Organizing Quality Improvement

June 24, 2011
A little more than two years ago, Antonio Linares, M.D., and his team at Lumetra, a quality improvement organization (QIO) based in San Francisco,

A little more than two years ago, Antonio Linares, M.D., and his team at Lumetra, a quality improvement organization (QIO) based in San Francisco, were tapped by the Centers for Medicare and Medicaid Services (CMS) to answer a question that was essential to its quality improvement plans: What type of program would be most effective in encouraging small- and medium-sized physician groups to adopt electronic medical records (EMRs)?

Evaluation of outcome management among CMS' beneficiaries would be seriously limited without auto-mated point-of-care data feeds from the majority of caregivers. Few facts were available when Lumetra began its special study aimed at promoting EMR adoption. Indeed, when Linares took charge of the multistate, two-year project dubbed Doctor Office Quality Information Technology (DOQ-IT), what constituted small- and medium-sized practices hadn't even been defined, let alone how these groups would utilize EMRs. That was September 2003.

"Linares says he and his team knew they were "on a new frontier" with the project. "We were beginning to pioneer activities that were in uncharted waters, [because] most of the data nationally came from large medical groups" with more than 20, often more than 50, physicians. First, they defined a small practice as consisting of one to three physicians and a medium-size practice as four to nine physicians. Next, they identified needs and created a network model.

To date, Linares and colleagues have disseminated tools and training to all states and territories, and approximately 40 vendors have signed on to deliver compliant products.

In addition to identifying the data that would foster adoption, and offering support to physician offices, a major component of the DOQ-IT initiative was to create models that could be scaled to other states. Four states were involved in this first phase: Arkansas, California, Massachusetts and Utah. Linares had to ensure that the model was applicable not only in California, where Lumetra is the designated Medicare QIO, but also in other states with different demographic needs and models of practice.

The final component of the DOQ-IT initiative was to develop nationwide training. The Knowledge Development Program kicked off in September 2004 with nearly 100 percent participation by representatives from all states plus the territories of the Virgin Islands, Puerto Rico and Guam.

The DOQ-IT program offers physicians free consultations across a spectrum of needs, all focusing on the EMR. The EMR adoption process is broken down into three major components: office readiness, needs assessment and workflow appraisal; vendor evaluation, contracting and system implementation; and optimization of EMR-generated data.

DOQ-IT support also includes redesigning care delivery to improve care management for the six CMS-specified chronic conditions through reporting, feedback and development of reminder systems. Once technology has been adopted, the program provides structure to help physicians prepare for participation in pay-for-performance (P4P) programs.

Improving EMR adoption is important to not just CMS' quality improvement programs but also to the local, community, regional and national health information exchange projects that David Brailer, M.D., Ph.D., national coordinator for Health Information Technology, has planned. To that end, Lumetra is an active participant in planning and development of the California regional health information organization (RHIO), known as CalRHIO.

At the national level, Linares has worked with the e-Health Initiative and the American Health Quality Association (AHQA), both based in Washington, D.C. The AHQA represents QIOs in creating a road map that all states can use to port the Lumetra-developed tools for use in building RHIOs.

"Coming up with a scalable model that would include the solo practitioner was the biggest challenge," says Linares, "and it speaks to the tremendous need that is out there." To provide the support required, his team uses a collaborative approach to create communities of practice and accelerate peer-to-peer learning opportunities.

Working alongside national experts to deal with difficult, thorny issues was a high point of the project for Linares. From the beginning, national experts were engaged in the DOQ-IT project, he says, "looking at the whole interface of, how do you merge evolving technologies such as EHRs [electronic health records] with the whole element of practice redesign and the cultural transformation in the physician office—the human factor? Do you start with the human factor and look at redesigning care to get ready for an EHR? Or do you start with the technology and introduce the technology first?"

Vendors were part of the process—and there were more than 300 of them when the project began. The first message Linares gave them was, "If you want to play, you have to agree on standardization." The first discussion—convened by CMS and including the vendor panel and the American Medical Association physicians' consortium as a vested stakeholder—was about uniform measures and standard specifications for the EMR inputs and outputs.

Issues that arose centered primarily on HL7, laboratory and other data-submission standards. "Clearly, vendors then self-selected themselves to participate in DOQ-IT," notes Linares. An open-door policy permitted vendors to review specifications and quality measures. Each must be able to submit abstracted data using standard specifications and verify that they can submit it to a QIO data warehouse. So far, more than 40 have declared competency, but certification, currently under way, will be required.

The current CMS contract, which began last fall, charges every QIO in the country and territories with supporting small physician practices in the adoption of IT using Lumetra components. QIOs must begin to interface with practices, helping them take incremental steps toward adoption of IT, such as e-prescribing, e-registry development, e-messaging incorporation, and use of e-lab or e-pharmacy data for patient management.

There is still a good deal of work to do. Much of it involves defining needs and refining tools as the adoption curve is mounted and technologies evolve. Each of the four pilot states will continue building on the DOQ-IT experience. They will work to fine-tune diffusion of technology for small-practice EMR adoption and quality improvement, especially as CMS moves into the P4P component of its recently launched Medicare Health Support program, previously known as the chronic care improvement project.

DOQ-IT tools have use outside research. Community health centers stand to benefit from DOQ-IT, too, says Linares. A California HealthCare Foundation project is asking clinics to do readiness assessment for EMRs using DOQ-IT structure.

Improving care is at the heart of Linares' deep sense of satisfaction and accomplishment. "We are working on what may become a fundamental component of every physician office for the future. We're working on a care tool—an EHR—that's going to improve care for patients across the country." At some point, it may replace pen and paper, and it may be the most efficient tool introduced into medicine in the last 100 years, he speculates. The EMR could transform medicine, much like antibiotics did in the '40s.

Linares is on the leading edge. "You're out there by yourself sometimes," he says, "and it's easy to look at your work and question it. There are no reference points to gauge milestones." But he's pleased to see that DOQ-IT is translating to physician adoption of electronic records—a basic component of tomorrow's medical care and a common language for physician practices.

Charlene Marietti

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