The Case for Centralized Quality Reporting: A Perfect Example

The Case for Centralized Quality Reporting: A Perfect Example’ TimeQuality measure reporting is one of the 3 basic tenets of the EHR Incentive Program—the other 2 being ePrescribing and data sharing (interoperability)—as identified in ARRA, the program’s defining legislation. It is a key component to improving the quality of patient care. In a recent EMR Straight Talk post—“A Waste of Physicians’ Money and Vendors’ Time”—I proposed a more cost-effective method of analyzing clinical quality measure (CQM) data that would deliver more useful information for quality improvement than the approach currently in place for meaningful use. I suggested that rather than requiring each of the 472 vendors of certified EHRs to program the same CQMs (no longer 125 as initially proposed, but still a burdensome 64), EHRs should simply collect and report the data, and CMS or its designate should provide the analytics. Such a centralized approach would not only be more efficient, but it would produce more consistent and reliable data. Most importantly, it would allow for the immediate implementation of any changes to measure specifications as necessitated by the availability of new medical information.

Recently, I confronted a perfect example of the ineffectiveness of the current system and the opportunities that a centralized approach would afford. A physician informed me that a new CVX (immunization) code was created for the influenza vaccine—CVX code 144. While I told this client that we could easily add this code to the EHR for his use in documenting vaccinations (which we did), these vaccinations would unfortunately still not be reflected in the numerator for NQF 0041 (Preventive Care and Screening: Influenza Immunization for Patients over Age 50)—a fact validated by CMS. New electronic specifications for CQMs will not be implemented until 2014, and the current specifications remain in force for 2012 and 2013.

As an EHR vendor, I certainly appreciate the fact that we are not subject to the expectation that we will reprogram measures off-cycle. That would wreak havoc with our development roadmap and resource planning. Furthermore, changing the calculations to accommodate the new codes would compromise data comparability. So now we have comparable—but incorrect—data that does not reflect actual vaccination status. Under this system, how will we ever stay current as medicine constantly evolves?

Just imagine if everyone could begin using the new CVX codes immediately because the electronic specifications were updated in one centralized location with one effort. This is just one example from a potential 64 CQMs. How much more value would we derive from all the work that we demand of physicians in capturing the CQM data? How can we accelerate healthcare improvement if we are always 2–3 years behind?

Here’s Proof: Your Time is Worth More Than You Think

When I speak with physicians and share with them this calculator, they are astonished to see the true value of their time.

Physician productivity is a major driver of practice revenue and profitability. Today’s rising practice costs, a more challenging reimbursement environment, the looming payment reform, a physician shortage, and the aging baby-boomer population make productivity increasingly critical. Whether you are comparing an EMR to paper charts, one traditional EMR to another, or a point-and-click EMR to a hybrid EMR, seconds count.

Last week, I suggested benchmarking to compare the relative effects on productivity of the different EMRs a practice might be considering. My EMR Reform plan includes “click” comparisons as a “report card” measure of efficiency. It may sound trivial—a few clicks more or less, or a few seconds here and there, couldn’t have much of an impact. But they do.

Consider this: approximately 80% of clinical workflow consists of the repetitive performance by physicians and medical assistants of 20% of their tasks. If generating a prescription requires 8 clicks in one EMR and 3 clicks in another, and each click takes just one second of a physician’s time, every prescription written has a potential impact—positive or negative—of 5 seconds on physician productivity. Add in the differential for other common workflows such as reviewing chart notes, sending a message, or reviewing and signing a test result (number of clicks, number of screens that must be navigated, etc.), and it is reasonable to assume that you can increase—or decrease—productivity by 30 seconds per exam, depending on the technology you choose.

For a typical orthopaedic surgeon who generates $1.1 million in revenue by seeing 125 patients per week, conducting office hours 20 hours per week, and taking 5 weeks of vacation, this 30-second-per-exam increase in productivity would enable this physician to generate an additional $57,000 per year (or $285,000 over 5 years). Conversely, an EMR that decreases productivity by 30 seconds per exam would cost this physician $285,000 over 5 years. Because this represents marginal revenue, it goes straight to the bottom line as almost entirely profit (or loss).

What Is a Hybrid EMR?

The continued success of hybrid EMR has prompted extensive debate about what actually constitutes one. While the Internet is now filled with discussions about EMRs, the number of conversations regarding hybrid EMRs has exploded. People are always asking me what it is that makes hybrid EMRs work so well and how they are different from traditional (CCHIT-type) EMRs. This is the first in a series of 3 discussions that will address this subject.

A hybrid EMR is a high-performance EMR that is successful in high-performance practices.

In 1997, SRS created the first hybrid EMR, concentrating on performance-driven practices, where high-volume physicians demanded unencumbered productivity. As others have followed our lead, hybrid EMRs continue to be designed with efficiency and speed in mind. This emphasis on performance criteria contrasts sharply with traditional EMRs. As a reading of the CCHIT criteria reveals, traditional EMRs are constructed for lower-volume, primary care practices where speed is not a primary driver.

SRS has built the largest national network of high-performance practices that successfully use an EMR. Our development process is driven by these practices and we work to facilitate the sharing of best practices among them.

In the next segment of the series, I will share my thoughts on a key defining characteristic of high-performance hybrid EMR—high usability.

A Physician’s Voice

It is one thing for me to describe the limitations of traditional (CCHIT-type) EMRs. After all, I have a vested interest in a hybrid EMR. I have devoted 12 years of my life to developing a type of EMR that reflects the physician’s voice and that offers benefits for workflow and quality of patient care. I could be accused of being biased. I would therefore like to share with you an opinion piece published last week in the New York Times, “The Computer Will See You Now,” in which Dr. Anne Armstrong-Coben, a clinical professor of pediatrics at Columbia, shares her personal experiences with a traditional EMR. This one user has hit the nail on the head when she concludes that “the computer depersonalizes medicine.” Her comments support the conclusions presented in the New England Journal of Medicine article, “Avoiding the Pitfalls of Going Electronic.”

Dr. Armstrong-Coben struggles to keep the computer from interfering with her ability to connect with her patients. “I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me.” She describes a chart produced by her traditional EMR as “a generic outline, screens filled with clicked boxes.” She recognizes that these charts are incapable of capturing the nuances that are so important to high-quality diagnosis and treatment. Dr. Armstrong-Coben suggests that alternatives like a hybrid EMR might be a better solution.

I maintain that the computer is a wonderful tool, but for most users it requires a conscious effort. Dictating an exam or writing on a piece of paper is more intuitive and efficient for most doctors. Computers force physicians to tear themselves away from their patients, shift their focus to a computer screen and interface with a keyboard and mouse. Doing so requires deliberate effort to navigate oftentimes-complex screens containing a myriad of dropdowns, check boxes and text boxes. The computer distracts the physician and dilutes the physician-patient encounter—unless the EMR is designed to allow physicians to practice and document exams as they have always done and are comfortable doing. That is what distinguishes the hybrid EMR from traditional EMRs.

With precision, Dr. Armstrong-Coben has identified the crux of the EMR-adoption problem.