IC 3 : Improving Continuous Cardiac Care Quality Improvement in Practice

IC 3 : Improving Continuous Cardiac Care Quality Improvement in Practice

Presenter Disclosure Information Paul Chan, MD FINANCIAL DISCLOSURE: None FUNDING FOR THE IC3 PROGRAM: Bristol-Myers Squibb / Sanofi

The Pyramid of Quality Clinical Evidence

The Pyramid of Quality Quality Care Clinical Evidence

The Pyramid of Quality Quality Care Guidelines Clinical Evidence

The Pyramid of Quality Quality Care Performance Measures Guidelines Clinical Evidence

The Pyramid of Quality Quality Care Performance Measures Appropriateness Measures Guidelines Clinical Evidence

The Pyramid of Quality Quality Care Performance Measures P4P Reporting Appropriateness Measures Payer-Endorsed QI Programs Guidelines Clinical Evidence

What is IC 3? First office-based QI program 1. potential vehicle for transforming performance measurement to quality improvement at the point of care 2. assess physician adherence to ACC/AHA Performance Measures. 3. assess the current state of office-based clinical care for cardiac patients.

Philosophy of the IC 3 Program Make it easier for busy clinicians to do the right thing for the right patient at the right time Track key performance measures Improve efficiency Coordinate care

Challenges with Performance Measures Consensus Accuracy Timely Reporting Do They Improve Quality?

Current ACC/AHA Performance Measures CAD Performance Measures BP Measurement Symptom & Activity Assessment Smoking Assessment Counseled to quit Anti-platelet Therapy Lipid Profile Use of Lipid Therapy β-blocker post-mi ACE/ARB in EF & DM Screening for Diabetes

Current ACC/AHA Performance Measures CAD Performance Measures BP Measurement Symptom & Activity Assessment Smoking Assessment Counseled to quit Anti-platelet Therapy Lipid Profile Use of Lipid Therapy β-blocker post-mi ACE/ARB in EF & DM Screening for Diabetes CHF Performance Measures LVEF Assessment Weight Measurements BP Measurements Clinical Symptom Assessment Activity Assessment Signs of Volume Overload Patient Education β-blocker in EF ACE/ARB in EF Warfarin for Afib Initial Lab Tests

Current ACC/AHA Performance Measures Afib Performance Measures Thromboembolic Risk Prior CVA/TIA Age 75 Hypertension Diabetes Heart failure or EF Warfarin use in High-risk pts Monthly INR in pts on warfarin

Current ACC/AHA Performance Measures Afib Performance Measures Thromboembolic Risk Prior CVA/TIA Age 75 Hypertension Diabetes Heart failure or EF Warfarin use in High-risk pts Monthly INR in pts on warfarin Cardiac Rehabilitation PMs Referral to a Rehab Program Within 12 months of ACS PCI CABG Valve Surgery Transplant Stable Angina

Current ACC/AHA Performance Measures Afib Performance Measures Thromboembolic Risk Prior CVA/TIA Age 75 Hypertension Diabetes Heart failure or EF Warfarin use in High-risk pts Monthly INR in pts on warfarin Cardiac Rehabilitation PMs Referral to a Rehab Program Within 12 months of ACS PCI CABG Valve Surgery Transplant Stable Angina Diabetes Performance Measures Poor HbA 1c (>9%) LDL Control (<100) BP Control (<140/80)

Physician X s Practice United (5) BCBS (9) Medicare (26) Medicaid (10)

Physician X s Practice United (5) BCBS (9) Medicare (26) Medicaid (10)

Physician X s Practice United (5) BCBS (9) Medicare (26) Medicaid (10) Physician X s Overall Performance = 90%

Physician X s Practice Payer Perspective of my Performance United (5) BCBS (9) Medicare (26) Medicaid (10) 40% 78% 100% 100% Physician X s Overall Performance = 90%

Patient ID Data

Visit Date and MD

CV Medical History

Current Vitals & Lab Data

Health Status & Physical Exam Data

Current Medications and Change in Meds

Education and Recommended Tests

Office Flow in IC 3 Pt presents for visit, reports med changes

Office Flow in IC 3 Pt presents for visit, reports med changes Vitals, health status assessed

Office Flow in IC 3 Pt presents for visit, reports med changes Vitals, health status assessed Data entered and Clinic Visit Form Generated

Office Flow in IC 3 Pt presents for visit, reports med changes Vitals, health status assessed Data entered and Clinic Visit Form Generated Physician Visit & Rx

Data Collection Pioneering web-based platform Existing EMRs 1. Build in required data elements 2. System Integrators (extract from existing EMRs) Paper forms / TeleForms

IC 3 Data Collection and Exchange Outpatient Visit

IC 3 Data Collection and Exchange ACC NCDR IC 3 Program Ongoing Data Submission to ACC Outpatient Visit

IC 3 Data Collection and Exchange ACC NCDR IC 3 Program Ongoing Data Submission to ACC Outpatient Visit Periodic Data Reports to Practice

IC 3 Data Collection and Exchange Payers CMS/PQRI United BC/BS Others Annual Reports to Payers ACC NCDR IC 3 Program Ongoing Data Submission to ACC Outpatient Visit Periodic Data Reports to Practice

Sample Quarterly Reports

Sample Quarterly Reports

IC 3 Program: Incentives for Practices To improve care Decision Support Frequent assessment of performance Trusted mechanism for reporting performance CMS PQRI initiatives Pay-for-Performance with payers Collect once, report to all

Strategic Partnerships EMR Vendors Centra Healthcare System State of Virginia Pilot Payers United Healthcare WellPoint WellMark Blue Cross

IC3 Program Registered Sites December 2008 274 offices; 86 practices across the country 46 states

Initial Results Compliance with ACC/AHA CAD Performance Measures 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2008 Qtr2 2008 Qtr3 2008 Qtr4 2009 Qtr1 Antiplatelet after MI ACE/ARB with LVSD Beta Blocker after MI

Key Challenges IT infrastructure Program integration into clinical practice Quality improvement Alliances / Business case Incentives for participants

Challenges Data Content Develop data dictionary Determining data quality: 1. Accuracy 2. Completeness

Challenges Data Collection Coordination with EMR s e.g., new elements; standardizing old elements Pioneering new web-based tool Cost issues with paper forms (TeleForm solution)

Current Data Collection Systems 13% 5% 43% 5% 9% 3% 22% GEMMS AllScripts GE Centricity NextGen MIE Others Paper

Challenges Workflow redesign issues pervasive Unlike traditional NCDR registries More than just data elements and definitions Requires changes in behavior of organizations and providers

Challenges NCDR as central data warehouse of disparate data sources developing Internal infrastructure to support this

Challenges Multiple stakeholders each with varied criteria for success.. Requiring different level of engagement Physicians Group practices Professional societies Standard setting organizations (CCHIT, NQF) Certification agencies (ABIM) Payers EMR vendors Disease management companies Patients Research community State and Federal government ( state of Virginia, CMS)

Challenges in Collecting Performance Measures Multiple barriers to collect performance measures for outpatients Lack of consistency in data collection and storage across practices Highly variable patient flow across practices Required information may not be available Consistency in completeness of data collection may be lacking Current performance measures are inherently difficult to collect Creators of performance measures greater focus on the feasibility of collection; pilot testing Consider rotating measures to decrease numbers

Thank You