Appendix B: Summaries
of PFQ Grantee Activities (continued)
PFQ Grant Summary: Effecting Change in Chronic Care: The Tipping Point
Lead Organization: American Medical Association (AMA)
Partner Team: Iowa Foundation for Medical Care (IFMC), Northwestern University,
Cook County Bureau of Health Services, United Healthcare Group
(UHC), Midwest Heart Specialists (MHS), Pittsburgh Regional
Healthcare Initiative (PRHI) and others
Title: Effecting Change in Chronic Care: The Tipping Point
Topic Area: Improving care processes and outcomes for chronic conditions
Principal Investigators: Karen Kmetik, PhD
AHRQ Project Officer: Cynthia Palmer
Total Cumulative Award: $1,211,074
Funding Period: 9/2002–9/2006
Project Status: Completed 9/29/2006
1. Project
Description
Goals. The goal of this project was to achieve a "tipping point" in quality
improvement in caring for patients with chronic illness—specifically adult
diabetes, coronary artery disease (CAD), and major depressive disorder (MDD)—by
advancing the widespread use of physician performance measures in various
settings. The primary interventions/tools for the project are measures
developed by the Physician Consortium for Performance Improvement, which is
convened by the American Medical Association (AMA), and the National Diabetes
Quality Improvement Alliance.
The
project originally aimed to test two approaches to collecting data on physician
performance. One would establish a regional data warehouse for pooling payer
claims data (United, Blue Cross, and CMS) in the Pittsburgh area and allow
physicians to retrieve the data to assess their own performance (the "Community
Model"). The other involved the electronic transfer of data from physician
offices and laboratories to a central data repository in the Midwest (the
"Practice Model"). The project planned to examine the impact of the two models
on improved care processes and outcomes, identify implementation issues and challenges,
and determine what would be necessary both to roll out the models nationwide
and sustain participation by key partners.
Activities and
Progress
Year
1. In the first year, the project standardized the performance measures and
tools for diabetes, CAD, and MDD, and began to pilot test two different models
that could be used to provide physicians with performance measurement data at
the point of care. The Pittsburgh Regional Healthcare Initiative (PRHI), one of
the project partners, began to test the Community Model, which would compile
data from health plans, laboratories, and a QIO to "pre-populate" a community
data registry for physician retrieval. The Iowa Foundation for Medical Care
(IFMC), another project partner, began to test the Practice Model, in which
physician practices would generate data and send the information to a QIO or
health plan for quality oversight purposes. Both models used the agreed-upon
standardized performance measures.
PRHI
secured the commitment of five primary care physician practices with a total of
111 physicians providing care to more than 250,000 patients to participate in
the pilot test. PRHI met with practicing physicians, health plans, and
laboratories to identify data capabilities and then secured preliminary
agreements from some payers for integrating data from multiple sources into a
regional community database called the Pittsburgh Health Information Network
(PHIN) overseen by the Pennsylvania QIO. Physicians would be able to access
patient data stored in the registry in standardized reports.
IFMC
secured the participation of four cardiology practices, a family medicine
practice, and an internal medicine clinic; 79 physicians from the cardiology
practices agreed to collect data for the CAD measures and 22 family
practitioners, and 2 PAs and 3 internists agreed to collect data for the MDD
measures. An assessment of the practices' current data capabilities found that
the practices were at various stages of implementing electronic health record
systems (EHRS). The four cardiology practices collected baseline data and
initiated ongoing collection of patient data.
Year
2. In the second year, IFMC's arm of the project progressed; the practices
that used EHRS successfully integrated the CAD performance measures into their
systems. The paper-based practice sites struggled to integrate data collection
into routine care, highlighting the significant advantage afforded to EHRS
users in entering and retrieving treatment data, and in managing the care of
patients. Based on this experience, the project decided to focus exclusively on
the collection and reporting of data electronically, either using a data
registry or the EHRS.
Year
3. Problems in implementing the PRHI community model that emerged in year
2 caused this component to be discontinued in the third project year. Project
leaders failed to secure the participation of the University of Pittsburgh Medical Center Health Plan and CMS to contribute to the data warehouse because of
legal concerns about data privacy. Without these vital sources of clinical data
for the registry, the PHIN was not likely to be widely used in the community.
In addition, the project did not have enough financial resources to build the
health information network, technical problems emerged in its design, and doubt
arose about the usability of the system by physicians.
While
work on the Community Model ended, the project realized that expansion of the
Practice Model would be needed to truly reach a "tipping point" in improving
the care of patients with chronic illness. Thus, the project expanded its
activities to (1) include more practice sites (e.g., community clinics) with
different EHR systems, (2) demonstrate the validity of physician performance
data collected, and (3) provide concrete examples of both the data extraction
process from physician offices' EHRS and the exportation of the data to other
private and public users.
Two
new partners were brought on board to allow for this expansion in the project
work. The project partnered with Cook County Bureau of Health Services to
conduct a disease registry pilot to show how quality measures could be
integrated into a commercial electronic disease registry system (DocSite) that
would allow for data collection, monitoring and improvement of patient care,
and provision of population-based feedback reports to participating physicians
and clinics. Northwestern University came on as a partner to work on a data
validity pilot to implement and validate heart failure (HF) measures for an
existing commercial EHRS (EPIC). Midwest Heart Specialists (MHS), a large
cardiology practice that was already involved in the project, worked with IFMC
and United Healthcare (UHC) to begin a data export pilot that involved
extracting data from an EHRS and exporting it to IFMC and UHC, using the HL7
file format which has been endorsed by HHS and CMS as the federal messaging
standard.
Year 4. The
final project year focused on publication of results from the performance
measures testing, validation work, and other implementation efforts, as well as
meetings to discuss the significance of the work and how it could be sustained
through, for example, the AMA's Cardio-Health Information Technology (HIT)
project.
2. Partnership
Structure/Function
AMA
served as the leader or convener for this partnership, which involved many
different organizations over the course of the four-year project. Partners
included payers (United Healthcare, CMS, and BCBSA), physician groups, a QIO, a
community health care coalition, an employer health coalition, and a
county-based system of ambulatory care clinics. AMA organized the partners'
resources into one or more of the project components and contracted with some
partners to support the work. AMA also convened all-partner meetings via
monthly phone calls as well as annual in-person meetings to share progress
reports and lessons learned. As the project progressed, all-partner phone calls
continued to occur at least quarterly but have begun to taper off as project
activities began to wind down and partners became involved in spin-off
projects.
Of
the initial project partners, PRHI and MBGH ended their involvement in the
project either because their part of the work came to an end or the organization's
priorities changed. United Healthcare, Northwestern University, and Cook County's Bureau of Healthcare Services came on as partners in later years of the
project as work expanded.
Table 1. Major Partner Organizations and Roles in the Project
|
Organization |
Role in Project |
Lead Organization (grant recipient) |
American Medical Association
(AMA)
|
Lead and coordinate the project, provide the
evidence-based performance tools and
interventions
|
Key
Collaborators |
Pittsburgh Regional Healthcare
Initiative (PRHI)—ended
participation when the Pittsburgh
Health Information Network failed to
become operational
Iowa Foundation for Medical Care
(IFMC)
(QIO for Iowa and other states)
United Healthcare/Ingenix CMS and Blue Cross and Blue Shield
Association |
Regional partner that served as the lead for testing
the Community Model; identified and recruited
physician practices to participate in pilot testing
Regional partner served as the lead for testing the
Practice Model; tested information tools for CAD
and MDD; identified and recruited physicians
practices to participate in pilot test; involved in
data export pilot with MHS and UHC Involved in data export pilot with IFMC and UHC
"Connectors" to other organizations to promote
dissemination grantee efforts
|
Target Organizations |
3 ambulatory care practices or
networks in the Chicago region:
Midwest Heart Specialists (MHS);
Northwestern University General
Internal Medicine/Medical Faculty
Foundation; Ambulatory and
Community Health Network/Cook
County Bureau of Health Services
|
Participate in the pilot tests of information
technology and tools to assess adherence to
performance measures for chronic diseases
|
3. Project Evaluation and Outcomes/Results
The project learned through the Practice Model that
getting physicians to use performance measures to improve care worked best in
practices that had an existing EHRS. According to the RAND evaluation report
after the third project year, AMA came to recognize that achieving a "tipping
point" in advancing widespread use of physician performance measures requires
(1) involving more practice sites in collecting data through different types of
electronic health record systems, (2) demonstrating the validity of physician
performance data that are collected, and (3) showing how the data extracted
from physician office EHRS can be easily exported to a wide array of public and
private users.
The interim RAND evaluation report, however, stated
that the project's experience has not addressed some challenges faced by
physician practices that want to take advantage of current technologies to
measure their performance against AMA quality standards: (1) how to incorporate
the Consortium's measures in physician office-based EHRS so that data on the
measures can be generated by the system, and (2) exporting the data to a health
plan or other party in a useable fashion. The evaluation indicated that the
experiences of the three pilots—disease registry, data validation pilot, and
data export pilot—are inconclusive on both these issues. However, physician
offices and clinics using the Consortium's measures in EHRS and disease
registries report that they have seen, at least to some degree, process
improvements and positive patient outcomes. While these results cannot be definitively
attributed to use of the Consortium's measures, the RAND evaluation concluded
that it is reasonable to believe the measures had at least some positive
marginal impact.
Individual results from the three pilot studies
include:
- Data export
pilot—After experiencing difficulty with the data format, MHS successfully
transferred a data file with "dummy" clinical performance data. One of the
organizations receiving the data viewed the pilot project as successful since
it demonstrated the ability to export clinical performance data from an EHRS to
a QIO. However, the other organization that received the data did not view the
pilot project as positively due to the problems it encountered with the format
of the data that was transferred, which made it less useful to them.
- MHS successfully
integrated Consortium measures into home-grown EHRS and has begun to provide
tracking reports from data collected on Consortium measures to practice
physicians. Validity testing for the Consortium measures was ongoing and a
manuscript of results was in development as of June 2006.
- Data validation
pilot—The Northwestern team has been able to integrate Consortium measures into
its commercial EHRS and generate performance data using HF measures and CAD
measures. Northwestern has been focused on educating their physicians on how
to document and enter patient information into the system and are working on
process and workflow redesign. Eventually, they hope to provide physicians with
performance reports. Northwestern's validation work has helped the AMA refine
its sets of HF and CAD measures. Two papers on the results of the validation
pilot have been written and submitted for publication.
- Disease registry
pilot—Cook County has integrated the Consortium's asthma and the Alliance's diabetes measures in a commercial electronic disease registry. Participating
ambulatory clinics have begun to use the measures to do population-based care
management. While the measures have been fully integrated in the disease
registry, inputting necessary data into the system remains a work in progress.
The RAND evaluation indicated that the measures have positively impacted
physicians in the nine participating primary care clinics. Many of the physicians
report that the registry has helped them provide higher level of care, as
evident in improving performance measures, decreasing number of patients in the
high-risk group and increasing number of patients in the low-risk group. Cook County is working to link its disease registry in its ambulatory setting to its
commercial EHRS in its inpatient setting.
Another important result of the project was a June
2006 meeting convened by AMA with 25 electronic medical record vendors, CMS,
and a Northwestern co-investigator to discuss improvements that could be made
to electronic health record systems and products, which would make it easier
for physician practice use.
4. Major Products
- O'Toole MF, Kmetik KS, Bossley H, et. al. Electronic health record systems: the vehicle for
implementing performance measures. Am Heart Hosp J. 2005; 3:88-93.
- Two papers
written by Northwestern that have been submitted for publication.
- A paper being
written by MHS.
- A paper being
written by Cook County RAND's third-year evaluation of the project.
5. Potential for Sustainability/Expansion after PFQ
Grant Ends
The success of MHS in implementing the Consortium's
CAD measures in an EHRS launched a follow-on project called
"Cardio-HIT—Physicians Advancing HIT to Improve Care", which was also funded by
AHRQ and led by the AMA and MHS. The three-year project plans to spread the MHS
model to six other physician practice sites in four different regions, using
different EHRS systems. The project hopes to establish a data warehouse to
enable feedback reports and benchmarking to support physician-directed quality
improvement. The seven practices will also work to integrate other Consortium
measures into their systems. AMA also recently received a two-year grant from
the Physicians Foundation for Health Systems Excellence, to continue working
with MHS and Northwestern and add four more sites, each with different
electronic record systems. Thus, the partnerships established between the AMA,
Midwest Heart Specialists, and Northwestern will continue with these two
projects.
Return to Appendix B Contents
PFQ Grant Summary: Long Term Care Quality Improvement Partnership
Lead Organization: American Medical Directors Association Foundation (AMDA-F)
Partner Team: Quality Partners of Rhode Island; 20 national organizations represented
in the National LTC Quality Coalition, and state or local chapters
Title: Long Term Care Quality Improvement Partnership
Topic Area: Improve implementation of AMDA Clinical Practice Guidelines for pain
management and pressure ulcer reduction in long-term care (LTC)
nursing facilities
Principal Investigators: David Polakoff, MD, MSc, CMD, Senior Vice President and Chief
Medical Officer, Genesis HealthCare Corporation. Co-PI is David
Gifford, MD, MPH, formerly with Quality Partners of Rhode Island, the
QIO support center for CMS' nursing home quality improvement
initiative, and currently Director, Rhode Island Department of Health
AHRQ Project Officer: Judy Sangl, ScD
Total Cumulative Award: $1,299,164
Funding Period: 9/2002–9/2006
Project Status: Completed 9/29/2006
1. Project
Description
Goals. This
project sought to determine the effectiveness of an approach for training
nursing home staff to implement clinical practice guidelines developed by the
American Medical Directors Association (AMDA), and to evaluate nursing homes'
experiences and lessons learned in using implementation toolkits. The specific
goals of the project were to (1) develop a Long-Term Care Quality Improvement
(LTC-QI) partnership that will enhance the quality of care and quality of life
for nursing facility residents; (2) create
national and local partnerships with LTC professional organizations, Quality
Improvement Organizations (QIOs), long-term care facilities, and a national
research network of more than 200 nursing facility medical directors to
disseminate toolkits that translate AMDA clinical practice guidelines (CPGs)
into practice; (3) identify and train interdisciplinary educators and mentors
in six states to provide onsite CPG and CPG toolkit implementation training for
5 to 10 nursing facilities in each state (50 total); (4) collect and/or analyze
data on both process and clinical indicators in the participating facilities to
determine the effectiveness of the CPG implementation model and identify how it
can be replicated independently in nursing homes; and (5) disseminate the model
and refined toolkits in both online and print versions.
Activities
and Progress. During the first year, the project created the National
Quality Coalition, consisting of 15 partners, including representatives of
nursing home associations (AHCA and AAHSA), the national QIO association
(AHQA), AMDA members, and other key stakeholders. The Coalition advised the
project on criteria for nursing homes participating in the project, strategies
to recruit nursing facilities, which states to target, and other key design and
implementation issues. Six states were selected for the project: California, Florida, Indiana, Ohio, Pennsylvania, and Texas.
The
project leadership team (the PI and Co-PI, AMDA Foundation staff, and Quality
Partners of Rhode Island) selected two CPGs—pain management and pressure ulcer
reduction—as the focuses for CPG implementation. These clinical topics had been
targeted for nursing home improvement nationally by CMS and were publicly reported
on CMS' Nursing Home Compare Web site. Quality Partners helped to develop a plan
for project implementation, specified indicators of CPG implementation,
selected data elements for program evaluation, and created a "readiness matrix"
to select participating nursing facilities.
In
the second year, facility recruitment began, and the selected long-term care
facilities designated project teams consisting of the nursing home
administrator, medical director, director of nursing, a data liaison, and
others. These teams participated in short (one day or less) training programs,
run by state nurse consultants who were themselves trained by the AMDA
Foundation Project Coordinator and Quality Partners staff. Training consisted
of review of the two guidelines, and guidance on how to initiate and manage
organizational changes to promote adherence. AMDA developed CPG implementation
toolkits that included sample letters/memoranda to staff. The implementation
training program was piloted during the 2004 AMDA symposium, and the
implementation program and CPG toolkits were piloted with six facilities in Pennsylvania. In the pilot state of Pennsylvania, CPG implementation training was provided
jointly to all participating teams, but in other states, nurse coordinators
provided (to the extent possible) facility-specific training sessions for staff
teams.
The
project team encountered unexpected problems and delays in recruiting
facilities, which led to the loosening of some participation criteria,
extension of recruitment areas to entire states rather than metropolitan
regions, and allowing "rolling" enrollment. The project developed a web-based
data reporting system and began collecting baseline data from participating
facilities. Data on the CPG implementation process were to be collected at
11-and 18-weeks post-training, whereas data on clinical measures were to be
collected at baseline, and at 9- and 15-months post-training.
Program
staff and partners in the National Quality Coalition made efforts to marshal
support from state and local chapters of the national organizations to assist
change in participating facilities, but generally were not successful due to
limited capacity on the part of state and local chapters. By the beginning of
the fourth year (October 2005), 54 facilities had been recruited, but some
dropped out before receiving training or submitting baseline data, and others
withdrew from the study due to changes in management or failure to submit
follow-up data. In April 2006, 40 facilities were formally enrolled in the
project and are expected to submit data for the evaluation.
2. Partnership
Structure/Function
The project
leadership team included AMDA, AMDA Foundation and its Research Network, and
Quality Partners. The team held frequent conference calls and meetings. The
National Quality Coalition had annual meetings and, in the first year or two,
quarterly conference calls, during which they provided input to the Leadership
Team on project design issues. On a more informal basis, they communicated with
state chapters and affiliates about the project, identified individuals in the
selected states to serve as trainers; and provided forums at their national or
state meetings to educate members about the project and recruit facilities for
participation. The national partners also disseminated information about
project activities through publications, Web sites, and listservs. The original
plan called for the identification of existing state and local coalitions to
assist with recruitment of facilities and support dissemination of the toolkits
and CPGs once the study was complete. Existing coalitions (or 'ready'
coalitions) were to be identified in each of the six states, and were to play
an active role in each phase of the study. Instead, only a few isolated local
chapters of the national organizations in some of the states offered assistance
to the participating facilities and teams.
Table 1. Major Partner Organizations and Roles in the Project
|
Organization |
Role in Project |
Lead Organization (grant recipient) |
AMDA Foundation (Janet
Pailet, Project Director)
|
Overall grant management; coordinate implementation of
activities at the local level, including CPG implementation;
create communication and dissemination plan
|
Key
Collaborators |
AMDA
AMDA Foundation
Research Network
American Health Quality
Association
Quality Partners of Rhode
Island
National LTC Coalition (15
partners)
|
Provide clinical and executive leadership; work with CPG
Steering Committee to create toolkits for pain and pressure
ulcers; foster local partnerships
Support for evaluation component (implementation and data
collection at facilities)
Liaison to QIOs—provide info about project and facilitates
participation; holds forums for training and disseminating
info
Subcontract for Technical Assistance; oversee evaluation
and analysis of implementation in participating facilities
Advise the project on criteria for nursing homes
participating in the project, strategies to recruit nursing
facilities, which states to target, and other key design and
implementation issues
|
Target Organizations |
40-50 nursing homes in 6
states (CA, FL, IN, TX,
OH, and PA)
|
Receive CPG implementation training and submit data to
evaluate changes in processes of care and outcomes, as well
as resource utilization
|
3. Project Evaluation and Outcomes/Results
The project collects process of care data through a
web-based system and examines clinical outcomes. A separate, non-web based data
collection effort gathers information about the CPG implementation process,
including the amount of staff time spent on different tasks, the number of
staff on the implementation team, compliance with each phase or component of
the implementation process, and usefulness of the toolkit elements. No
preliminary results were available when this summary was written (October 2006).
4. Major Products
A manuscript, "Strategies for overcoming barriers to
recruitment and enrollment of nursing homes in a national clinical practice
guideline (CPG) implementation study" is in final preparation, and plans
include manuscript development after data analysis is completed. Articles
about the project and the pilot states appeared in state LTC association
newsletters, trade journals and newsletters, and a few local newspapers.
Project staff also wrote and issued a monthly e-mail newsletter, distributed to
about 35 individuals and organizations, including those on the National LTC
Quality Coalition.
5. Potential for Sustainability/Expansion after PFQ
Grant Ends
The CPG implementation process is designed to be
sustainable, in that the intervention involves only a modest amount of initial
training and consultation by the state nurse coordinators. For facilities that
wish to implement CPGs, AMDA sells an implementation manual, which is available
to any nursing facility at a modest price. But the motivation for using the CPG
implementation manual and toolkits depends on evidence showing that their use
contributes to tangible improvements in quality of care measures. Those who
received training to be CPG implementation trainers also may be resources for
the state QIO or other nursing homes that wish to utilize their expertise.
Those QIOs that were involved in the project in the six states are more likely
to promote this approach as part of their overall nursing home quality
improvement activities.
The National Quality Coalition established by the
project involves organizations whose mission includes promoting quality of care
improvements in long-term care facilities. Although the coalition itself may or
may not last beyond the end of the project, communication and coordination
among the members are likely to continue regarding related activities. At the
end of the AHRQ grant period, the project was testing the feasibility of
transitioning the NQC to a Research Advisory Board for the AMDA-Foundation
Research Network.
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