American College of Physicians: Internal Medicine — Doctors for Adults ®

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Keeping pace with emerging health care innovations

From the September ACP Observer, copyright 2005 by the American College of Physicians.

By C. Anderson Hedberg, FACP

In my first President's Column ("ACP membership: United to meet today's challenges," April ACP Observer), I pointed out that "we are in the midst of revolutionary changes in American medicine—ones that internal medicine and the College will play pivotal roles in directing." After my first four months as your President, I can report that this is indeed the case, and that events are moving swiftly.

Those of you who regularly read ACP Observer know that significant changes are taking place in three arenas: health information technology, performance measurement and pay for performance.

ACP's main objective in all three areas is to make sure these changes enhance quality improvement. The College also wants to ensure that such changes increase office efficiency, help contain spiraling health care costs and bring about much-needed payment reform.

An 'historic innovation'

Some information technology experts claim that creating interoperable systems for health care may be the most complex activity attempted in the electronic age. While this may be true, it is simply inconceivable that interoperability will not be accomplished in due time, given the enormous progress already made in connecting so many other industries and endeavors.

I have talked with several internists who have adopted a full electronic health record (EHR), and I have a colleague who has developed a paperless office. Despite the travails of start-up, none would go back to a paper system because of the efficiency, convenience and quality they have all achieved. They deliver a strong recommendation to stay the course, and for all of us to embrace this historic innovation.

Yet before we do so, we have many hurdles to clear. The Aug. 2, 2005, issue of Annals of Internal Medicine featured an article on the complexities and high costs of forming an interoperable network. The same issue contains an excellent article on the major impact that introducing EHR software had on one small practice. And using data gathered by the Commonwealth Fund, researchers have found that only 27% of doctors reported using EHR software routinely or occasionally—proof that much more development is needed.

For practicing physicians, the key development is the ambulatory EHR, with software that will allow us to:

  • Collect and access complete clinical data on all patients, including history, physical examination, laboratory results, diagnostic studies, visits and consultations.

  • Access information and decision-support systems, such as ACP's PIER.

  • Build and maintain disease-oriented patient registries.

  • Collect data for performance measurement.

  • Connect seamlessly to practice business software.

  • Provide electronic ordering systems and online prescribing.

Overcoming barriers

Office-based internists face serious barriers to introducing EHR software into their practices. These include installation and maintenance costs, the time and effort needed to incorporate the new system into daily activities, and disruptions to office flow and patient satisfaction during the transition.

Hundreds of vendors are pushing information technology products into the health care market. The bewildering array of companies makes it hard to select products that have any guarantee of staying in the market for long.

Adding to that confusion is the number of organizations and agencies trying to set national information technology standards. ACP staff has made an informal count of more than three dozen private and public organizations working toward that goal.

The good news is that talented ACP leaders and staff are lending their expertise to several of the most important national standards-setting organizations. For example, John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, is on the board of the eHealth Initiative and the steering committee of Connecting for Health, while the College maintains a representative to Health Level Seven. And the College strongly supports the Office of the National Coordinator for Health Information Technology, led by internist David Brailer, MD.

Dr. Tooker also serves as a commissioner of the Certification Commission for Healthcare Information Technology. The goal of this organization is to help physicians by developing a certification process for information technology products. In addition, ACP's Practice Management Center will continue to help internists make choices as the EHR field advances.

And to help alleviate the costs of installing and maintaining an EHR, the College is giving its full support to the National Health Information Incentive Act of 2005 (H.R. 747). If passed, the bill would give physicians financial incentives—in the form of grants, loans and tax credits—to invest in EHR software. It would also build into Medicare reimbursement an add-on code for visits and services facilitated by information technology.

Performance measurement

Performance measurement and pay for performance are also controversial, but the pathway these innovations are following is clear. Performance measurement is an important quantitative tool physicians can use to improve quality, detect deficiencies and track improvements.

For years, health plans have been collecting performance measurement data, returning that information to network physicians to help guide their care of patients. Organizations such as the National Committee for Quality Assurance, the National Quality Forum and the Leapfrog Group have long been interested in the performance measurement movement.

ACP's Board of Regents has formed a Performance Measures Subcommittee to evaluate performance measurement sets relevant to internal medicine. Subcommittee members will also help develop policy on the use of performance measurement tools for accountability and reimbursement.

Last year, ACP recognized that the proliferation of performance measures and pay-for-performance programs will have a major impact on internists' reimbursement and practice operations.

That led ACP leaders to help form the Ambulatory Care Quality Alliance (AQA), a consortium of physician, hospital, employer, government and consumer stakeholders.

The AQA recently approved a starter set of performance measures that could be adopted nationally by health plans as early as next year. (See "Market forces push pay for performance" in the May ACP Observer.) These criteria, developed by panels of expert physicians, seem reasonable and practical, but they must face continuing evaluation as they are tested in practice.

In their efforts to advance performance measurement, College leaders are making sure that performance measures are evidence-based, risk-adjusted when necessary and truly reflective of physician performance, without being too costly or burdensome to implement.

Pay-for-performance programs have already begun in some parts of the country, and the Centers for Medicare and Medicaid Services recently announced its intention to implement its own pay-for-performance initiative. In later columns, I plan to comment on these developments as they unfold.

For now, ACP members, leaders and staff will stay engaged in the design and implementation of these initiatives. I believe that, with the proper emphasis and guidance, these programs can help us achieve our goals of quality improvement, practice redesign and reimbursement reform, with lower costs and the best possible service for our patients.

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