The validation of a disease registry system

Dana Nicole Pauley Persinger, DO, Doctors

Hospital, Doctors Hospital Family Practice Center, 2030 Stringtown Rd, Grove City, OH 43123.

E-mail address: dpauley@osteo.wvsom.edu.

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The Centers for Medicare and Medicaid Services (CMS) plans a decrease in the fee schedule for reimbursement by 1.5% to eligible professionals and group practices that do not adhere to guidelines to satisfactorily participate in data submission on Physician Quality Reporting System quality measures. Therefore to avoid the 2015 payment reduction, eligible individuals and practices must utilize the Physician Quality and Reporting System (PQRS) quality measures during the 2013 reporting period.1 There are different methods of reporting information on individual quality measures or group measures via Medicare Part B Claims, qualified PQR registry, qualified Electronic Health Record (EHR), or qualified PQR data submission vendor. In this study, a qualified registry (American Osteopathic Associa- tion Clinical Assessment Program [AOA-CAP] for PQRS) was compared with data available from an Electronic Health Record with the purpose of using the information acquired for quality improvement, patient engagement, clinical informatics, team-based care, and reduced healthcare costs.2 Identification of opportunities to advance patient care management and treatment response through practice inventory leads to ways of improving healthcare and implementing change.

The thought behind recognizing patient populations at risk, using tools to engage patients through motivational interviewing, shared decision making, and access to resources in addition to ensuring providers are consistently practicing to scope, is prevention of hospitalizations and emergency department visits therefore reducing downstream healthcare costs while improving the delivery of healthcare.2 This is the goal of Patient Centered Medical Home by providing comprehensive primary care, facilitating partner- ships between individual patients and personal physicians and when appropriate patient families. It is by incorporating these principles of personal physician, physician-directed medical practice, whole person orientation, and coordinated care that the hallmarks of quality, safety, and enhanced access would achieve goals of improving patient experience, lessen staff burnout, improve quality of care, and reduce healthcare costs.2,3

Quality improvement is a continuous process, and there are multiple models available to assist in achieving health- care progression. The Donabedian model gives 3 dimensions for care quality: the structure representing the attributes of settings where care is delivered, the process of determining if good medical practices are followed, and outcome being the effect of care on health status. The Institute of Medicine's 6 domains identify specific areas of improve- ment focusing on safety, effectiveness, patient centeredness, timeliness, efficiency, and equitability. The Duke models incorporate 5 prospective models that may be combined and used together. Those models are the FADE: Focus, Analyze, Develop, and Execute; the PDSA: Plan, Do, Study, and Act; the Six Sigma DMAIC: Define, Measure, Analyze, Improve, and Control; the CQI: Continuous Quality Improvement; and the TMQ: Total Quality Management. Lastly, the root cause analysis, which is a retrospective approach to error analysis through data collection and analysis.4

Without integrating prospective or retrospective models or both into clinical practice, ambulatory care centers are likely to overlook areas of improvement. Therefore, they fail to meet quality improvement initiatives and perhaps become a liability to the healthcare community.

‌Methods and results

Table 1 Three quality measures across 2 available reporting systems

Doctors Hospital Family Practice Center

(systolic o 140 and diastolic o 80) (HgbA1c 4 9%)

Blood pressure control Poor glucose control

LDL o 100 mg/dL

EHR, all Medicare patients seen during 2011 (N ¼ 77), % (CI)

66.40% (74.63-58.17)

13.41% (19.29-7.53) 62.42% (70.85-53.99)

CI ¼ confidence interval; LDL ¼ low-density lipoprotein.

The retrospective cohort study used data from the AOA- CAP for PQRS 2011, a CMS qualified, web-based registry with Health Insurance Portability and Accountability Act compliance.5 The registry was developed to provide osteopathic internal medicine and family practice residency programs with measures to improve the quality of patient care and a training tool to support the core competencies of practice-based learning and systems-based practice.6 Patient level data collected through the registry are analyzed using measures recommended by the National Quality Forum andPhysicians Consortium for Performance Improvement.7,8 Residencies collect and submit information on diabetes mellitus through standardized data and case definitions aspart of the residency accreditation requirements. Accreditation is based on reporting and not performance.9

A sample of 30 Doctors Hospital Family Practice Center Medicare fee-for-service charts submitted through the AOA- CAP for PQRS registry was compared with all Doctors Hospital Family Practice Center EHR Medicare patients with greater than or equal to 2 visits during 2011 to assess reliability of practice performance against evidence-based guidelines to improve patient outcomes and quality of care. Three quality measures were compared, which were blood pressure control (systolic blood pressure less than 140 and diastolic less than 80), poor glucose control (hemoglobin A1c greater than 9%), and low-density lipoprotein control (less than 100 mg/dL), resulting in no statistically significant differences between 2 available reporting systems for measur- ing performance across 3 measured variables (Table 1).

Discussion

Several recognized barriers to improvement of care have been publicized including but not limited to uncertainty regarding decision making in individual cases, as patients enrolled in trials often do not match the population of the patient receiving care, and regarding the establishment of guidelines for determining the appropriateness of care.10 Despite efforts to improve clinical decision making, lack of data still exists.10 Additional barriers to consider are the variable interpretations of data, discrepancies within pub- lished guidelines, underuse and overuse of medical technology and drug therapy, and the fact that medical knowledge is constantly evolving. Also, there are gaps in improving quality of care and reducing inequities largely owing to failure of healthcare organizations to incorporate known improvement measures into the process of care.11

Strengths of this study include ease of access to medical records for review, voluntary data entry, and despite multiple providers at various levels of training, outcomes are consistent and not statistically different between small and large samples. Weaknesses of this study include accuracy of blood pressures recorded, potential limitations of data entry owing to various levels of experience with

EHR, and any technological challenges or disruptions that could have affected data entry. In addition, there is concern over collecting adequate data on racial and ethical disparities owing to inadequate sample sizes, missing data, and lack of information on contributing factors.12‌

‌In conclusion, the AOA-CAP for PQRS is a consistent representation of overall practice population performance against evidence-based guidelines to improve patient out- comes and quality of care as there were no statistically significant differences between 2 methods of measuring performance across 3 measures available. Furthermore, the AOA-CAP for PQRS registry service is a reliable indicator and method of obtaining payment incentives and avoiding upcoming penalties for eligible providers who do not comply with CMS PQRS quality measures data submission.‌‌‌

‌References‌

1. Centers for Medicare and Medicaid Services. Physician quality reporting system. ⟨https://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/PQRS/downloads/2012WhatsNewPQRS_ Final508_1-23-2012.pdf⟩; Accessed 22.10.12.‌‌

2. Reid RJ, Fishman PA, Yu O, et al: Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15:e71–e87

3. American Osteopathic Association. Patient-centered medical home.

   ⟨http://www.osteopathic.org/inside-aoa/development/practice-mgt/Pages/ patient-centered-medical-home.aspx⟩; Accessed 29.12.12.

4. United States Department of Health and Human Services. What is quality improvement? ⟨http://www.hrsa.gov/healthit/toolbox/HealthITAdop tiontoolbox/QualityImprovement/whatisqi.html⟩; Accessed 29.12.12.

5. American Osteopathic Association. CAP for PQRS. ⟨http://www. osteopathic.org/inside-aoa/development/quality/cap-for-pqrs/Pages/ default.aspx⟩; Accessed 22.10.12.

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7. National Quality Forum. Standardizing ambulatory care perfor- mance measures. ⟨http://www.qualityforum.org/Measures_List.aspx⟩; Accessed 7.03.12.

8. Physician Consortium for Performance Improvement. Chicago, IL: American Medical Association; 2012

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