Wrapping physicians' minds around quality improvement
From the November ACP Observer, copyright © 2005 by the American College of Physicians.
By Charlotte Huff
In many ways, said Robert A. Greene, FACP, associate medical director of the Rochester Individual Practice Association (RIPA) in Rochester, N.Y., convincing physicians to adopt the mindset needed for pay for performance mimics working through Elisabeth Kubler-Ross' famous five stages of grief.
The practice association, with about 3,000 physicians, has for several years been aggressively establishing patient registries and implementing other quality improvement innovations to help clinicians reach targeted performance goals for diseases ranging from asthma to heart disease.
"First, there is denial," said Dr. Greene, describing the mindset stages. "Physicians say, 'There is nothing wrong. I'm practicing perfectly fine medicine.' " Then, he said, you show them the data—and they get angry. "In general people will say, 'You are not going to tell me how to practice medicine. This is cookbook medicine.' "
Once you get past anger and denial, however, "then you get to talk about the medical issues," he said. "We're happy to discuss those."
In the growing quality improvement movement, mindset is only one of several hurdles physicians must clear as they learn to shape raw data into potentially better patient care.
But quality program veterans say that changing physicians' perspective is a key first step to making quality improvement work. Instead of just dealing with individual patients and the specific complaint that brings each to the office, physicians have to start thinking about populations of patients within their practice—those who have diabetes and need regularly scheduled tests, for instance, or eligible patients who need an annual flu vaccination.
Physicians may have to bolster that new mindset with revamped office procedures or updated technology. But upgrades won't help, veterans say, unless you first change physicians' minds. According to Dr. Greene and his colleague, RIPA medical director Howard B. Beckman, FACP—whom Dr. Greene credits with the stages-of-grief analogy—emotional challenges may be the most significant barrier to pay-for-performance success.
"Mindset is the critical factor," Dr. Greene said. "Doctors in general predictably are uncomfortable with physician profiling per se." If you don't work through that lack of comfort he added, "they won't work with you."
Physicians who have launched quality improvement initiatives cite the following approaches to help convince physicians to start thinking—and acting on—patient populations:
Pick uncontroversial initiatives. When RIPA first started out with quality improvement in 2000, leaders were careful to pick a topic they knew physicians would buy into: reducing inappropriate antibiotic usage to treat otitis media and sinusitis.
Yogesh K. Patel, FACP, who helped start a diabetes management program for the physician network at NorthEast Medical Center in Concord, N.C., also said that performance goals have to be above reproach. In convincing network physicians to support the new diabetes initiatives, the program set as its goal getting diabetic patients' HA1c levels below 7--a widely accepted standard of care.
"If we started picking [performance] elements that were questionable," he said, "then it would be harder to get physician buy-in."
Show them the figures. According to Drs. Beckman and Greene, seeing data on care patterns can be a real eye-opener—as Dr. Greene learned firsthand. During the inappropriate antibiotic-usage project, he discovered that he prescribed clarithromycin to 20% of his sinusitis patients, a surprise to him.
But data results should just be the start of a long conversation, said RIPA's Dr. Beckman. "When sitting down with physicians who are dissatisfied with their results," he said, "the best approach is to first discuss the underlying data and methodologies."
Dr. Beckman recalled one physician who was flummoxed by his seemingly high prescribing of azithromycin. Further investigation found that his patients were getting the drug at a regional walk-in clinic. Clinic staff were then educated that azithromycin wasn't a first-line antibiotic and usage subsequently dropped.
Hard data can change physicians' practice patterns—and stimulate a little healthy rivalry.
Discussing methodology before medical practice can defuse initial anger. "Doctors appreciate being provided accurate data in a non-judgmental fashion," Dr. Beckman said. "This allows them to reflect on the results and draw their own conclusions. Often, just having the conversation results in meaningful behavioral change." It also helps, he said, that he and Dr. Greene both continue to practice—and have to worry about the same performance goals themselves.
Hard data can also stimulate a little healthy rivalry, said Keith E. Griffin, ACP Member, chair of NorthEast's diabetes management program. In addition to quarterly reports for the entire NorthEast network, physicians receive reports about their own clinics and individual performance. "That fosters," Dr. Griffin said, "a little competition."
Show them the money. The point of quality improvement is better patient care—but translating that care into higher revenue can help convince physicians to adopt a more population-based approach. In Rochester, the IPA's inappropriate antibiotic usage project generated more than $1 million in savings in both 2001 and 2002 for RIPA's insurance partner, Excellus BlueCross BlueShield, Dr. Greene said. The RIPA panel as a whole received more than half those savings each year in a gainsharing arrangement. That money was put into a pay-for-performance fund that boosted individual physicians' compensation by as much as 5%. "It's not enough money to make or break anybody," Dr. Greene said. "But it's enough to get their attention."
Don't reinvent the wheel. Many physicians shy away from tracking patient populations because they don't have the time to redesign office processes. To get around that barrier, see if you can partner with health plans that can turn claims data into quality improvement tools, instead of designing those tools yourself.
According to Dr. Greene, Excellus sends primary care physicians and cardiologists—who now number about 850—a patient registry four times a year with information on every chronic disease patient, including whether patients have received key tests, such as an eye exam and an HA1c for patients with diabetes.
And RIPA and its partners are now launching an automated reminder system. Each morning, participating physician offices receive a fax from the health plan, listing the services needed by patients with one of the three chronic conditions being tracked who have scheduled visits that day. Dr. Greene said physicians could take a similar approach, working with local insurers to access database information and then pull raw data into simple spreadsheets and query programs.
Another option is to work with local hospitals or labs, said Doron Schneider, ACP Member, a general internist in Abington, Pa., who participates in ACP's "Closing the Gap" project to improve diabetes care. Physicians can import the data into a practice-based Microsoft Access program, he said. At that point, information about how your patients fare against performance goals is only a few keystrokes away. "Then you can start to build consensus within the group that there is a gap here," Dr. Schneider said. "And you can raise awareness within the office staff."
Use staff. Pursuing quality improvement and pay-for-performance goals "can create additional counseling demands for physicians," said Sarah T. Corley, FACP, a physician consultant with a practice management and electronic health records (EHRs) software provider, and Governor for ACP's Virginia Chapter.
The minutes required for those interventions can quickly add up, she added. To ease that time burden, make use of standing orders so a nurse can immediately give patients a pneumococcal vaccine or order a mammogram. To boost compliance, office staff can even make the mammogram appointment while the patient is standing there.
According to E. Rodney Hornbake, FACP, a general internist in Essex, Conn., who has tracked 450 chronic disease patients without the help of an EHR or additional staff, staff involvement is vital.
Dr. Hornbake said he runs monthly queries in a patient registry software program and sorts the results into Microsoft Excel. He may scrutinize HA1c levels, for example, ranking patients from highest to lowest levels. Using a highlighter, he then draws a line through the cut-off point of concern. "Everyone above the line," he said, "is a target."
He then asks his two medical assistants to pull the charts for patients at highest risk. At day's end, they all gather to discuss intervention strategies.
"I use traditional staff incentives, like praise and fair wages," Dr. Hornbake said. "But I also make sure they're invested in the long-term by asking for their input along the way."
Change patients' mindset. Physicians also point out that changing patient mindset is just as important as changing their own.
To bolster the upcoming RIPA automatic reminder system, for instance, Excellus plans to send out letters to chronic disease patients annually, detailing what tests and other preventive work they've missed that year.
And this fall, Dr. Hornbake is working with a fourth-year medical student to implement group visits for patients with moderately elevated HA1c levels. At the end of the session, Dr. Hornbake meets with those who have the highest levels.
At the same time, he said, he takes a personal tough-love approach with non-compliant patients, outlining their long-term medical risks.
"I just tell people that if they are not interested in getting their hemoglobin down below 7, I'm not interested in being their doctor," he said. "I haven't had to kick anyone out of the practice yet—but I get their attention."
Charlotte Huff is a freelance writer specializing in health care who is based in Fort Worth, Texas.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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