivery of patient reminders into electronic medical records.

The monthly summaries include a one page snapshot of tests and screenings needed for an individual patient (patient care report).  Some offices without an EMR system print it out and stick it right at the front of the patients’ chart, so when the physician walks into the room, they know what additional care the patient needs.

Anecdotes
.

“Medicaid patients are assigned to us, but we didn’t know what they needed without the patient care reports.”

“Two of our patients identified through the program as needing colorectal cancer screening turned out to have colorectal cancer.  Finding this early probably saved their lives.”

“We pay our staff a little bonus quarterly based on our report scores.  Each staff person helps with the reconciliation, so if you walk through our office, you may hear someone say, ‘Are there any more of those reports to work on?’”

The Immediate Future

The Quality Health First Program faces many opportunities and potential challenges as it continues to grow and expand throughout the Beacon boundary – and beyond.

We are working on developing the ability to report utilization and cost by care system, starting with the Medicare population. This will allow us to integrate measures of efficiency with the quality reports that physicians already use to improve the care process. The intention is to improve value by addressing both quality and cost.

The program also faces challenges. The first is the issue of ‘free riders’. Physicians by and large do not differentiate between patients. When they focus on quality improvement, they will do so for all patients. This opens the door for a health insurer to benefit without contributing to the success of the program.

The second challenge is the development of Accountable Care Organizations (ACOs).  Although primary care provides the base for our quality program, the focus of ACOs is on the system of care, rather than primary care physicians alone. This may force a fundamental redesign of the program but may open the possibility to serve the broader needs of care systems acting as ACOs.

The Beacon Program provides us with a mechanism to work through these issues and help inform other Beacon Communities, and others across the nation, as they begin to develop quality reporting programs.  It also gives us an opportunity to expand participation and potentially incorporate a broader set of measures into the program.  We are ready for the challenge!

 Email This Post  Print This Post

This entry was posted on Monday, May 16th, 2011 at 11:14 am and is filed under All Categories, Chronic Care, Health Care Costs, Health IT, Health Reform, Quality, Spending. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.