Proving Your Quality of Care Compliance: A Case Study

  The fact that the healthcare system is on the verge of a complete overhaul is not a newsflash. For more than a decade, measurement of physician performance (ie, offering incentives to improve care) has been the focus of many governmental, professional, and private groups. However, questions remain unanswered as to what should be measured, how things should be measured, and how to get the requisite “buy-in” from physicians and other wound care providers.   A recent editorial in JAMA discusses these challenges and emphasizes some important things to remember about measuring performance: 1) Select measures that physicians can definitively impact. (Many times, healthcare systems choose measures that an individual doctor can’t affect.) 2) Make “doing the right thing”¹ feasible. (Your information technology [IT] system must ensure that document can be easily supported.) 3) Consider measures that will be important to the patients and their care. (Having a specific lab value as a goal may not be the best reflection of good care.²)   When officials at Precision Health Care, a national wound center and hyperbaric management company based in Boca Raton, FL, wanted to develop a treatment algorithm for wound care, they consulted with a thought leader in the wound industry who encouraged them to “keep it simple” because many organized wound centers “miss the boat” on wound care basics – such as offloading diabetic and pressure ulcers, placing venous stasis ulcers into compression, and screening the vascular status of all patients with lower extremity ulcers. One analysis of electronic health record (EHR) data from wound centers found that only 17% of patients living with venous leg ulcers received compression.¹ Why is this? It’s either due to doctors not knowing how to provide the service, or they forget to do so consistently, or they do not document when they provided such services.

Merging EHR With Best Practices

  Instead of attempting to devise a complicated, multi-page algorithm for wound assessment and management, Precision officials decided to adopt a basic clinical practice guideline (CPG) that focused on vascular screening and compression for venous ulcers, vascular screening and offloading for diabetic ulcers, and nutritional screening and pressure reduction for pressure ulcers. (It was also decided to always assess hemoglobin A1c in diabetics and conduct biopsies on nonhealing wounds.) It seemed like an easy-enough plan.   Clinicians were educated on the CPGs and the importance of adhering to them to improve patient care and healing rates. The decision was also made to monitor compliance quarterly and review findings with one’s peers. The results were not considered “stellar” after the first quarter of assessment, as the average rate of compliance for any one measure was less than 50%. However, the problem was not a lack of buy-in from the providers, but a much more manageable issue — the CPGs had not yet become “routine” in their minds. To alleviate this concern, reminders to adhere to guidelines were strategically placed throughout patient-care areas and compliance evaluations began to take place on a monthly basis. As a result, CPG documentation showed improvement after one month’s time. But when that success was short-lived (at the end of the second quarter, documented compliance was actually below the first quarter), new measures were needed.

Failure to Act or to Document?

  Healing rates remained in the 90th-percentile range, so clinicians were doing the appropriate things. Why, then, did the CPG documentation not reveal 100% compliance with measures? Upon further examination, clinicians were found to occasionally document CPG compliance in the incorrect area of the EHR (while manually reviewing the records, reviewers gave credit for those measures). As the JAMA article states, the IT system has to “make it easy to do the right thing.” The EHR we employed had been designed with special “macros” (computer instructions that represent a sequence of operations) that made documenting compliance with the CPGs as easy as “clicking on the box.” It was not necessary for clinicians to type anything into a “field.” “Structured language programming” within the EHR could credit the clinician with having implemented the CPG because the EHR could interpret the use of the macro. However, the automated compliance checks built into the computer could not interpret what the clinician “typed in the box.” Human reviewers manually counted and gave credit for these typewritten entries. Patient outcomes were good because clinicians were, indeed, following appropriate practices. However, clinicians were doing a poor job using the EHR designed to help them document their care. Once this issue was addressed, compliance with documentation improved significantly and matched the data seen in patient outcomes. So, it was demonstrated how well physicians were actually doing with CPG adherence.

Tying Care Quality to Compensation

  According to JAMA, the US healthcare system should reinforce the tendency for physicians to act as “knights who are motivated by professional values,” rather than as pawns who passively respond to their circumstances.² The way physicians are rewarded should reinforce their intrinsic motivation to pursue excellence. There may be no better argument for developing better wound care quality measures. For several years, the only measure relevant to wound care was the Physician Quality Reporting System (PQRS), which tallied the percentage of venous ulcers prescribed any type of compression. However, as more wound care physicians become employed by healthcare systems and management companies, employers want to devise compensation packages that include wound care quality measures. Without sound measures from Medicare, these companies have to create their own quality standards to assess and incentivize physician performance. Dedicated clinicians are rarely motivated to do what’s appropriate for patients solely by money, but tying compensation to quality measures does help keep the importance of documenting quality of care a priority. When officials at Precision decided to track the assessment of vascular status and the implementation of compression, an interesting challenge was noted: Only part of the challenge was documenting what was done (eg, venous ulcer compression). The bigger challenge turned out to be documenting what was not done. For example, a physician may not place the patient in compression due to inadequate vascular supply, but forget to document that he or she did not provide compression for a medical reason. Most PQRS quality measures allow a clinician to specify the reason that a quality measure was not performed (eg, patient factors, system factors, or medical reasons). It is important to ensure that the EHR makes it easy for the physician to document both what was done and what was not done, as well as why. However, the reality is that tying performance to physician salaries is the final part of the equation. Quality measures must be directly relevant to patient care (evidence based) within the control of the physician to implement and must be easy to document in the EHR (both what was done and not done). Only then can one expect that quality measures will link to patient outcomes and that compliance with them can be tied to physician payment. But how do we continue to pursue excellence in the long term?   The breakthrough at Precision came when point-of-care (POC) charting was implemented. The Health Information Technology for Economic and Clinical Health Act of 2009, which is driving the adoption of EHRs, pre-supposes that clinicians conduct POC charting (completed in the room with the patient). No longer can clinicians frequent the “dictation closet” or chart at the end of the day. Only with POC charting are all of the advantages of EHR adoption achieved (ie, warnings about drug interactions). Since EHR uses structured language to help document compliance with CPGs, humans aren’t needed to review the charts. Weekly or daily reports can then be generated in order to provide more feedback, so there’s no lag time in identifying “lost opportunities” for improvement. All new patient consultations are now reviewed. Any patients living with venous, diabetic, or pressure ulcers (or other chronic leg ulcers) who do not have documentation of CPG implementation are brought to the clinician’s attention the following day. In addition, a report analyzing all new admits for that week is generated to ensure CPGs are being incorporated into the patient’s treatment plan. What gets measured gets managed. Since the EHR can automate these reports, it is not labor intensive and the results are easily extractable. This has truly harnessed the EHR to work with staff in this endeavor.

Lessons Learned

  Much was learned from the experience of linking the CPG implementation process to the EHR. The concept of utilizing national CPGs for ulcer care did not receive any objections by clinicians. By using macros in the form of pre-programmed menus in the EHR, clinicians could more easily comply with CPGs. However, the process had to be tweaked to further improve the flow and remove obstacles. Through consistent feedback, officials learned that the clinicians could modify old habits and adapt behaviors. Obstacles for success in this endeavor included POC documentation and clinician accountability. Without true POC charting (regardless of whether electronic or paper), clinicians can’t appropriately practice and document the care each patient deserves. Continued accountability for clinicians to document all considered decisions in the care of their patients will also align best practices in wound care. Another lesson learned: Feedback must be given frequently, even daily.

Further Improvements

  The next step at Precision will be to utilize EHR technology to share reminders with clinicians at the time they’re conducting their charting. Reminders will be provided before the user “signs off” the program (ie, “You’ve noted a venous ulcer as the problem. Did you consider compression therapy?”) Clinicians must embrace accountability and allow technology to assist them to do what’s needed. Continual measurement of compliance to the CPGs will keep this goal a priority and allow “proven outcomes” as the move to accountable care organizations (ACOs) occurs. According to another recent JAMA article: “Three features of EHRs are critical to enable ACOs to succeed: interoperability . . . automated real-time quality measurement, and smarter analytic capacities.”³ Patient quality of care and reimbursement for that care will depend on this proof of quality being provided. M. Darlene Carey is director of operations of Precision Health Care, Boca Raton, FL. She utilizes metric management to enhance performance and embraces workflow improvement to remove obstacles to success.

References

1. Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Rep Reg. 2010;18:154–158. 2. Cassel C, Jain S. Assessing individual physician performance, does measurement suppress motivation? JAMA. 2012;307(24):2595-2597. 3. Bitton A, Flier L, Jha A. Health information technology reform in the era of care delivery reform, to what end? JAMA. 12;307(24): 2593-2594.