Published Online: June 25, 2014
Jason J. Wang, PhD; Chloe H. Winther, BA; Jisung Cha, PhD; Colleen M. McCullough, MPA; Amanda S. Parsons, MD, MBA; Jesse Singer, DO, MPH; and Sarah C. Shih, MPH
To assess performance on quality measures among small primary care practices that recently adopted an electronic health record (EHR), and how performance differs between practices that have achieved patient-centered medical home (PCMH) recognition and those that have not.
Retrospective cohort study.
Comparison of practice characteristics and performance on quality measures across 150 independent practices from 2009 to 2011 by recognition status for Physician Practice Connections–PCMH.
PCMH-recognized practices performed significantly better than nonrecognized practices on 5 out of 7 clinical quality measures at baseline, and the differences were maintained over the 2-year study period. Both groups improved on all clinical quality measures. Though the magnitude of differences was small, PCMHrecognized practices had a higher number of patients diagnosed with hypertension and proportionally more black patients. A significant difference in PCMH-recognized practices is that they received, on average, 4 additional quality improvement visits compared with nonrecognized practices.
Among small practices that have adopted EHRs, practices with PCMH recognition consistently outperformed practices without recognition on most clinical quality measures. With adequate assistance, small, resource-strapped practices can continue to have higher performance on clinical quality measures.
Am J Manag Care. 2014;20(6):481-489
Patient-centered medical home (PCMH) recognition in small practices is associated with higher performance on quality measures over time.
Small practices with PCMH recognition perform better on quality measures related to chronic conditions
The differences observed between the practice groups appear to be sustainable over the 2-year study period.
Quality measure performance is correlated with greater participation in a quality improvement program.
The patient-centered medical home (PCMH) concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions.1-3 This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the shortcomings of the current healthcare system.4
Components of the PCMH model include practice-based policies and processes intended to improve healthcare quality, patient experience, clinician satisfaction, and costs of care.5 Pilots and demonstration projects have yielded mixed results, but positive reports associate PCMHs in large practices and institutions with decreases in costs for patients enrolled in Medicaid; increased care of Medicaid patients; and positive patient and clinician experiences.6-8 Recently published studies have also shown that components of the medical home (eg, care coordination, pre-visit planning) are associated with positive effects on clinical outcomes for patients and quality of life for clinicians.9,10
The process of transforming and achieving recognition as a medical home can be difficult, especially for small practices with few resources.11,12 Additionally, small practices located in low income neighborhoods face challenges unique to their settings (eg, smaller panel size for quality measurement, lack of information systems, and lack of support staff) which can further exacerbate their ability to generate the documentation needed to demonstrate transformation and meet the standards for recognition.13 Promoting the adoption of PCMH standards in small primary care practices in lower income neighborhoods with a large proportion of chronically ill patients can be advantageous for reducing healthcare inequalities.14
As part of a larger public health initiative, the Primary Care Information Project (PCIP), a bureau within the New York City Department of Health and Mental Hygiene, has offered assistance to small, independent practices in New York City to complete the application for the National Committee for Quality Assurance’s (NCQA’s) Physician Practice Connections–Patient Centered Medical Home (PPC-PCMH) recognition program.15 This study assesses the clinical quality outcomes of PCIP-participating practices that have achieved PPC-PCMH recognition from NCQA, and compares performance on quality measures from 2009 through 2011 in practices that have been PCMH-recognized with those that have not.
In an effort to transform primary care and improve population health, PCIP assists primary care practices in the adoption and use of electronic health records (EHRs). From its inception in 2005 through early 2012, PCIP assisted over 3000 primary care clinicians located in over 600 independently owned practices to adopt preventionoriented EHR systems. Collectively, PCIP participants represent over 20% of New York City’s primary care clinicians and serve approximately 2.6 million patients.16
Recognizing that digitizing the information around healthcare alone would not bring about the changes needed to improve the delivery of clinical preventive services, PCIP offers additional support to address both technical needs and quality improvement (QI).17 PCIP employs a field team dedicated to assisting clinicians in optimizing work flows and leveraging data from their own EHR systems to track clinical quality performance. Much of the QI curriculum was modeled around the standards articulated by the NCQA’s PPC-PCMH program. This included an initial visit to identify practice leadership or champion for QI activities; follow-up meetings with the practice or provider to review progress on meeting QI objectives; using the functions within the EHR, such as the registry tool that generates lists of patients by selected characteristics (eg, diagnosis of hypertension with blood pressure over 140/90 mm Hg without a visit to practice in past 6 months and no scheduled visit in next 3 months); and reviewing the quality reporting tool—a specific feature within eClinical- Works co-developed with PCIP to display quality measures tied to the city’s health policy agenda.18 PCIP offered visits to practices every 4 to 6 weeks; staff were available by e-mail and phone to answer questions in addition to the on-site visits.
To encourage and facilitate the PPC-PCMH recognition process, PCIP established a multi-site application and offered to practices the ability to apply under the 2008 standards. Fees for the application were also subsidized by PCIP. Because some of the PCMH standards had been met across all PCIP practices, such as having an EHR with clinical decision support, clinicians did not have to repeat some of the standard documentation related to their EHRs in their NCQA applications. PCIP practices eligible to be included in the multi-site application were eligible to receive 36.75 points, which at the time was adequate for obtaining Level 1 recognition. However, all practices still needed to provide supporting documentation to demonstrate to NCQA their use of the systems; if practices wished to do so, they could work towards a higher recognition level by submitting additional documentation. NCQA then reviewed the documentation gathered by practices and submitted by PCIP to determine whether clinicians in the application met Level 1, 2, or 3 PPC-PCMH standards. By early 2012, PCIP had assisted roughly 25% of its member practices in achieving NCQA recognition, including 269 sites representing 169 practices and 657 clinicians to meet 2008 standards. Practices applying for PPC-PCMH recognition after July 1, 2012, are required to follow 2011 standards.
Primary care practices were included in this analysis if they had 5 or fewer clinicians and adopted the eClinicalWorks EHR system prior to October 2009. Pediatricfocused practices were excluded as the quality measures analyzed were limited to adult primary care. Practices were also excluded if data were unavailable for either of the 2 analysis periods: October 2009 and October 2011. Because the process of obtaining NCQA recognition can take between 6 to 12 months, practices were categorized into the PCMH-recognized group if they achieved NCQA recognition at any time up until February 2012.
As part of a contract negotiated with eClinicalWorks, PCIP established an automated monthly data transmission process to receive summarized data generated from each practice’s EHR. Practices receiving support from PCIP have agreed to provide data transmitted through this process. The data transmitted consisted of clinician-level aggregated counts of patients meeting numerator and denominator definitions for each of the quality measures, developed to be consistent with National Quality Forum measure definitions. 19 EHR utilization data are also received monthly, including number of labs reviewed, order sets used, number of monthly encounters per full-time equivalent (FTE), number of unique patients seen per month, as well as proportions of patients by age group, gender, race/ethnicity, or with a diagnosis of hypertension, diabetes, or both. PCIP staff used Salesforce, a commercially available, Webbased customer relationship management (CRM) application to monitor activities with the practices (eg, site visits with QI or other PCIP staff, attendance at classes or seminars hosted by PCIP or the vendor), maintain program administration and contact information, and track practice milestones such as initial contact for recruitment and date of EHR “go-live.”
Selection of Quality Measures
Seven clinical quality measures of care and documentation were selected for analysis: (1) antithrombotic therapy for patients with diabetes or ischemic vascular disease; (2) blood pressure control in hypertensive patients with and without diabetes (2 separate measures); (3) body mass index (BMI) recorded; (4) glycated hemoglobin (A1C) testing in patients with diabetes; (5) smoking status recorded; and (6) smoking cessation intervention, including counseling, prescription drugs, and referrals to the New York State fax-to-quit hotline for identified smokers (Table 1). These 7 measures were selected because they are indicators of clinical performance aimed at preventing and reducing smoking, diabetes, and cardiovascular disease, all of which are leading contributors to a large burden of morbidity and mortality within New York City and the United States.18,20 These chronic conditions are also frequently reported by PCIP field staff as some of the most common conditions among patients in practices seeking NCQA PCMH recognition.
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