We can’t fix flaws in data without electronic records, experts say
Technological investments seen as an outcomes imperative
When a medical group or health plan scores poorly on a standard performance measure, is the problem inadequate care? Or inaccurate data? Pointing to serious problems with data collection, performance measurement experts are calling for a massive national investment in computer technology and a new willingness for physicians to move from old-fashioned paper systems to electronic records.
Some large health care purchasers are becoming fed up with the slow pace of improvement in performance assessment, and antiquated systems are partially at fault, says David Hopkins, PhD, director of health information improvement for the Pacific Business Group on Health in San Francisco. "[Purchasers are saying,] We don’t think you have the quality of information to ensure optimal quality of care.’
"If health plans and providers cannot identify even who their diabetic patients are from automated systems, then we have a problem," he says. "If physicians cannot readily ascertain when they last gave a Hba1c test to their diabetic patients and quickly get those patients in, that’s a problem."
Medical groups that can track care electronically will set a new standard, says Hopkins. For example, Kaiser Permanente, based in Oakland, CA, has committed hundreds of millions of dollars over the next five years to automate physician offices, clinics, and other facilities nationwide. (See related article, p. 6.) Brown & Toland Medical Group, an independent practice association (IPA) in San Francisco, spent $3.75 million to develop an Internet-based system with Healtheon, a Santa Clara, CA, software firm. While that system is geared toward administrative information, it sets the foundation for future, clinical-oriented applications.
"Some large IPAs and multispecialty groups are stepping up to the plate and making those investments," Hopkins says. "Once a few of them have done that, I think it puts a lot of pressure on everybody else to explain why they’re not doing it."
Scrutiny reveals incomplete, inaccurate data
As the measures used for performance assessment become more complex, the weaknesses in health care data collection become more apparent. Audits show that HEDIS (Health Plan Employer Data and Information Set) data collected for reporting to the National Committee for Quality Assurance (NCQA) in Washington, DC, are fraught with inaccurate coding, inadequate documentation, and misinterpretation of the indicators’ specifications.
For example, in its 1996 audit of Medicare data for selected measures, IPRO, a health care quality improvement organization based in Lake Success, NY, concluded that two measures contained enough errors to make them invalid for comparison. The measures were eye exams for people with diabetes and follow-up after hospitalization for mental illness.
Some problems, such as misinterpretation of HEDIS specifications, can be resolved through audits before the data are reported. But other issues, such as the incompleteness of claims databases, can only be fixed with fundamental — and expensive — changes, says Herman Jenich, MPP, associate vice president for managed care of IPRO, which conducted audits of Medicare managed care data for 1996 and 1997.
"What you’re left with is those difficult core system problems that you can’t change [easily]," says Jenich.
"As we move toward deeper, more clinical issues, without some movement toward electronic capture [of information] above and beyond claims data, you’re going to have thousands of medical records that have to be reviewed."
The results of medical record abstraction rely greatly on the skills and training of the reviewers and the data collection tools they use. The American Medical Group Association (AMGA) in Alexandria, VA, found problems with medical record abstraction early in its outcomes program and now requires participating medical groups to gather information at the time of care.
"We highly advise that people initiate some form on concurrent data collection like an electronic medical record from which they can abstract the standard data they need," says Julie Sanderson-Austin, RN, AMGA’s vice president for quality management and research and corporate operations.
"We’ve had years of trying to get information out of medical records," she says. "We know that it’s flawed. Everyone’s going to interpret what they see on paper differently unless it’s a standard template of objective data."
NCQA, which accredits health plans and developed HEDIS to measure quality of care, recognizes the clash between the need for information and the availability of it. In 2000, health plans seeking accreditation will be required to collect data on six diabetes measures, including blood glucose levels. Such clinical information cannot be derived from claims data.
Similar measurement sets are under development for other medical conditions.
In its publication titled A Road Map for Informa-tion Systems, NCQA urged health plans to provide financial incentives for providers to automate their clinical information. (For ordering information, see editor’s note, p. 4.) Some health plans do provide financial incentives related to the quality of data, such as encounter data. Aetna US Healthcare, based in Blue Bell, PA, recently implemented E-Pay in some of its markets, which promises physicians payment within 15 days if they submit "clean" claims (without errors) electronically.
But will health plans provide financial support to medical groups for the computer systems themselves? Only if the medical group predominantly serves one health plan, says Allan Pryor, PhD, chief medical informatics officer of Intermountain Health Care (IHC), an integrated delivery system in Salt Lake City that includes a health plan. It works with 400 salaried physicians and 1,500 affiliated physicians.
IHC is installing its new Healthcare Enterprise Management System, which was developed with 3M Health Information Systems of Minneapolis, in the offices of all salaried physicians. (For a related story on physician buy-in for computer-based patient records, see p. 6.)
Independent physicians who are "tightly aligned" with IHC — those who mainly treat IHC health plan members and use IHC facilities — receive the HEMS software and training free of charge. However, they must provide their own hardware, which may include wireless hand-held or laptop computers to allow for instant decision support.
In fact, the huge capital costs of installing electronic medical records may force medical groups to form distinct alliances with health plans. "More and more, some of the health plans are only going to work with those who are tightly aligned," he suggests.
Medical groups link with software vendors
Some medical groups and IPAs are teaming up with software vendors to support the development of electronic records.
Tom McAfee, MD, chief medical officer of Brown & Toland, says he’s convinced that an electronic connection between physician offices and the central administrative offices will produce efficiencies and significant cost savings.
"I think we’re going to continue to see pressure from employer groups to reduce costs," says McAfee. "The major purchasers of health care continue to believe that health care expenditures are higher than they should be because there’s waste in the system. We’re going to have to continue to be more efficient to continue to provide quality care for less money."
Initially, the Internet-based RACER (referrals, authorizations, claims, eligibility, and reporting) system is designed to automate such tasks as determining health plan eligibility, obtaining referrals and authorizations, and filing claims. But McAfee says the system will evolve into a more complete electronic record, with disease management and outcomes data collection.
"This is the road map," says Cecilia Montalvo, vice president of strategic development for Brown & Toland Physician Services Organization, the administrative arm. "You’re putting the highway down. It creates the potential for all kinds of future applications."
Still, few medical groups have made the investments necessary to allow electronic collection of clinical data. Among health plans, only Kaiser Permanente can collect and submit most of its HEDIS data electronically. (See related story, p. 6.)
Many health plans provide financial incentives to medical groups to improve data collection related to HEDIS. But Hopkins says they haven’t gone far enough.
"We’re trying to standardize it so incentives are aligned from one plan to another [and] providers have one set of incentives," he says. "We don’t think it works so well if every plan has its own incentives.
"The ultimate purpose is to improve quality of care," Hopkins says. "The ability to collect and report data relating to quality of care is going to be a very key part of [improving care]."
Editor’s note: To obtain a copy of the report, A Road Map for Information Systems ($75 plus $10 shipping and handling), contact the NCQA Publications Center, 2000 L St. NW, Suite 500, Washington, DC 20036. Telephone: (800) 839-6487. Fax: (202) 955-3599. World Wide Web: http://www.ncqa.org.
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