The Quality Equation

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His physician wit crackling, Joel C. Berman, M.D., dubs pay-for-performance programs as “pennies for performance.” According to Berman, a family physician at the Concord (N.H.) Hospital Physician Group, the financial incentives many health plans offer in their P4P programs are inadequate to entice medical groups to participate given the high cost of purchasing an electronic medical record system—a virtual prerequisite to measure and uphold quality.

Even providers who can afford EMR technology discover that adapting it to improve care quality is a difficult undertaking. Berman’s long-automated group participated in a diabetes quality improvement program sponsored by the National Committee for Quality Assurance, winning recognition in September 2004 after a yearlong effort for outstanding care. Supported by the EMR, the 30-physician practice boosted performance outcomes across all 11 NCQA measures, which have been adopted by Medicare in its national P4P pilot projects.

But even with the EMR tools in place, Berman recalls, getting those improvements took concerted effort largely because of one variable: patients. If P4P programs overlook one thing, it is that improved outcomes depend on patient compliance. For example, one of Berman’s physician colleagues consistently produced desirable blood pressure results among his patients, regardless of how sick they were. Only after extensive conversations with the physician did Berman learn his colleague’s secret. “It was not rocket science, but a frame of mind,” Berman says. “He was focused on blood pressure, and very aggressive in adding a second or third medication. There is a natural resistance to prescribing additional meds, and we get seduced by patient pleas not to. Patients string us along and we let it go. But my partner would not take no for an answer.”

Ultimately, the EMR is adept at prompting physicians to order tests and helping them keep tabs on results, but the effort can be for naught without active patient management. “You can’t participate in a P4P program without an EMR,” says Mike House, the chief information officer at Cheshire Medical Center/Dartmouth Hitchcock Keene (N.H), part of Dartmouth Hitchcock Health System. “The EMR can facilitate data capture, but you must set up mechanisms to engage patients.”

Keeping tabs

In April, Dartmouth Hitchcock Health System wrapped up its first year in a P4P demonstration project funded by Medicare, one of 10 taking place nationwide, House says. With 100 multispecialty physicians, Cheshire Medical Center is one of three group practices joining the effort at Dartmouth, which stands to receive up to $4 million in bonus payments from Medicare if quality measures for diabetes, congestive heart failure and coronary disease are upheld during the three-year program. Although Medicare is still crunching the first year’s data, House is convinced that performance has improved. “We know our documentation has improved,” he says. “And we have seen hospital admissions and readmissions for diabetics go down.”

Using an EMR from Chicago-based Allscripts, Cheshire Medical Center is keeping tabs on some 4,500 diabetic patients, tracking 22 measures required by Medicare. “You have to be religious in documenting problems in the EMR, especially comorbidities,” House says. “You also need to get physicians in the habit of reviewing disease-state measures even when the patient is there for another reason.”

The $3 million EMR technology includes a patient portal, which boosts communications with physicians with secure messaging, House says. For example, patients can send their physicians electronic queries about concerns over rising blood sugar results, a critical component of keeping diabetes in check. In one case, a patient sent a 4 a.m. note to his physician, complaining about not feeling well and including blood sugar scores. Later that morning, the physician responded with suggestions about insulin intake, averting a possibly serious complication.

Monitoring patients

But more than electronic tools are needed, House cautions. Cheshire appointed a nurse to work directly with a core group of 200 at-risk diabetes patients, House says. “You have to constantly go after patients to cajole them back into self-management,” he says. Cheshire’s nurse manager would spend up to 45 minutes on the phone with each patient, falling far short of the number of daily contacts the medical group figured she could make.

Improved clinical outcomes may depend on altering patient behavior, but caregivers still must take the lead. And EMR technology, by capturing performance data, can be a reminder to healthcare providers who are failing to do basic interventions for patients with chronic diseases. For the Concord physician group, the EMR’s ability to trap collective data was a real eye-opener, Berman says. After doing its initial analysis of physician performance, the group found it was lagging in several areas besides ordering eye exams. “We popped our superiority bubble,” Berman says. “The more you measure, the more you realize how you overestimate how well you were doing.”

For his part, House would like to expand Cheshire’s capacity to analyze physician performance data. Cheshire can extract collective performance data by writing its own database queries, a time-consuming effort. Allscripts offers a module that can streamline report writing against its clinical database, but it costs about $250,000, according to House. Still, the investment might be a good bet, he says. “Once you shine a light on your performance, it is amazing the results you get. We created some friendly competition among our physicians, and it was amazing how fast the numbers improved.”

Gary Baldwin is technology editor of HealthLeaders magazine. He can be reached at




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