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

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EMRs and performance measures offer promise—and problems

From the November ACP Observer, copyright © 2003 by the American College of Physicians.

By Phyllis Maguire

Traverse City, Mich.—While much of the health care industry is focused on developing both electronic medical record (EMR) software and performance measures, significant challenges remain that could affect the way physicians practice-and how they are paid.

That was the message delivered to the Board of Governors at its October meeting by two internists who have studied performance measures and EMR systems: Regent William E. Golden, FACP, who chaired the College's Task Force on Performance Measures and is a director of the National Qualify Forum, and Patricia L. Hale, FACP, Chair of the College's Medical Informatics Subcommittee and a member of the College's Performance Measures Work Group.

Consumers and employers have fueled most of the interest in performance measures, largely as a way to contain costs and improve quality, Dr. Golden said. Unfortunately, he added, many consumer and purchaser groups don't always understand the technical limitations of measuring data. They also don't understand how data produced by the measurement process could then be used in medical decision-making. (See "Performance measures should help, not punish, doctors.")

There are other major hurdles to developing appropriate performance measures. How, for example, do you extract relevant data from patient charts and handle small sample sizes of patients? And how do you measure the quality of a physician's care over an extended period of time?

EMRs: not ready yet

EMR systems invariably come up in the discussion of performance measurements, Dr. Hale explained, because they can theoretically remove one major obstacle to implementing physician measures: retrieving data.

Dr. Hale said, however, that while EMR software can track down data on an individual patient or chart a patient's progress in fighting a condition like hypertension, the technology has major gaps when it comes to performance measures.

Before performance measures can be tied to compensation, for instance, EMR software needs to be able take into account confounding patient factors such as co-morbidities or a patient who refuses to take her medication.

And data are only as good as the person entering them, something that can be an issue in hospitals where overworked staff often enter data. In many cases, Dr. Hale explained, hospital staff fail to attribute patient care to the correct physician. They instead ascribe a patient's care to the admitting physician, not the doctor who actually treated the patient.

Because there is no standard for EMR systems, she added, even those physicians who take the plunge and buy EMR software often cannot connect with the systems used by labs, hospitals, other physicians and health plans. That is important, she explained, because tests and other services might not be credited to the appropriate physicians, a factor that would definitely affect their quality scores—as well as their compensation.

Physician buy-in

As the public discussion heats up of how EMR systems could help implement performance measures, many ideas are "floating around" for how to get EMR software into physicians' offices, Dr. Golden said.

Suggestions include government grants and rotating loans, while the Centers for Medicare and Medicaid Services (CMS) has considered underwriting an EMR infrastructure for medical groups. The astronomical cost of building that infrastructure, the reasoning goes, would be offset by savings resulting from better quality care.

Even that scenario raises issues. "If the CMS gives us EMRs, is it going to be continuously auditing our practice?" Dr. Golden asked. The issue of who will own data used to implement quality measures is just one more unanswered question in the performance measurement debate.

Doctor participation

Both Drs. Hale and Golden said that the challenges to EMR technology and performance measures demonstrate the need for physicians to get involved in crafting appropriate measures. If physicians, who understand the complexity of medical data, aren't part of the development process, they warned, measures that are too simplistic may be imposed upon medical groups and individual practitioners.

In recent years, ACP officials have been taking a growing leadership role in the drive for performance measures. In addition to its Performance Measures Work Group, the College has been working with the eHealth Initiative and the Markle Foundation, a New York-based foundation that focuses on emerging information technology.

The College has also been working with other medical organizations, such as the AMA's Physician Consortium for Performance Improvement, which is examining the issue of performance measures.

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