Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Public Reporting - Public Reporting of Provider Performance on Quality Measures
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Accountability and transparency are catch phrases in many industries. To give substance to these concepts SETMA has launched this section of our website. Here, we will report to you, our patients and our community, the care we are giving your health. Four questions are addressed and answered in this introduction:
  • What will we be reporting?
  • Why will we be reporting?
  • How will we be reporting?
  • How often will we be reporting?
We believe this reporting will benefit you, our patients, and it will benefit us, as every SETMA provider is challenged to improve his or her performance and every patient is challenged to improve their compliance with healthcare initiatives recommended to them.

But before we describe those measurement sets, review with us where we were ten years ago. Eleven years ago, in May, 1999, SETMA published a paper entitled, "More Than a Transcription Service: Reorganizing the Practice of Medicine With Electronic Patient Records (EMR)". That article is still on our website under Your Life Your Health. At that time, SETMA had been using EMR for only four months. We began Tuesday, January 19, 1999, after having purchased the EMR in March, 1998. By May, 1999, we recognized that succeeding with an EMR was a short-sighted goal. We began to understand that if all we were gaining with EMR was an electronic means of documenting a patient encounter, it was too expensive and too hard to justify the expense and the effort. Ours goals changed and we began to pursue "electronic patient management" (EPM).

EPM focused on the gaining of leverage and advantage in patient care and treatment outcomes with the EMR. EPM remains our goal to this day and has been the guiding principle in the development of our disease management tools, our patient-care functions and our reporting modules. Along with our applying of "systems thinking" from the work of Dr. Peter Senge to our design of our EMR (see that explanation under the EPM-Tools section of this website, EPM has guided our growth in electronic patient management.

In the May, 1999 article a section entitled "What you measure, you value," stated:

"SETMA used to measure and report daily: productivity, tests ordered, x-rays ordered, etc. We recognized that to be dysfunctional. We were promoting failure."

The reason was that we realized that we were reporting on what we were doing "to patients" and not paying as much attention to what we were doing "for patients." We were taking care of the business of medicine but we were not as focused on the improvement of our patients' health.

The paper went on to says that we needed to focus more on: "Outcome -- how rapidly a person recovers from an acute illness and how effectively we manage chronic illness." As this became our focus, we began to see the power of an EMR, and the article stated:

"In fact, the EMR allows the patient to be cared for by a team without loss of continuity or personal attention. EMR allows triage to be tied intimately to nurses taking the patient's history and to the provider doing the physical examination and the plan of care. EMR allows multiple people:
  • "To interact with a patient at each encounter,
  • "To document that interaction and
  • "To share the data collected with all others who interact with the patient."
  • "After review to incorporate the work of others into the patient evaluation safely and accurately."

This "walk down memory lane" is both refreshing and embarrassing. It is refreshing because we were thinking about measuring things which we valued, but ten years later the things which we are measuring are much, much different than what we discussed in 1999. We believe that we are now measuring the heart and soul of excellence in medicine and in healthcare delivery.

What will we be reporting?

"A test will be given next week," announces the teacher, instantly creating anxiety and apprehension in the class. "What will we be tested over?" "What do we need to know?" Relief sweeps over the class when the teacher announces, "It will be an open book test and here are the questions, you will be asked." Excellent testing should be as educational of what the student should know, as it is evaluation-al of what he/she does know. Tests should indicate to the student what is important and test should not just be tools which shows the student what he doesn't know. Often we associate test with a classroom setting in a formal educational program, but the reality is that all of life and all of our life experiences are a test of one sort or another. SETMA's "Open-Book Tests" are: HEDIS, NQF, NCQA, PQRS, PCPI.
  • Healthcare Effectiveness Data and Information Set HEDIS - 90% of health plans in the United States measures quality by the various HEDIS quality measures. Some HEDIS data evaluates health-plan functions and some healthcare-provider functions. It is the latter in which we are presently interested. HEDIS measures are developed by the National Committee on Quality Assurance (NCQA), which was formed in 1990. Annually, NCQA publishes an approximately 300-page HEDIS Technical Specification for Physician Measurement.

    As SETMA has been developing its Medical Home, it occurred to us in that HEDIS and other measures of quality performance by healthcare providers are open-book tests and in that the "professor" has given us the test questions, we should measure ourselves to see how we are doing. In addition, in that we have that data, we should share it with our patients and with our community. So, we shall.

    As a result, SETMA has embedded HEDIS measures of quality in acute care, chronic care and preventive care into our EMR. Every day, on every patient, a patient's care is measured by this and other quality measures.

  • Physician Consortium for Performance Improvement (PCPI) - this measurement set for various conditions such as hypertension, diabetes, congestive heart failure and others have been developed by the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Institute of Medicine (IOM) and the medical and surgical specialty societies. These data sets are intended as "open-book tests of provider performance, where the questions have been given to the provider." The hope is that as providers measure their own performance that quality of care will improve. SETMA has embedded Consortium's data sets into our EMR and we will report on the results of these as well as HEDIS.

  • National Quality Forum (NQF) - In 1998, A report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, proposed the formation of the Forum as a part of a national agenda for improvement in healthcare delivery. Formed in 1999, NQF's mission statement declared, "The mission of the National Quality Forum is to improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs." NQF's vision is that "the NQF will be the convener of key public and private sector leaders to establish national priorities and goals to achieve the Institute of Medicine Aims—health care that is safe, effective, patient-centered, timely, efficient and equitable. NQF-endorsed standards will be the primary standards used to measure and report on the quality and efficiency of healthcare in the United States. The NQF will be recognized as a major driving force for and facilitator of continuous quality improvement of American healthcare quality."

    As of October, 2008, NQF has endorsed 514 "national voluntary consensus standards." For NCQA recognition as a medical home a physician group must report to its providers and to an external agency their performance on at least 10 of these measures. SETMA has chosen 30 NQF measures on which to report for 2009. In 2010, we will begin reporting on more than 60. SETMA's performance on these measures will be posted to our website as well as reported to our providers.

  • National Committee for Quality Assurance (NCQA) - As previously noted, NCQA publishes HEDIS measures each year. NCQA also has published the requirements for recognition as a Patient-Centered Medical Home. It is NCQA which requires a practice to report internally to healthcare providers and externally to health plans on at least 10 NQF-endorsed measures. NCQA has nine standards for measuring the qualification of a practice as a Medical Home. Each standard has multiple elements and each element has as many as 18 specific measures. NCQA recognizes three levels of Medical home depending upon how many standards, elements and measures the practice meets. SETMA will submit an application for Medical Home recognition early in 2010. We began the steps to prepare for this application's submission in February 2009.

    All applicants are required to report their performance on three major conditions for Medical Home recognition. SETMA has chosen diabetes care, hypertension care and cholesterol care as our three conditions. In addition, because the core of Medical Home is the "care coordination" function, SETMA will provide a document to our patients at the time-of-service which summarizes the steps taken by SETMA to coordinate that patient's care. Also, that document will summarize for the patient their HEDIS and NQF measures status, with a list of the measures which have not yet been met. This report care to the patient on the provider performance will also function as a report to the patient of what is missing in their care. This data will also be reported to this section of our website.

  • Physician Quality Reporting System (PQRS) -- The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting System (PQRS). The 2009 PQRS Measures Specifications Manual for Claims and Registry Release Notes is a 442-page document which explains this program.

    PQRS requires that a practice report on at least three individual measures or one "Measures Group" (a comprehensive group of measures which apply to a single condition such as diabetes, preventive care, etc.) in order to be recognized by CMS. For 2009, SETMA has reported on two measurement groups - Preventive Medicine and Diabetes - and in 2010 will add multiple other measurement groups. Our performance on these will also be reported on our website.

    Every day, on every patient, SETMA providers measure their own performance. Every day an audit will be done on HEDIS, NCQA, NQF, PCPI and PQRS data sets and the results will be reported to each SETMA provider. Quarterly, staring at the end of this year, SETMA will post these results on our website. We want our patients to know that we take their healthcare seriously.
Why will we be reporting publicly on our performance?

We have already stated that accountability and transparency are the principal reasons for public reporting of our performance, but there is more to accountability and transparency in healthcare than that. We believe that public reporting of quality performance will change provider and patient behavior. Typically healthcare providers only receive delayed, retrospective reviews of their performance, which does not change behavior significantly, in our judgment. In the Old Testament, a verse declares that "because punishment against an evil deed is delayed, the hearts of men are set upon doing evil." The principle is that without immediacy between the consequences and/or evaluation of an action and the action itself, the potential for the consequence to effect positive change is diminished or eliminated. While auditing provider performance is never for punitive reasons, the principle is the same. If the reporting of the results is significantly removed in time from the events being audited, it will have little impact upon provider behavior.

In his book, The Fifth Discipline, Peter Senge of MIT used the classic metaphor of the Frog in Boiling Water to address the same issue from a different perspective. He explains, "If you put a frog into cool water; he will swim around. If you begin to heat that water, the change is so gradual that the frog will not recognize the danger until it is too late for the frog to escape." The same is true of patients and healthcare providers. Because the changes in patient health are generally very slow and without immediate consequences (symptoms), both provider and patient can become complacent.

The medical literature addresses this complacency with the concept of "treatment inertia," the tendency on the part of healthcare providers to do nothing, even when something should have been done. Most of the research on "treatment inertia" has been done in the medical education arena where it is expected that "best practices" will always be present. There is no intent in this project of punishment, or of boiling anyone in hot water, but the intent is to find a way to change provider behavior and to overcome "treatment inertia." SETMA believes, as is also addressed by Senge, that the only effect way to change patient and provider conduct in the face of chronic conditions which cause no short-term discomfort but which have long-term devastating consequences, is to create discomfort in both in order to overcome "treatment inertia" and/or current apathy toward inevitable bad outcomes.

We also believe that patient behavior will change when they are given a summary of the quality of care they are receiving. We believe that provider behavior will change when they are given "real time" evaluation of their performance in regard to quality measures.

As the volume of evidenced-based, quality measures increases, it will be more and more obvious as to where we want to go in healthcare delivery and it will be more and more obvious as to whether or not we have gotten there. The missing piece, and the one many organizations and agencies are working on, is the auditing of provider performance so that providers can know where they are.

It is impossible to improve unless you have a standard against which to measure yourself and unless you are willing to honestly determine how well you are presently performing. When SETMA began discussing the public reporting of our performance, one provider said, "but what if it shows that we are not doing well?" That is just the point. It is better to know that you are not doing as well as you should, with the determination to improve, than to know what quality care looks like but to have no accurate measure as to whether or not you are performing well or excellently. SETMA providers are committed to practicing excellent medicine; the first and greatest evidence of this is that they are willing to have their performance measured and to have the results of that measurement public.

In summary, our goals in public reporting are:
  • First, we want to know what we are doing. Without auditing our performance, we will never know how we are performing. The COGNOS Project will allow us to objectify our performance. (For more information on this project, see "Patient-Centered Medical Home SETMA's COGNOS Project" and "Public Reporting of Provider Performance on Quality Measures") We will no longer "think" we are doing well; we will know if we are doing well.
  • Second, we want to improve what we are doing. Evidenced-based medicine with the treatment targets established by science can tells us where we want to be. If we know where we are and if we know where we want to go, we can design and way to get there.
  • Third, when we know that a patient is not treated to target or to goal, we want to know why. COGNOS will allow us to know if evidenced-based standards of care are being employed. If they are, and if the patient is still not to goal, it will allow us to address hindrances and/or obstacles to the patient getting to goal.
  • Fourth, we want to change provider behavior. The medical literature is replete with evidence of "treatment inertia," the nature inclination of people, even well-intentioned people, not to change things. Change requires that there be more pain or discomfort in staying the same as is required to make a change. SETMA believes that comparing provider performance and publishing that performance internally by patient name and externally as an aggregate practice performance will motivate providers to change.
  • Fifth, we want to change patient behavior. Like the frog dropped into a kettle of cool water which is then placed on the fire, changes in a patient's health are often so subtle and so slow that devastation overtakes them before they realize they are sick. SETMA has used and intends to expand the use of patient data, through the COGNOS Project, to create discomfort in patients to make them "jump out of the heating kettle" of deteriorating health before it is too late.
  • Sixth, we want to examine through statistical methodology and epidemiologic-principles patterns of care and outcomes. We want to be able to ask questions and analyze our data to get answers both retrospectively and then prospectively to those questions.
How will we be reporting?

SETMA will use an IBM software product COGNOS in order to efficiently produce the data we will be publicly reporting. COGNOS is described as being for "Business Intelligence and Financial Performance Management." It is a data-mining software program which is elaborate, robust, complex and excellent. The use of COGNOS in healthcare is not new but it is not common place.

SETMA engaged a consulting firm LPA Systems ( to take our goals and help us create reporting tools via COGNOS. SETMA's aggregation of and the reporting on the amount of data tracked by SETMA is a major, daily undertaking and would be time and personnel intensive if it were not automated. Additionally, the size of the reports which SETMA envisions and the database from which these reports are being mined are such that without a data-mining tool, it could take longer than 24 hours to run the reports. In addition, the running of the reports could slow our system to the point that the usefulness of the EMR in patient encounters could be adversely affected.

Through COGNOS, we created a "data mart" which will eliminate this problem. Simply put, a "data mart" is a repository for the data points required for the completion of the above described tracking. While SETMA's EMR has hundreds of thousands if not millions of data points, only 200 to 300 are needed to evaluate the outcomes of our care. The "data mart" will create a secure folder for these data points and all queries will be pulled from the "data mart." These reports will take seconds to run rather than hours and they will be automated requiring no personnel time for producing or distributing the reports.. COGNOS will allow SETMA to continue to move healthcare delivery forward and to improve the care all of our patients receive. Welcome to the future of medicine; welcome to SETMA.

How Often will we be reporting?

Internally, we will report every day to every provider on every patient. This data, because it identifies patients and providers will not be made public. We will also provide every patient with the results of whether or not performance measures have been met in their care. This data, also, because it identifies a patient by name will be provided only to the patient and provider involved in the care and will not be made public.

It is our intention to report data without patient or provider identification and as an aggregate - a total of all patients seen by all elements of SETMA - on our performance monthly and quarterly. As we have more experience with this effort, we will modify the frequency of our reporting to maximize its usefulness to our patients and to our community.


Hopefully, this very new undertaking will be valuable to you. We are confident that it will be valuable to us.
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