IV. Findings (continued)

II. Integration and Delivery of the USPSTF Recommendations in Health Plans

2.1. Incorporating the USPSTF Recommendations into Practice

Delivery of the "A" and "B" USPSTF Recommendations. The USPSTF recommends that clinicians discuss the "A" and "B" recommendations with eligible patients and recommend them as a priority. According to the USPSTF, the "A" and "B" grades demonstrate that there is good or fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms. Respondents in each of the four plans were asked: "Are all or some of the services that are recommended by the Task Force, the "A" and "B" recommendations, being delivered throughout your health plan?"

Conversations with respondents indicated that the perception is that many of the "A" and "B" recommendations are being delivered in the health plans. The plans offer many, though not all, of the "A" and "B" recommendations to members. Additionally, many, though not all of the "A" and "B" recommendations are being integrated into each of the plans' clinical recommendations (discussed further in the section entitled "Integration of the USPSTF Recommendations"). Though we cannot determine whether the recommendations are being delivered in practice, respondents indicated that the "A" and "B" recommendations are a priority at their health plans.

Some respondents had difficulty commenting on the delivery of the recommendations because they were unfamiliar with which clinical preventive services recommendations are "A" and "B" recommendations. Others did not recognize the USPSTF grading scheme at all.

Another notable finding is that respondents indicated that some of the "A" and "B" recommendations are being delivered across health plans, but not due to the fact that they are highly recommended by the USPSTF. In the case of the hybrid plan, respondents suggested that several "A" and "B" recommendations are being delivered because they coincide with the National Committee on Quality Assurance (NCQA)'s Health Plan Employer Data and Information Set (HEDIS) measures. At the governmental plan, the "A" and "B" recommendations are being delivered because these recommendations were integrated into the plan's overall medical policy manual of performance measures. Interestingly, no respondents indicated that the "A" and "B" recommendations are being delivered because the USPSTF found good or fair evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.

Our discussions about the delivery of the recommendations in each of the plans are discussed in greater detail below.⁵⁹

Open-Panel Plan. Our interviews with open-panel plan respondents indicate that the perception is that some of the "A" and "B" recommendations for clinical preventive services are being delivered throughout the plan. The Medical Director for the plan answered that "as far as he/she knows, all of the "A" and "B" recommendations are being delivered. Several of the respondents had never heard of the "A" and "B" recommendations, including a Director of Quality Improvement. Other respondents from the open-panel plan indicated that the "A" and "B" USPSTF recommendations are "used sometimes" but could not comment on delivery.

Another Director of Quality Improvement from the plan could not say with certainty whether all or some of the recommendations were being delivered, but did provide us with prevention materials that reference the USPSTF Guide for Clinical Preventive Services, 2006. Through further review of the plan's prevention materials, located on the plan's Web site, we found that the open-panel plan's "Guide to Preventive Health Services" is the USPSTF Guide for Clinical Preventive Services, 2006. The plan provides a direct link to the USPSTF recommendations. This suggests that all of the USPSTF recommendations are made available and offered by the plan, though the level of delivery of the recommendations is less clear.

Closed-Panel Plan. Respondents from the closed-panel plan indicated that some, but not all, of the USPSTF's "A" and "B" recommendations are being delivered. Only one respondent, a Director of Quality Improvement, indicated that the vast majority of the "A" and "B" recommendations are being delivered. In fact, this respondent told us that the plan "basically adopted the USPSTF recommendations." At least six of the 12 respondents interviewed at the closed-panel plan said that some or most of the USPSTF recommendations are being delivered. Interestingly, other respondents were less certain about whether the recommendations are being delivered. Since the closed-panel plan has its own methodology for reviewing and adopting clinical preventive services recommendations, some respondents were unsure of whether the "A" and "B" recommendations aligned with the plan's guidelines. For example, several Directors of Quality Improvement and Clinical Advisors indicated that most, though not all, of the "A" and "B" recommendations are being delivered.

Hybrid Plan. According to the Director of Quality Improvement at the hybrid plan, all of the "A" and "B" recommendations are being offered to members; however, it is likely that only a certain subset are actually being delivered. At the hybrid plan, providers are only held accountable for the delivery of recommendations that are measured by the NCQA. Specifically, the Director of Quality Improvement at the hybrid plan indicated that many of the "A" and "B" USPSTF recommendations are being delivered because they overlap with HEDIS specifications. Providers at the hybrid plan are strongly incentivized to score well on the HEDIS measures, and as a result, only certain recommendations are a priority for the plan. Respondents provided several examples of "A" and "B" recommendations that are being delivered, including screenings for breast cancer screening, cervical cancer, colorectal cancer, and diabetes as well as adolescent and childhood immunizations. These services are also measured by HEDIS. Quality improvement staff indicated that the "A" and "B" recommendations that overlap with HEDIS specifications are being systematically implemented and measured. However, it is difficult to ascertain how many of the other "A" and "B" recommendations from the USPSTF are being implemented and measured, since providers are not held accountable for other recommendations. A Clinical Advisor at the hybrid plan estimated that many, but not all, of the "A" and "B" recommendations are being delivered.

Governmental Plan. Similar to the other plans, our conversations with respondents indicate that the perception is that the some of the "A" and "B" recommendations are being delivered. The Director of Quality Improvement for the plan was unfamiliar with the USPSTF's grading methodology, and could not comment on delivery. Similarly, two of the three Clinical Advisors and a Quality Improvement Staff member were unfamiliar with the USPSTF recommendations and the grading methodology. The majority of the respondents indicated that they were more familiar with the guideline terminology used by the governmental plan. One Clinical Advisor explained that the governmental plan develops its own highly sophisticated manual of performance measures, which incorporates many of the "A" and "B" USPSTF recommendations. The manual also draws from other sources of clinical preventive services recommendations. This may partly explain why the majority of the respondents from the governmental plan were unfamiliar with the USPSTF's "A" and "B" grading methodology. A Clinical Advisor and Quality Improvement Staff member provided a few examples of performance measures that coincide with the "A" and "B" recommendations: screenings for cervical cancer, breast cancer, colon cancer, and hypertension. Finally, one respondent said that the plan incorporates the "A" and "B" recommendations as much as possible.

Integration of the USPSTF Recommendations. In order to explore how the health plans integrate the USPSTF recommendations, we asked respondents: "Can you provide a few examples of how the recommendations are integrated?" We received a number of responses to this question. Three of the most common themes are presented in Exhibit 10 and discussed below.

Exhibit 10: Integration of USPSTF Recommendations

Means of Integration	Open-Panel Plan	Closed-Panel Plan	Hybrid Plan	Governmental Plan
1. Integrated into CPS manuals, measures, and publications	x	x	x	x
2. Integrated via health IT	x	x	x	x
3. Integrated into patient health education materials		x	x

1. The USPSTF recommendations are integrated in health plan provider manuals on clinical preventive services, performance measures, and/or other publications

• Health plan provider manuals. The open-panel plan integrates the USPSTF recommendations into its system by posting a direct link to the USPSTF recommendations for providers. The link is accessible when providers select "Preventive Health: Guide of Clinical Preventive Services" and directs the provider to AHRQ's pocket guide of USPSTF recommendations (http://www.ahrq.gov/clinic/pocketgd.htm). The open-panel plan also posted an electronic memo to providers that the plan "has adopted the Guide to Clinical Preventive Services, 2005 as [its] recommended best practice reference for clinical preventive services." The memo discusses that the plan "has created a direct link from [its] Web site... to be both convenient and helpful to [providers] in caring for [their] patients." The memo also explains that the publication was developed by the USPSTF as part of an AHRQ initiative, and is endorsed by the U.S. Department of Health and Human Services, the Public Health Service, the Office of Public Health and Science, and the Office of Disease Prevention and Health Promotion. In addition to the direct link to the recommendations, the open-panel plan posts an in-house phone extension for providers to call for copies of the USPSTF pocket guide.
• Health plan manuals of performance measures. The governmental plan produces a provider manual of performance measures that incorporate clinical preventive services. The USPSTF recommendations for influenza immunization, pneumococcal immunizations, breast cancer screening, cervical cancer screening, and colon cancer screening are integrated into the manual. For each of the USPSTF recommendations, the manual directly references the Task Force, providing a link to AHRQ's USPSTF Web site. The manual also contains a general discussion of the evidence supporting the USPSTF recommendations.
• Health plan publications. The closed-panel plan integrates the USPSTF recommendations into its quarterly journal publication for physicians and nurses. The Task Force is often referenced by the journal publication. References to the Task Force appear to begin in 2001, particularly within articles that address preventive health. Examples of USPSTF recommendations cited by the journal in recent publications include chemoprevention of breast cancer (2005 issue), screenings for major depression (2004 issue), and weight management (2003 issue).

2. The USPSTF recommendations are integrated electronically using health information technology tools such as electronic medical records (EMR), clinical reminders, and order sets for clinicians

The closed-panel plan, hybrid plan, and government plan integrate the USPSTF recommendations into their EMRs. The open-panel plan is less advanced in terms of its ability to integrate the CPS recommendations using health IT, as it currently does not have an EMR. The closed-plan, in particular, has a sophisticated EMR that integrates the USPSTF recommendations, such as mammography screening for breast cancer, and prompts physicians to recommend the service for eligible patients. The closed panel plan's EMR also has a clinical reminder application which prompts providers to deliver the appropriate screenings for patients. The governmental plan integrates clinical reminders and the hybrid plan utilizes order sets, a clinical decision support tool.

3. The USPSTF recommendations are incorporated into the plan's patient health education materials that are distributed to the member population

The hybrid plan utilized the USPSTF recommendations to inform the development of patient education materials distributed to the member population. The plan publishes a manual called "Preventive Health Guidelines for Members," which presents a series of clinical preventive services recommendations for members. The booklet was developed with input from the hybrid plan's participating providers, and based on recommendations from the USPSTF, the American Academy of Family Physicians, the American Academy of Pediatrics, and the Centers for Disease Control. The booklet presents clinical preventive services recommendations in three phases: birth-18 years, 19-64 years, and pregnancy. Adults 65 and older are covered in a separate manual. The booklet also provides recommendations related to all populations such as injury prevention, use of tobacco, alcohol, and other drugs, sexual behavioral, and managing diseases. The recommendations are presented in a concise manner for members. Furthermore, the booklet also discusses that the recommendations may not always be covered benefits, and therefore, the information should be discussed further with their providers.

2.2. Major Uses of Health Information Technology

Health IT plays a key role in the integration and delivery of clinical preventive services recommendations. For the purposes of this evaluation "information technology" is defined as: "The wide range of electronic devices and tools used to acquire, record, store, transfer, or transform data or information."⁶⁰ A robust body of empirical research suggests that health IT, and more specifically, clinical decision support systems, have the potential to significantly affect the cost, quality, efficiency, and safety of health care delivery."^61-62 Our interviews confirm the relevance of clinical decision support systems in health plans that implement clinical preventive services recommendations. Health plans use EMRs, clinical reminders, and other health information technology tools such as order sets to not only integrate and deliver the USPSTF recommendations, but also track and monitor the data for quality improvement purposes.

This section examines how health plans have used health IT to integrate and deliver clinical preventive services. We asked a series of questions on health IT and quality improvement to Directors of Health IT, Directors of Quality Improvement, Health IT Staff, Quality Improvement Staff, and Clinical Advisors. This section begins with a discussion of how health IT is utilized for clinical preventive services integration, specifically focusing on EMRs clinical reminders, and order sets.

Using Health IT to Integrate the USPSTF Recommendations. Each of the health plans uses health IT to integrate the USPSTF recommendations though their sophistication varies considerably. We asked respondents: "Can you provide some examples of how the Task Force recommendations are integrated into your health IT systems?" We also asked (1) whether the health plan provides clinical recommendations and (2) whether the plan has an EMR.

We found that health plans used health IT in similar ways to integrate the Task Force recommendations. However, the plans had differing capacities to use health IT. Governmental and closed-panel systems, where providers are employees of the plan, had the greatest integration of Task Force recommendations using health IT, followed by the hybrid system (in which approximately half of plan members access services through plan-affiliated providers and half through contracted providers). Finally, the open-panel system, which contracts with providers who may provide services under several health plans, had the least integration of the Task Force recommendations using health IT.

To explore these trends further, we briefly discuss the use of four key health IT tools: electronic medical records, community health records, clinical reminders, and order sets.

Electronic Medical Records. The majority of the health plans used EMRs, which are defined as "databases (or repositories) that contain the health information for patients within a given institution or organization."⁶³ EMRs contain the aggregated datasets gathered from a variety of clinical processes. Examples of data included are laboratory data, pharmacy data, patient registration data, radiology data, surgical procedures, clinic and inpatient notes, preventive care delivery, emergency department visits, and billing information.⁶⁴ Given that EMRs are purchased and utilized by health providers and provider networks, the integration of the Task Force recommendations into the EMRs varied greatly by type of health plan.

Governmental and closed-panel systems, where providers are employees of the plan, had the greatest integration. The governmental plan has a highly sophisticated EMR which enables providers to access records across the country through a remote process. The hybrid plan, in which approximately half of plan members access services through plan-affiliated providers, integrates Task Force recommendations into its EMR, but the scope is more limited as contracted providers (who provide services to members of multiple health plans) may not use the EMR. As a result, integration is less consistent, reaching only those members who seek services from plan-affiliated providers. A further complication is that some services are likely to be captured within the EMR, while others are not depending upon where the service is obtained (e.g., when a member seeks specialty care it may or may not be with a plan affiliated provider and as a result may or may not be captured). The open-panel system, which allows private physicians to contract with multiple health plans, does not currently have an EMR. The open-health plan is in the process of implementing a patient-centered community health record, which will enable providers to view patient health records and lab tests electronically.

Patient-Centered Community Health Record. A patient-centered community health record (CHR) allows multiple health care providers treating the same patient to view that patient's medical information via a secure Web site on the Internet. The CHR is different from an EMR because it connects health care providers to a centralized and secure source of patient information. The open-panel plan is in the process of implementing a CHR which will provide an electronic reserve of health care information for all members covered by the plan. Open-panel providers will be able to use the CHR to see member claims data, lab information, prescription drug information, and immunizations.

Clinical reminders. A clinical reminder is a clinical decision support application that can act on data in the EMR. Clinical reminders are one of many support features that makes relevant information available for clinical decision-making. Specifically, clinical reminders support the provision of preventive services by prompting providers to deliver recommended preventive services to eligible the physician that the patient is a candidate for mammography.

The governmental plan and the closed-panel plans use clinical reminders to support the delivery of preventive services from the Task Force. Traditionally, clinical reminders have been primarily mailed or faxed to providers. Today, the governmental and closed-panel plans have the ability to integrate clinical reminders directly into their EMRs, in effect, notifying plan providers at the point of service. A Clinical Advisor from the closed-panel plan indicated that "we use lots of alerts around preventive care—especially for clinical preventive services." Quality Improvement Staff members from the closed-panel plan indicated that electronic reminders are an important and useful tool for tracking the delivery of clinical preventive services: "From a practice-level, electronic reminders have helped teams and providers to realize all of the struggles they faced with manual tracking. They recognize how easy it is to lose things if they just write it down on a piece of paper."

The closed-panel plan is planning to implement clinical reminders for all of its recommended clinical preventive services. The governmental plan utilizes clinical reminders for physicians and nursing staff. For example, a Health IT Staff member indicated that certain clinical reminders target nurses, while others target social workers. While the hybrid plan has an EMR, the plan has limited ability to integrate clinical reminders for preventive services. The open-panel plan does not use clinical reminders. According to the Director of Health IT for the open-panel plan: "Other than the physician looking up and seeking that a service hasn't been performed, the system doesn't remind them."

Order Sets. The hybrid plan utilizes order sets, an electronic clinical decision support tool that can be directly integrated into the EMR. Order sets contain typical orders associated with clinical conditions. For example, for a particular clinical condition, an order set contains diagnosis information, relevant documentation, clinical orders, and patient instructions, follow-uo and level of service information. Order sets are used widely at the hybrid plan. According to one respondent: "Doctors can go in to the [order sets] and it brings up a list of orders or a list of questions they need to ask and answer based on diagnoses. It drives the decision-making." Order sets are not to be confused with clinical reminders, as the order set does not prompt the physician to provide a service through the EMR (e.g. mammography). Currently the plan does not operate order sets for all of its clinical preventive services recommendations.

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