Quality Indicator Physician Resource, July 2007

QUALITY IMPROVEMENT STRATEGIES TO ENHANCE PATIENT OUTCOMES

Quality Indicator™

Physician Resource

The July 2007

“Assessment seems simple, justasking how much it hurts,” Carrexplains. “Unfortunately, the prob-lem is not simple because there is nodirect relationship between physicalpathology and the intensity ofpain. Pain is a complex and subjec-tive phenomenon with a number ofdimensions, including intensity,quality, duration, and impact onfunctionality. There are marked dif-ferences in severity, quality, andimpact of pain reported by patientsappearing to suffer from the samephenomenon.”

The subjectivity of pain can causeconfusion among providers, Carrsays. An array of instruments is avail-able to measure pain among patients,but many of these instruments

address only one or two dimensionsof pain, he adds. “Others evaluatemultiple dimensions yet combinethem together without differentiat-ing among them,” he says.

Assessment InstrumentsVarious assessment tools are useful inspecific settings and for measuringspecific types of pain. The most com-monly used tools are simple ques-tionnaires that provide a snapshot ofa patient’s experience with pain,such as the Brief Pain Inventory. TheBPI is useful because it is concise andeasy to administer, but it is limited inits ability to measure functionalitylevels, Carr says, adding that it alsocannot measure the outcomes of amultidisciplinary treatment regimen,

including psychological counselingor physical therapy.

Other tools that physicians useinclude the Oswestry DisabilityQuestionnaire (a 10-item assessmentfor back pain) or the Multi-dimensional Pain Inventory (a 61-item instrument used to assess apatient’s mental health). These toolsassess pain treatment outcomes forspecific conditions. Carr and hiscolleagues have developed theTreatment Outcomes in Pain Survey(TOPS), which at 120 items (witha 61-item follow-up instrument)is lengthy and viewed by someprimary care physicians as cumber-some to administer. But it providesdetailed information on the effectof a multidisciplinary regimen oftreatment and of a patient’s levelof functioning.

The worst possible result of usingan inappropriate pain assessment toolis that it may not reflect the positiveeffect pain treatment may have on

(Continued on page 11)

Assessment Tools HelpPhysicians EvaluatePatients’ Pain

Pain accounts for more than 70 million physician officevisits annually, according to the American Pain Societyin Glenview, Ill. Some pain-related visits result from trau-

ma, infection, or acute illness. Others relate to recurrent acutepain, such as migraine or back pain. Many visits are due tochronic pain, such as pain caused by osteoarthritis and neu-ropathies, and others are associated with progressive diseases,such as cancer or AIDS. Regardless of cause, accurate assess-ment is required before a physician can prescribe the appropri-ate treatment, says Daniel Carr, MD, professor of pain researchat the New England Medical Center in Boston.

IN THIS ISSUE

EditorialNew Systems Needed toImprove Use of Guidelines.............2

Quality ImprovementPursuing Perfectionto Advance Quality.........................3

StrategyInitiatives Should Focus onPhysician-Patient Relationship........6

TechnologyEMRs Help ImproveCare Quality....................................9

Vis i t www.Qual i tyIndicator.com

EDITORIAL

2 The Quality Indicator/July 2007

Helen DarlingPresidentWashington Business Group on HealthWashington, D.C.

Timothy T. Flaherty, MDFamily Practice PhysicianNeenah, Wis.

Charles F. Miller, MDMedical Coordinator, DOD/VAClinical Practice GuidelineProject ConsultantDirectorate of Quality ManagementU.S. Army Medical CommandFort Sam Houston, Texas

Lee Newcomer, MDExecutive Vice PresidentVivius Inc.St. Louis Park, Minn.

Jacque Sokolov, MDChairmanSokolov, Sokolov, BurgessScottsdale, Ariz.

Laurence D. Wellikson, MD, FACPExecutive DirectorSociety of Hospital MedicinePhiladelphia

Mark E. Williams, MDProfessor and ChiefDivision of General Medicineand GeriatricsDirector, Geriatric ServicesUniversity of Virginia Health SystemCharlottesville, Va.

Editor in chiefJames G. Nuckolls, MDMedical DirectorCarilion Healthcare Corp.Roanoke, Va.

EditorJoseph BurnsPhone: 508/495-0246Fax: 508/495-0247E-mail: [email protected]

PublisherPremier Healthcare Resource, Inc.150 Washington St.Morristown, NJ 07960Phone: 973/682-9003Fax: 973/682-9077E-mail: [email protected]

ADVISORY BOARD

The Quality Indicator, Physician Resource, is published by Premier Healthcare Resource, Inc., in Morristown, N.J. © Copyright strictly reserved. This newsletter maynot be reproduced in whole or in part without the written permission of the publisher, Premier Healthcare Resource, Inc. The advice and opinions in this publicationare not necessarily those of the editor, advisory board, publishing staff, or the views of Premier Healthcare Resource, Inc., but instead are exclusively the opinionsof the authors. Readers are urged to seek individual counsel and advice for their unique experiences.

Richard Reece, MDContributing editorPhone: 860/395-1501Fax: 860/395-1512E-mail: [email protected]

New Systems Needed to Improve Use of Guidelines

Afew years ago, researchers writing in the Archives of Internal Medicineestimated that it takes 17 years for clinical practices to accept quality stan-

dards. And although the medical literature shows numerous examples of howtreatment recommendations go unheeded, in reality many physicians are deliv-ering appropriate care and following the recommendations of best practiceguidelines, but they are simply failing to record their steps for a wide variety ofreasons. Often, health care information systems are not designed to collect theright information at the point of care. After all, physicians are being asked totreat more patients than ever before, leaving less time for documentation.

But there are other shortcomings in the system as well. Each year, researchersconduct more than 10,000 clinical trials, and while not all of these result in newbest practice guidelines, it is still impossible for practicing physicians to keep upwith the torrent of ensuing data and recommendations.

Also, unwieldy administrative systems make it difficult for physicians to trackclinical advances, to know what’s happening in other parts of the health caresystem, and to collaborate with colleagues.

In a recent report, Molly Joel Coye, MD, president and CEO of the HealthTechnology Center in San Francisco, said that health care information systemsare archaic. The report, Spending Our Money Wisely: Improving America’sHealthcare System by Investing in Healthcare Information Technology, recommendsestablishing a health technology loan program modeled after federal programsused to provide states with money for transportation and environmental initia-tives. The report, which is available online at www.healthtech.org, was issuedby HTC and Manatt, Phelps & Phillips, LLP.

Claude Lenfant, MD, former director of the National Heart, Lung, and BloodInstitute, also offers suggestions on how to address this problem in the Aug. 28NEJM. In “Clinical Research to Clinical Practice—Lost in Translation?” he rec-ommends increasing the level of accountability of physicians in private practice,following the benchmarks established by the National Committee of QualityAssurance, and encouraging professional organizations and specialty societies todevelop practice recommendations to close the gap between what we know isthe best care and what gets delivered and recorded in physicians’ offices.

It will take professional exhortations to do what’s right and economic supportfrom the federal government to make it economically feasible for health systemsand physicians to implement the systems they need.

The Quality Indicator/July 2007 3

QUALITY IMPROVEMENT

Pursuing Perfection toAdvanceQualityBy George J. Isham, MD

Disjointed care systems and ineffec-tive processes impede physicians byerecting barriers to putting best sci-ence standards of care into practice.IOM called for fundamental changein the nation’s ailing health care sys-tem. It challenged stakeholders totransform care systems in order to ful-fill six goals: health care that is safe,effective, patient-centered, timely,efficient, and equitable.

Based in Minneapolis, Health-Partners is a family of nonprofit, con-sumer-governed health care organiza-tions consisting of a 671,000-memberhealth plan, a 427-bed teaching hos-pital, and the HealthPartnersMedical Group. The medical grouphas 32 primary care and specialtyclinics with 600 physicians practicingin 35 medical and surgical specialties.

Our opportunity to dramaticallyimprove patient care opened up in2001, when the Robert WoodJohnson Foundation, in Princeton,N.J., selected HealthPartners to takepart in the Pursuing Perfection pro-gram. With a grant of $1.9 million,HealthPartners set out to make essen-tial changes, all aimed toward meet-ing IOM’s six goals.

Today, Pursuing Perfection atHealthPartners includes hundreds of

initiatives. We are transforming ourdelivery of care through projects thatcenter on the basic care process, theculture and structure of the organiza-tion, and the environment of thehealth care system.

Process TransformationThe focal point of efforts to reconfig-ure the care process is a new plannedcare model with prepared practiceteams. Teams—which include physi-cians, registered nurses, licensed prac-tical nurses, and clerical staff—col-laborate in the care of patients andinvolve patients in managing theirown health.

The core of the planned care modelis to have prepared practice teamswork together with activated,informed patients in continuous heal-ing relationships that are supportedby the ongoing availability of healthinformation for interactive, real-timeapplication, and sharing of knowl-edge. Teams build relationships withpatients and coordinate care across allsettings in a structured process thatencompasses four continuous phasesof engagement with their patients:1. Previsit: the time when health risk

or a need for services is first recog-nized and the patient contacts aclinic

2. Visit: the time from the patient’scheck-in to departure

3. Postvisit: the time from departureto the completion of the care planestablished during the visit

4. Between visits: the time from com-pletion of the care plan to the nextprevisit.The teams put the patient at the

center. They formulate care plans toensure that the right team membercompletes the right task at the righttime at the right stage of an ongoingcare process that keeps the patient

fully informed and actively engaged.The teams follow a simple set of

rules. First: Patient care is designed tomeet individual patient’s needs andrespond to that patient’s values, pref-erences, and choices. Second: Teamsprovide proactive care, not just reac-tive assistance. Third: Teams imple-ment best-practice guidelines to applythe best science in patient care.HealthPartners uses guidelines devel-oped by the Institute for ClinicalSystems Improvement, a nonprofit

“Disjointed care systems and ineffective processesimpede physicians by erecting barriers to puttingbest science standards into practice.”

In 2001, the Institute of Medicine issued a landmark report, Crossing the Quality Chasm: ANewHealth System for the 21st Century. The report described not just a gap but a chasm between thequality of care we provide and the quality of care we want for our patients and could deliver to

them. The authors concluded that poor quality is not due to the absence of effective treatmentsor to any lack of knowledge about them. The report confirmed my clinical and medical manage-ment experience: The quality chasm is a systems problem.

George J. Isham, MD, is the medicaldirector and chief health officer forHealthPartners, an integrated care deliv-ery organization in Minneapolis.


QUALITY IMPROVEMENT


organization that supports collabora-tion on QI among 45 Minnesota med-ical groups. Fourth: A team’s work isorganized around the processes of pre-visit, visit, postvisit, and between vis-its. Fifth: Team members cooperateand coordinate their work fully withone another and the patient.

In 2002, HealthPartners undertooka pilot project to test the new model atthree medical group clinics. In Apriland October 2003, we conductedCare Design Collaborative sessions toroll out the model and prepared prac-tice teams beyond the pilot sites.Today, 87% of all PCPs are in pre-pared practice teams, and all potential208 teams are in place at 32 clinics.

Prepared practice teams are con-verting best-science guidelines intopractical protocols. For example, the

interdisciplinary behavioral healthteam at HealthPartners West Clinic,one of the first pilot sites, introducedevidence-based guidelines for thediagnosis and treatment of depressioninto primary care. The revampedworkflow has achieved significantresults. Patients with depression haveexperienced an average one-thirddecrease in symptom severity, andhalf of those with major depressionhave experienced a 50% reduction.

Culture ChangeTo be successful in transformingHealthPartners, it is essential toengage all of our 9,800 employees. Toraise awareness, understanding, andsupport, HealthPartners commis-sioned Minneapolis playwright SylJones to develop Fire in the Bones, atheater-based training program pre-sented to all employees. The perfor-mance dramatizes the ways in whichthe current health system fails not

only patients and their families butalso health professionals.

Leadership training is an integralcomponent of Pursuing Perfection.We initiated an enterprisewidecampaign and training program tobuild leadership skills, foster respectin employee interactions withpatients and members, and developrespectful workplace interactionsamong staff. In 2005, in response toongoing employee surveys, moreresources were devoted to internalcommunication throughout theentire organization.

The structure of the organizationincludes information systems thatsupport change, especially in careprocesses. Therefore, under PursuingPerfection, HealthPartners accelerat-ed electronic medical record imple-

mentation. Today, 3,800 users,including all HealthPartners MedicalGroup physicians and nurses, haveEMR access.

The EMR supports clinical processtransformation and the new caremodel in several significant ways.First, most guidelines are now auto-mated for evidenced-based, best-prac-tice care. Based on the patient’s signsand symptoms, the EMR presents abest-practice alert with a summary ofthe guideline and an explanation thatphysicians can discuss with patients.

Second, to improve patient safety,the EMR provides real-time medica-tion interaction alerts when physi-cians enter orders for medications.Third, HealthPartners had producedseparate data files with diagnosis-spe-cific patient registries so that clini-cians could identify patients with cer-tain conditions, but patients withmultiple diagnoses were listed sepa-rately on different registries. Today,

patient registries are patient-centeredand comprehensive.

Fourth, visit summaries for patientsexplain their conditions, documentthe care provided that day, and sum-marize follow-up care steps. The EMRthereby supports patient involvementin their care plans. Physicians reportthat these summaries are among themost useful tools provided by theEMR to improve communication andincrease the efficiency and effective-ness of office visits.

In March, HealthPartners launchede-care initiatives, enabling patients todo online appointment schedulingand to pick their clinic, physician,and date and time of appointmentsfor primary care. Usage is increasingmarkedly, with a 71% jump betweenMarch and April.

Total cost savings have beengreater than anticipated. Movingpaper charts around betweenPCPs and specialists was a $3 millionannual expense, which the EMRessentially eliminated.

Environment ChangeNo one health care organization cantransform itself without addressingthe broader health system environ-ment. Thus, HealthPartners supportsexternal change, particularly in thearea of provider reimbursement.Reimbursement is a basic barrier toquality improvement. Traditionally,health plans pay for a process of careconsisting of units of service, andthere is not a direct relationshipbetween what providers are paid andimproving care processes, ensuringimplementation of best practices, orachieving specific health outcomes.

HealthPartners structures financialrewards for quality through Pay forPerformance, which includes twomain elements: the OutcomesRecognition Program (ORP), andPayment for Quality (PFQ).

(Continued from page 3)

“Deep-seated, lasting change calls for sharedvision and commitment.”


To improve clinical processes andachieve better outcomes, the com-mitment of PCPs is essential, inpart because they are on the frontlines of care delivery. ORP, started in1997, offers bonus awards to primarycare clinics that achieve superiorresults in promoting health andpreventing disease, based onHealthPartners’ quality goals. Yearlyfinancial bonuses are tied to targetsthat HealthPartners reviews andadjusts annually to keep incentivesaligned and sustain continuousprogress toward priority health goalsfor our members. Since 1997,ORP bonus awards have totaledsome $2.9 million.

To complement ORP, Health-Partners launched PFQ in 2001. PFQpays providers for quality through stan-dard reimbursement agreements. PFQblends two elements —payment forquality and payment for process—intomarket-based reimbursement rates forPCPs, specialists, and hospitals. In2006, HealthPartners paid about $8.5million under PFQ, and that is pro-jected to top $10 million this year.

Minnesota Orthopaedic SpecialistsPA, a 10-physician group practice inthe Twin Cities, illustrates howPFQ works. In negotiation withHealthPartners in 2002, the groupdecided to concentrate primarily onbest practice for menisectomyarthroscopy. The group set a goalof increasing the number of patientsmeeting care guidelines (appropriatesymptoms and findings, a trial ofconservative therapy before adecision to perform surgery, andpostsurgical documentation of find-ings and outcomes) from 67% atbaseline in 2002 to 80% in 2003. Thegroup reached 83% in 2004 andreceived the full amount negotiatedfor payment for quality. In 2005, thegroup continued to strive for evenmore improvement.

In addition to our own reimburse-ment innovation endeavors, Health-Partners is engaging other payers indiscussions about restructuring reim-bursement. The discussion involvesefforts to recognize and reward mea-surable improvements in health out-comes, such as our own programs, aswell as alternative payment methodsfor new types of care, including groupvisits and e-care.

Lessons LearnedHealthPartners has been learningimportant lessons as we transform thedelivery of care to cross the qualitychasm. First: Transformation effortsmust be undertaken at multiple levelswithin health care organizations andaddress the external environment aswell as internal systems and processes.

Second: The challenges are daunt-ing in their complexity. Transforma-tion is an ongoing process thatrequires new models of care deliveryand fundamental cultural andorganizational changes. Therefore,sustained, long-term commitmentis essential.

Third: Specific transformation ini-tiatives, such as the HealthPartnersplanned care model, often begin withpilot projects. Moving from pilots toorganizationwide rollout is complicat-ed. Rollout requires education andfull participation from management

and staff at new sites so that everyoneunderstands the rationale for change,the action steps required, the specificresponsibilities of all involved, andthe methods for monitoring progressand evaluating results.

Fourth: Care guidelines summarizebest science but must be translatedinto protocols in specific care settings.Our prepared practice teams workdiligently to define logical caresteps to implement guidelines intheir workflow.

Fifth: Transparency is essential. Inthe transformation process, trans-parency must be a basic goal and afundamental value. Deep-seated, last-ing change calls for shared vision andcommitment that can come onlyfrom trust. In turn, trust requiresopenness within the organization.Senior leadership must embracetransparency as an objective and avalue.

Sixth: In planning, implementing,and evaluating any change undertak-en to transform health care, patientsmust be at the center. One essentialquestion must be the touchstone:How does it affect the patient?Transformation efforts to reshapehealth care will be successful to theextent that they improve patients’experience, care, and outcomes.—More information on quality improvementis available on our Web site (see page 12).

Support for Pursuing Perfection

The authors of Crossing the Quality Chasm: A New Health System for the21st Century partnered with the Robert Wood Johnson Foundation and

the Institute for Healthcare Improvement to support provider organizationsin transforming themselves based on IOM principles. In 2001, the founda-tion and IHI announced Pursuing Perfection, a $20.9 million initiative. Thefirst phase began in 2001, with distribution of $50,000 planning grants to 12organizations. In 2005, seven finalists, including HealthPartners, eachreceived two-year, $1.9 million grants to implement restructuring plans andto share their work with health care organizations across the nation.


STRATEGY

Initiatives Should Focus onPhysician-Patient Relationship

“The most significant reason thatquality health care has lagged inAmerica is the failure of systems toacknowledge the critical and uniquerole physicians play in making qualityinitiatives real,” says Alice Gosfield, ahealth care attorney in Philadelphia.“Current discussions about pay for per-formance miss some essential points,particularly whether the efforts neces-sary to earn the additional money aresufficiently rewarded by the amount ofpayment received.” Gosfield, a formerchairman of the board of directors ofthe National Committee for QualityAssurance (NCQA) in Washington,D.C., has written extensively aboutenhancing the quality of care throughincentive systems.

Net ResultsUnder most current pay-for-perfor-mance (called P4P) initiatives, hospi-tals and physicians are paid an addi-tional sum of money for rendering ser-vices that further quality, Gosfieldsays. Yet the net result of most P4Pinitiatives is that they will have littleeffect on some of the most difficultproblems the health care system faces,particularly the problem of overuse ofservices, says James Reinertsen, MD,a rheumatologist and CEO of TheReinertsen Group, a consulting firmin Alta, Wyo. He is also a senior fel-low in the Institute for HealthcareImprovement, in Boston. Reinertsenand Gosfield have collaborated on

several studies and have cowrittenarticles about the physician’s role inproviding quality care.

P4P payment methodologies,including those of the federal Centersfor Medicare & Medicaid Services(CMS), fall into one of three cate-gories, Gosfield says. Under one cate-gory, the programs pay a bonus whena physician meets a certain thresholdof behavior. For example, a physicianwho meets the NCQA Diabetes

Physician Recognition Program stan-dards gets paid $100 per diabeticpatient per year in a program calledBridges to Excellence.

In the second category, a pool ofproviders is arrayed normatively andeach one is compared against the oth-ers. The best performers get paid apremium based on their relative sta-tus with respect to the performance ofothers, as in the newly formed CMSPremier Hospital Quality IncentiveDemonstration Project.

In the third category, physicians orother providers are offered a poten-tial pool of money that they canreceive only if they meet certainthresholds and provide savings when

compared with a control group, suchas the Medicare Physician GroupPractice Demonstration.

“There’s no question that in P4P,where additional payments are madeon top of other monies they arealready receiving, physicians willexperience increased revenue inreturn for some measure of demon-strated quality,” says Gosfield in “TheDoctor-Patient Relationship as theBusiness Case for Quality: Doing

Well by Doing Right,” an article pub-lished in the spring issue of the Journalof Health Law. “The real question,however, is whether the efforts neces-sary to earn the additional money aresufficiently rewarded by the amountof payment received.”

Regulatory EnvironmentMany P4P programs make paymentsbased on data produced by healthplans, Gosfield explains. But reportsshow that physicians are so con-cerned about inaccuracies in the datathat health plans produce (and uponwhich their bonuses are based) thatthey have their staff check the data.In other words, physicians are

The result of most P4P initiatives is that they havelittle effect on such difficult problems as overuseof services, says James Reinertsen, MD, of TheReinertsen Group.

Many physician consultants hail the growth of pay-for-performance initiatives, saying thatsuch initiatives help to focus attention on improving quality of care. But some expertswho have studied the business case for quality care argue that these initiatives may be

missing the big picture. Instead of focusing on pay for performance, they argue, all quality initia-tives should be based on recognition of and support for the physician-patient relationship.


expected to respond to the incentivesof the payment systems in order torender quality services to theirpatients, but these incentives do notnecessarily produce the desired result,Gosfield notes.

In fact, most approaches to qualityimprovement occur in a regulatoryand punitive environment, Gosfieldcharges. “Quality is now unequivocal-ly a fraud and abuse issue and isincreasingly a focus of enforcementattention,” she says in her article. TheStark and federal antikickback lawsand regulations can be viewed asquality related because they addressthe issue of utilization, she adds.Many states have laws that mirror thefederal antireferral laws.

“Despite the detail and broadsweep of these quality-focused regula-tions, they have not improved healthcare,” Gosfield continues. “Theyhave not engaged physicians or per-suaded them that quality initiatives

merit their attention. Physicians seemost of these penalties, regulations,sanctions, and disincentives as enor-mous hassles aimed at the miscreantfew among whom they do not num-ber themselves. Indeed, if these lawsand programs had engaged physi-cians, we would not be consideringtoday whether there is a business casefor quality.”

Straight TalkIncreasingly, health plan CEOs areaware of the strong business casethat exists for improving the qualityof health care, say Gosfield andReinertsen. Earlier this year,Reinertsen coauthored a report byErnst & Young, CPAs in New York,Straight Talk About Clinical QualityFrom Health Care CEOs. The reportconcluded that health care leaders areclear that clinical quality has movedto the forefront of their organizationalstrategic agendas. “In many instances,

these organizations have always had asignificant focus on quality, but it hassharpened and intensified, at least asseen by the CEOs, during the past yearor two,” the report says.

Ernst & Young conducted a one-day discussion that included abouttwo dozen health plan CEOs.Although pay-for-performance mod-els have received a lot of attention,the CEOs had several concerns,according to the report. One of theirprimary concerns was that the focusof virtually all P4P programs is on thesubset of problems characterized byunderuse of health care services (forexample, foot exams for patients withdiabetes, appropriate medications forcongestive heart failure, and variouspreventive services).

The participants in the discussionviewed the problems of overuse andmisuse as more difficult to address. It isextremely difficult to pay physiciansbonuses for not delivering a service, forexample, even if the current practiceof overuse is clearly harmful. On theissue of misuse, current measurementmethods for determining that a proce-dure or treatment was delivered badlyare underdeveloped, says the report.

Cost of BonusesAs bonuses are paid out in P4P pro-grams, the payments for all other ser-vices hospitals and doctors providemay have to be reduced. The CEOsechoed Gosfield’s concern that thereare considerable costs associated withachieving the bonuses, ranging frominvestment in quality infrastructurefor training and information systemsto the staffing and supply costs ofdelivering services not now beingdelivered. For all those reasons, theCEOs concluded that the effect oncurrent P4P programs is on the mar-gins of health care delivery.

“The net effect of the overuse focus

Five Principles for Improving Quality

One way to improve the quality of health care is to adopt five principlesthat would improve how care is delivered, says Alice Gosfield, a health

law attorney in Philadelphia. Each principle is important for organizationsseeking to foster quality improvement in the health care system, she says.“Bringing all five of these principles together would revolutionize healthcare delivery in this country,” she adds. Those five principles are

1. Standardizing, or encouraging the use of, evidence-based medicine, aswell as standardizing forms for documentation.

2. Simplifying: “The wide variety of financial incentives, contractualobligations, documentation requirements, utilization review systems,medical management programs in managed care entities, and adminis-trative burdens that have no relevance to the delivery of evidence-based medicine should be removed from the physician practice envi-ronment,” says Gosfield.

3. Making all physician activities clinically relevant, including paymentmethodologies, documentation requirements, design of informationtechnology support mechanisms, manpower resource planning, andrecruiting.

4. Engaging the patient (in treatment choices for example).5. Fixing public accountability at the locus of control.

—MS


STRATEGY


is that these pay-for-performancemodels will likely have little influ-ence on some of the biggest qualitychallenges we face,” concludes theErnst & Young report.

To address these concerns, Gosfieldand Reinertsen have proposed amodel that they call the “unified fieldtheory applied.” The core of theirUFT-A model lies in improvingquality by enhancing the ability ofphysicians to spend more and bettertime with patients. Gosfield andReinertsen have established a Website that explains their efforts in moredetail (at www.uft-a.com).

Applying Science“The fundamental policy challengesto improve quality are to eliminatethose aspects of the current environ-ment that steal touch time from thedoctor-patient relationship and tosupport those measures that enhanceoptimized time and touch,” Gosfieldsays. “Time and touch are critical to aphysician’s approach and treatment ofa patient. They affect a physician’sability to grasp the subtleties in eachpatient’s situation and are significantwhen fashioning an effectiveapproach to the patient. Time andtouch are essential to optimal commu-nication, which implements appropri-ate treatment. To customize the appli-cation of science, the physician mustlisten, explain, examine, comfort,teach, treat, perform procedures orsurgery, and otherwise address the spe-cific and variable needs of the individ-ual patient. This touch time is whatdefines the art of medicine.”

In working with physicians,Gosfield says she found that theywere angry “all the time about every-thing.” In fact, they were so angrythat they were unable to help them-selves, she adds. “Physician anxietydoes not turn on a perceived loss ofautonomy alone,” Gosfield recounts.

“Rather, there is a very complex con-fluence of disparate policy, legal, andmarket forces that whipsaw physi-cians in their daily lives, to whichthey respond as if these forces areunrelated to each other. What wasneeded, I thought, was a unitary plat-form upon which more of their activ-ities could be based.”

To improve quality systemwide,physicians must play an aggressiverole in promoting quality, concludes

Reinertsen. “The early efforts tochannel the attention of physiciansto the quality of care are transitionalmodels,” he says. “Physicians mustwork with payers and purchasers onpayment systems that drive a compre-hensive agenda and make a betterbusiness case for high quality.”—Reported and written by Martin Sipkoff, inGettysburg, Pa. More information on quali-ty improvement is available on our Web site(see page 12).

Nine Elements to Improve Care

The “locus of control” in the health care system is at the heart of thephysician-patient relationship, says Alice Gosfield, a health law attor-

ney in Philadelphia. During a patient visit, physicians are capable of con-trolling only two fundamental aspects of care, she says: the application of thescience that is appropriate to their patient’s needs and the quality of theirdoctor-patient interactions. Seeking to improve the quality of the relation-ship between physicians and patients, Gosfield and James Reinertsen, MD,identified the following nine elements that can enhance these two aspectsof care:

1. Payers and physicians should select clinical practice guidelines.2. Clinical practice guidelines should be translated into applicable ICD-9

and CPT codes. Payers should foster the use of clinically relevant doc-umentation systems that support the medical necessity of the servicesprovided and enumerate the care actually provided to each patient.

3. Note standards should be in easily accessible templates. Claims report-ing can be standardized into documentation templates that reflect evi-dence-based medicine and that save time by virtue of standardization.

4. The full pathway of care, not just care administered by physicians,should be documented. Considering the full pathway implied by guide-lines can add greater strength and scope to its application.

5. Appropriate deviation should be accommodated. This elementaddresses the frequent resistance to the application of guidelines ascookbook medicine, Gosfield says. For example, the typical patientwith congestive heart failure may also have diabetes and hypertension.A physician might follow one preferred regimen in the absence of thoseexacerbating factors, but would have to follow a different branch ifthose other conditions exist.

6. Patients should be engaged.7. Services should be priced according to an analysis of the cost of pro-

viding those services. This step can aid in constructing a budget fordelivering care, says Gosfield.

8. Compliance should be measured.9. Analyze and refine. —MS


“Just as the development of theCAT scan, the MRI, and the laparo-scope have improved patient out-comes, information technology willenhance the quality of care providedby primary care physicians,” Zelnickcomments. “That’s why the programheavily emphasizes the appropriateuse of IT in its training.”

Improving Proficiency“Ten years ago, we had residents andfaculty who were uncomfortable withthe computer,” Zelnick says. “Somedid not even know how to type. Sowe had to start teaching basic com-puter skills.” But that situation has

changed. In fact, fostering comfortwith computer usage becomes easiereach year as younger residents jointhe program, he adds. “The residentsentering our program now are com-fortable with e-mail and other com-puter functions,” Zelnick says. “Butstill, everyone is at a different skilllevel with regard to computer profi-ciency.” To facilitate learning, theprogram provides all residents with alaptop computer to use during theirthree years in Cedar Rapids.

“Because the residents have thislaptop to use as their own, training isexpedited,” Zelnick explains. “Theybecome very comfortable with thistool in a short time. They learn howto use it, how to repair it, and how tocall the technical personnel if there isa problem. They take it home and useit to send e-mail, play games, surf theInternet, and look up medical refer-ences. This leads to a general profi-ciency that helps them become morecomfortable accessing our EMR sys-tem and the patient educationresources we provide.

“We can also get our rotating med-ical students up and running on our

computer system in a day or so,”Zelnick continues. “We lend them alaptop for the month, and they goright to work seeing patients.”

Each faculty member has a laptop aswell. “It was cheaper for us to giveeveryone his or her own laptop andput the laptops on a wireless networkthan it was to put a computer in everyexamination room,” says Zelnick. Thenotebooks use a wireless network thatwas installed in 1998 and that Zelnickbelieves was the first in the state.

The residents who were trained in1998 to use the computer in the examroom to educate patients and print outcustomized handouts were later able toadapt quickly when the program addedthe EMR in 1999, Zelnick explains.

Thorough CareDuring his first 10 years in privatefamily practice, Zelnick recognizedthe power of computer technology.“Even the simplest billing programcan give physicians some informationthat can help them understand theirpractices better,” he notes. “In the1980s, we installed a simple billingsystem on a personal computer. Afterabout three or four months of usingthe system, I realized that the systemcould run a report analyzing the typesof conditions the practice was treat-ing. To my amazement, the mostcommon chronic disease that wewere billing for was diabetes. I knewwe had patients with diabetes, ofcourse, but I did not realize that theycomprised our most common officevisit for a chronic disease.

“The computer enabled us toquickly assess our disease mix andprompted us to provide patient edu-cation and otherwise focus on theneeds of this patient population,”Zelnick continues. “In fact, wetrained a nurse to become a diabeteseducator. Given that we were located

TECHNOLOGY


“Physicians spend 80% of their time doing about20 things,” says Charles Zelnick, MD, of theCedar Rapids Medical Education Foundation.

EMRsHelp Improve CareQualityBy Richard L. Reece, MD, contributing editor

Electronic medical record systems can greatly enhance the quality and efficiency of familypractice, says Charles Zelnick, MD, assistant director of the Cedar Rapids MedicalEducation Foundation in Iowa. The foundation runs a program that trains residents in a

three-year family practice program, and Zelnick calls the program “an electronic family practiceresidency” because it emphasizes the use of computer systems at the point of care. Some 20 resi-dents have been trained and have worked in the program’s Family Practice Center and at localhospitals and physician offices.


TECHNOLOGY


in a rural area, our patients wouldhave had to travel 180 miles to dia-betes classes. So we started offeringteaching in our office because thedata revealed that diabetes was a bigproblem in our practice.

“So arming a physician with power-ful information at the point of care iskey to providing high-quality care inan efficient manner,” Zelnick says.“Physicians spend 80% of their timedoing about 20 things. It makes senseto examine those 20 things from anindustrial engineering point of viewand strive to perform them well. For afamily physician, activities involvedin a well-child visit, a visit for an earinfection, a hypertension visit, and adiabetes visit should be well engi-neered as far as work flow.”

Enhancing CareTo enhance their ability to providethorough care efficiently, physicianscan build prompts and reminders intothe EMR. “For example, immediatelyprior to a visit with a patient who hasdiabetes, I can call up the electronicrecord and instantly find out the dateof that patient’s last A1C test, last eyeexam, and last urinalysis,” Zelnickoffers. “The system also prompts meas to what drugs the patient should betaking. I find that the system not onlyhelps me ensure that I am providinghigh-quality care, but it actuallyspeeds up the visit. When I look atthe record before I enter the examroom, I know what needs to be done.”

The EMR also enhances both prac-tice efficiency and care quality by issu-ing reminders for flu shots, vaccines,Pap smears, colon-cancer screenings,and other preventive care measuresthat physicians in a busy practice mayforget. “There is no doubt thatprompting the physician at the pointof care to provide these services is keyto ensuring that high-quality care isprovided at a time when it is doable

and efficient,” Zelnick comments.While facilitating high-quality care

is often the most compelling reason toadopt an EMR, Zelnick points outthat EMRs also offer a financial returnon investment. “One of the easiestways to achieve some return oninvestment involves the eliminationof dictation,” he says. “During the firstyear we had our EMR, we saved$40,000 on transcription costs alone.”

Physicians also have an opportuni-ty to use the EMR to improve docu-mentation. “With better documenta-tion and system feedback with regard

to proper coding, it is easier to code avisit properly,” Zelnick says. “Becauseof more thorough documentation,undercoding is no longer a problem.We are able to substantiate the extrawork that we are doing to providethorough care, and thus recapturesome of our investment that way.”

To maximize both care quality andreturn on investment, physicians mustaggressively seek opportunities to usethe EMR effectively. “If physicianshave a great system but do not use itcorrectly, it will not improve productiv-ity,” Zelnick says. “Therefore, physi-cians must be aware of opportunities touse the tool and to take advantage ofthose opportunities. They have to lookat how they can use this tool to offerhigher quality medicine and to seepatients more efficiently. Any chanceto avoid doing the same work overagain is an opportunity to save time. Asan example, we can now access ouroffice’s electronic charts from emer-gency rooms and home, which tremen-dously speeds up hospital admissionsafter hours and avoids errors.”

One of the often-promised goals ofEMRs is the paperless office, and

Zelnick believes these systems offersuch potential. “We are getting closeto having a paperless office,” he says.“We are even scanning in all of ourreferral letters and other papers thatcome in from outside our practice. Asa result, the amount of paper flow backand forth has diminished tremendous-ly. In fact, we were able to cut our mail-box sizes in half. We had a record roomthat was full of big racks of records; wetook all of the big shelves out and nowthe room is a lounge for the physicians.We’ve got couches and furniture inthere and we put a big desk in the cen-

ter with computer terminals and peo-ple can sit down, answer their phonecalls, read mail, check flags and charts,and most important, talk with eachother. It’s probably the best teachingenvironment in the whole office.”

Looking AheadThe next goal for Zelnick and his col-leagues is to incorporate some of thenew challenges of medicine into thetraining they offer. “We now have atremendous body of knowledge aboutwhat constitutes high-quality, cost-effective medicine, along with opti-mal care guidelines for many condi-tions,” Zelnick points out. “The chal-lenges are to be able to apply thatknowledge effectively in a 15-minuteoffice visit, and to keep up with newknowledge as it is developed. To meetthese challenges effectively, it is essen-tial that computer technology beproperly incorporated into healthdelivery systems to efficiently improveboth patient care and outcomes.”—Edited by Deborah J. Neveleff, in NorthPotomac, Md. More information on qualityimprovement is available on our Web site (seepage 12).

“Any chance to avoid doing the same work overagain is an opportunity to save time,” says Zelnick.


COVER STORY


patient care, Carr says. “The worst ofall possible worlds is not knowing theresult of care,” he says. “Because ofthe subjective nature of the painexperience, you may not know thatyou are having a positive effect,meaning you might stop a treatmentor fail to be reimbursed for a treat-ment. That makes choosing the cor-rect instrument critical to the qualityof care.”

Defining PainIn fact, one well-known definition ofpain is subjective. Margo McCaffery,the author of Pain Clinical Manual,2nd ed. (St. Louis: Mosby Inc., 1999),says, “Pain is whatever the experienc-ing person says it is, existing whenev-er he or she says it does.”

“Since McCaffery proposed this def-inition more than 30 years ago, it hasbecome widely accepted in health caresettings worldwide,” says Diane Scheb,acute pain program coordinator andclinical nurse specialist at SarasotaMemorial Hospital in Florida. “Thedefinition provides a firm foundationfor the assessment and management ofpain because it establishes the patientas the authority on the existence andseverity of pain.”

The International Association forthe Study of Pain, a research organi-zation in Seattle, uses a slightly moreobjective definition: “Pain is anunpleasant sensory and emotionalexperience arising from actual orpotential tissue damage or describedin terms of such damage.”

Illness and PainThe American Pain Society recom-mends all pain be assessed first as adifferentiated condition of a diseasestate or injury. The society recom-mends that health care professionalsask three central questions of anypatient who reports pain before mak-ing a determination about how much

pain the patient is experiencing:1. What is the extent of the patient’s

disease, injury, or physical impair-ment?

2. What is the magnitude of the ill-ness? That is, to what extent is thepatient suffering, disabled, andunable to enjoy usual activities?

3. Are symptoms amplified for psy-chological or other reasons?Once a physician or other health

care provider establishes the degreeof disease or injury, pain should berecognized as cultural and social phe-nomena, pain experts assert. Patientsoften do not report their experiencesbecause they are embarrassed to bein pain or feel other cultural pres-sures to deny their condition. Theexperience of pain is so subjectivethat it is frequently unreported bypatients in general health careassessments, especially by those con-ducted by primary care physiciansand hospitals using generalist patientsatisfaction measures, says KarenCarroll, a researcher with theVeterans Affairs Healthcare Systemin San Diego.

Chronic or Acute PainAccurate pain assessment varieswith specific circumstances, sayexperts, and the assessment toolsused vary widely depending on theexperience of the provider, thenature of the pain (whether it isacute or chronic), and the kind ofinformation being sought, such as

whether a patient is suicidal. Inacute clinical situations, attention isusually given to the physical andsensory components of pain, such asintensity, location, and temporalcharacteristics, Carr says.

For patients with recurrent andchronic pain, physicians will assess arange of psychosocial and behav-ioral factors known as levels of func-tioning and quality of life. “In suchcases, health care providers may beunable to identify the actual physi-cal basis for the patient’s reportedpain,” Carr explains. “This does notmean there is no physical basis forthe pain.”

In the most basic evaluative tech-niques, such as the BPI, patients areoften asked to quantify their pain byproviding a general rating of painthrough answers to questions, such as,“Is your usual level of pain mild, mod-erate, or severe?” Carr says. “In theseinstances, the patient is being asked toquantify pain retrospectively.”

As managed care plans continue tofocus on cost-containment, outcomesassessment instruments, such as theMedical Outcomes Study Short Form36-Item Questionnaire (or SF-36),have assumed increasing importance,Carr says.

Distinguishing TOPSTOPS is distinguished from theSF-36 and other pain and quality-of-life instruments in several ways.

The American Pain Society recommends all painbe assessed as a differentiated condition of adisease state or injury and that health care pro-fessionals ask specific questions of any patientwho reports pain before making a determinationabout how much pain the patient is experiencing.



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First, it is based on a particularclinical treatment model developedfrom models that assess disability,says William Rogers, a senior scien-tist at the New England MedicalCenter. Second, it explicitlyacknowledges and measures contex-tual factors important in pain treat-ment. Third, it is designed to trackindividual change and to documentthe outcomes of groups of patients,such as all those followed in oneclinic or by one clinician. Fourth, itis available as part of a system thatcan be quickly and efficiently admin-istered as part of routine clinicalcare, he adds.

TOPS is administered on paperand the completed forms can

be scanned for computer assessment,but there is no reason it could notbe completed by computer or tele-phone, Rogers says.

“Nothing about TOPS confines itsapplication to patients seen within apain clinic,” he points out. “Weadministered some of the dimensionsin an on-site occupational healthclinic of a major employer and foundthat TOPS performed well in docu-menting excellent treatment out-comes. The TOPS instrument alsocould be used in primary care,although there may be logisticalproblems in scoring it in a busy,generalist practice.”

All pain assessment tools fail,however, in one significant area.

None can accurately and objectivelyquantify pain, and the tools that areused to measure pain invariably relyon subjective standards. At the coreof any pain assessment is thepatient’s self-evaluation, Carr con-cludes. “Assessment of a patient’spain depends on the patient’s overtcommunication, both verbal andbehavioral,” he explains. “Givenpain’s complexity, a physician mustassess patients’ moods, attitudes,coping efforts, resources, responses offamily members, and the impact ofpain on their lives.”—Reported and written by Martin Sipkoff, inGettysburg, Pa. More information on painmanagement is available on our Web site (atwww.QualityIndicator.com).


Quality Indicator Physician Resource, July 2007

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