A roadmap for quality improvement in physician offices.

According to the National Center for Chronic Disease Prevention and Health Promotion, (1) chronic diseases, such as heart disease, stroke, cancer and diabetes, currently affect over 90 million Americans, account for 70 percent of all deaths in the United States, and contribute to more than $1 trillion in medical care costs every year.

Lifestyle choices profoundly influence the outcomes of these chronic conditions. For example, the use of tobacco is associated with over 18 percent of all deaths in the United States, while diet and lack of exercise contribute to more than 14 percent of all deaths. (1)

Although numerous studies have demonstrated the cost-effectiveness of prevention using population-based approaches, (2) the medical profession has focused most of its efforts on the delivery of acute care services for individual patients.

In contrast, the infrastructure, cultural changes and methodological framework necessary to improve the management of subpopulations of patients with specific chronic conditions within private medical practices have been much slower to develop. However, a number of factors are motivating medical practices to integrate population-based care management into routine clinical care:

* The need to improve workflow, eliminate waste and improve clinical performance and profitability

* The opportunity (or threat) of public reporting

* The movement of payers to quality-based payment

* The new requirements for maintenance of board certification 

* The need to maintain privileges and participation with hospitals and health plans

Population-based medicine targets interventions at discrete subpopulations of patients within the medical practice and anticipates needed services according to evidence-based guidelines using quality measures to track results and make adjustments.

Physicians integrate care management into their routine clinical care by using these guidelines and quality measures to assess patients' needs, create care plans and coordinate and monitor services for their patients.

In order to meet the need for better chronic care management successfully, a medical practice will need to progress through nine discrete steps.

I. Define the subpopulation of patients in need of care management.

Care management focuses planned care on specific populations of patients within a medical practice.

For example, many physicians engaged in improving chronic care management focus on patients with diabetes mellitus because of the evidence that effective preventive care can significantly decrease morbidity and mortality. (3)

Every percentage point drop in the Hemoglobin A1c test can lower the risk of microvascular complications by 40 percent. Effective blood pressure control can reduce the risk of heart disease and stroke by 33 percent to 50 percent.

Improving lipid profiles in patients with diabetes can lower the risk of cardiovascular complications by 20 percent to 50 percent.

Using either a practice billing system or an electronic health record (EHR), physicians can identify patients with a specific diagnosis and then develop practice-based interventions to ensure patients receive recommended services and follow-up.

2. Choose a physician performance measurement set of quality measures.

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Physician performance measurement focuses on processes and outcomes of care according to evidence-based guidelines. If patients receive recommended services (the processes), then the health (the outcome) for the population as a whole will improve.

For example, the Physician Consortium for Performance Improvement (4) (PCPI) hosted by the American Medical Association (AMA) has developed a number of physician performance quality measures to help physicians measure their work and develop feedback reports for analysis. The National Quality Forum has endorsed many of the AMA PCPI quality measures. (5)

Practice-based feedback reports help physicians better understand the care they deliver and where they should focus their efforts to redesign the clinical workflow in their practices to continuously improve the quality of care for their patients.

Although originally developed for the purpose of continuous performance improvement, these measures are also now being reevaluated by public and private payers of physician services for their appropriateness for public reporting and quality-based payment in the future.

3. Use a clinical information system to track quality measures.

After the medical group selects the particular quality measurement the practice will focus on, they must capture and track the selected quality measures used for quality improvement.

Although chart reviews have traditionally been used for this purpose, they are labor intensive, costly to perform and the amount of data collected are limited. Computerized patient registries, designed to track specific chronic conditions and associated quality measures, are more effective.

Electronic patient registries can be used to identify patients in need of care, as well as to generate feedback reports to the practice, but they still require significant labor costs for data entry.

EHRs with the functionality to collect data prospectively as the clinical work occurs promise to be the most efficient way of collecting clinical data for quality measurement. An effective clinical information system designed to improve chronic care management should perform three major functions:

* Guide medical decisions at the time of care

* Reach out to patients in need of services

* Generate feedback reports to the physician on overall performance

4. Establish patient goals for quality improvement.

Once a medical practice determines which chronic disease it wants to measure and how it plans to measure it, the practice tracks its performance over a specified time period.

The data are gathered, reports generated, and the practice analyzes the results to determine the current level of clinical performance and to establish goals to target for performance improvement.

The performance goals will align and coordinate process activities for improved results. As physicians and office staff compare their current performance to the goals they have for their patients, they become motivated to implement changes in their work to improve performance.

5. Analyze the current workflow processes to identify areas for improvement.

After goals are established, the medical practice needs to develop a plan of action that identifies how the practice will achieve its performance goals.

The team begins by identifying and mapping the clinical workflow processes to analyze the current operations in the practice related to its goals.

Mapping the workflow helps the team recognize areas in need of improvement, for example, points in the process with excessive waiting time, or ineffective patient self-management due to the patient's low confidence in managing their own health needs, or hand-offs that cause information to fail to move from one team member to the next.

Often the team will identify more than one area in need of improvement and will need to prioritize where to focus its efforts. It is often helpful to obtain baseline measurements of problem areas in order to determine the effectiveness of future interventions.

For example, patient cycle time measurement and interruption lists, in addition to workflow maps, can help practices identify bottlenecks with excessive patient waiting. (6)

6. Implement a change in the workflow process.

After mapping the current workflow, the care management team develops strategies to improve the workflow by identifying new processes that can improve clinical outcomes and achieve quality improvement goals.

For example, if the medical practice has an EHR, the EHR can be programmed with reminders and prompts of overdue preventive and chronic care services to assist the physician in developing patient-specific care plans. Nurses and patient-care representatives can use computer-generated reports of patients who are overdue for medically necessary services, such as mammography screening for women or dilated retinal eye exams for diabetics.

Office staff can then reach out, call these patients and schedule them for these services. Medical practices using paper-based medical records can use flow sheets to track patient care longitudinally. (7)

7. Measure and analyze results.

After implementing a change in the workflow process, the clinical information system captures the data elements of the physician performance measurement set.

For properly configured EHRs, these data can be collected prospectively as a normal part of the clinical workflow. For paper-based clinical information systems, the data can be collected retrospectively using chart reviews or tracked using flow sheets.

The clinical information system organizes the data into reports that can be analyzed by the team to determine the effectiveness of the change in workflow.

8. Repetitively implement workflow changes and measure results until goals are reached.

As the care management team studies the results of its workflow process improvements, it makes adjustments in the workflow to improve care. This cyclical process of planning, doing, studying and acting (PDSA cycles) results in continuous quality improvement toward the clinical performance goals of the clinical team.

9. Sustain the improvements.

Once the quality improvement goals are reached, the team needs to put plans in place to monitor the improvement and alert it to the need for further attention if performance gains should begin to slip.

By monitoring the results on a regular basis, the organization is able to sustain improvements in care while refocusing efforts on other areas of the medical practice in need of performance improvement.

As medical practices progress through these nine steps, they will develop the skills and infrastructure necessary to address the chronic and preventive health care needs of patients more effectively and efficiently.

The integration of population-based care management into routine clinical practice will require changes in culture, changes in the use of health information technology, and most importantly changes in the design of clinical workflow processes.

If these changes take place at critical, value-added points in the patient-care process, then the quality of care will improve and the value of physician services to patients will increase.

Kevin Fergusson, MD, MSHA, is medical director of the Physician Office Quality Improvement Organization Support Center at the Virginia Health Quality Center in Glen Allen, Va. He can be reached at [e-mail]

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Note: The analyses upon which this article is based were funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. VHQC/SS/1-31-2007/506

References:

1. National Center for Chronic Disease Prevention and Health Promotion, accessed online at http://www.cdc.gov/nccdphp/overview.htm#3 on July 25, 2007.

2. The Guide to Clinical Preventive Services, (AHRQ Publication No. 06-0588), Agency for Healthcare Research and Quality, 2006.

3. National Diabetes Fact Sheet, National Center for Chronic Disease Prevention and Health Promotion, accessed online at http://www.cdc.gov/diabetes/pubs/estimates05.htm#preventingcomplications on July 25, 2007.

4. Physician Consortium for Performance Improvement, http://www.ama-assn.org/ama/pub/category/2946.html

5. The mission of the National Quality Forum is to improve the quality of American health care by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs. Last accessed online at http://www.qualityforum.org/about/mission.asp on July 25, 2007.

6. Barker LA. Strategies for better patient flow and cycle time. Family Practice Management, 9(6), June 2002.

7. Moser SE, Goering TL., Implementing preventive care flow sheets. Family Practice Management. 8(2), Feb. 2001.

By Kevin Fergusson, MD, MSHA

Table 1 Plan, Do, Study, Act (PDSA) Cycle for Quality Improvement

Plan the improvement process
* Determine the objectives
* Predict the outcome

Do the new process and collect data
* Document unforeseen problems or unexpected observations

Study the results of the new process
* Analyze the data and compare to the predicted outcome
* Summarize what was learned

Act to hold the gains and continue to improve