Small Practices’ Experience With EHR, Quality Measurement, and Incentives
Published Online: November 21, 2013
Rohima Begum, MPH; Mandy Smith Ryan, PhD; Chloe H. Winther, BA; Jason J. Wang, PhD; Naomi S. Bardach, MD; Amanda H. Parsons, MD; Sarah C. Shih, MPH; and R. Adams Dudley, MD, MBA
Use of incentives and pay-for-performance (P4P) to realign payment to address problems of low quality of care or gaps in preventive services has had limited success in improving the quality of healthcare.1-6 For the most part, studies on P4P have focused on large group practices.7-10 Small practices, where the majority of patients still receive care nationally,11 historically face greater obstacles to improving care because they have lacked the scale and organizational structure to conduct quality improvement activities or participate in P4P.12,13
It is important to assess clinician attitudes toward key program features, such as the selection of target quality measures, trust in performance reports, and relevance of quality targets. Understanding clinician motivations and opinions toward a quality improvement program may help predict the extent to which they change their clinical behavior.14 Specific program features, such as the frequency and type of performance feedback and available assistance for meeting program goals, could potentially affect clinician awareness and understanding of particular programs. Clinician skepticism about the accuracy of reports, or distrust of or lack of transparency in data used for reporting or payment, may lead to less engagement of clinicians in incentive programs or quality improvement efforts.15-17
With widespread implementation of electronic health records (EHRs),18 EHR-enabled solo and small group practices have been shown to be capable of responding to quality improvement (QI) initiatives, as well as programs that incentivize using quality measurement.19 It is unknown how clinicians will feel about quality measurement and pay-forperformance using EHR-derived quality measures. To address this gap in the literature, we surveyed clinicians participating in Health eHearts, a cluster-randomized trial of the effect of a financial incentive and QI assistance program on measures of cardiovascular care compared with the effect of providing quality reports and QI assistance. The Primary Care Information Project (PCIP), a bureau of the New York City Department of Health and Mental Hygiene, piloted Health eHearts in practices that recently adopted an EHR and that were receiving ongoing QI visits to improve practice work flows using health information technology. Survey domains included overall experience with the program, as well as experience with the tools supporting QI efforts. In addition, we assessed whether there were differences in experiences or attitudes and whether these attitudes differed for practices receiving incentives or not.
Practice Selection and Assignment
PCIP recruited 140 small practices to participate in Health eHearts. The program duration was April 2009 to September 2011. Practices were eligible if they have been “live” on the EHR for at least 3 months, had a minimum of 200 patients with cardiovascular diagnoses related to the quality measurement targets, and were transmitting quality measures through the EHR to PCIP. Practices agreed to be randomized into “recognition” or “rewards” groups. Rewards consisted of financial incentives for each numerator met for 4 areas of cardiovascular care: aspirin therapy, blood pressure control, cholesterol control, and smoking cessation intervention (ABCS). Incentive amounts ranged from $20 to $150 per patient with goal achieved, with higher payments for harder to treat patients (eg, comorbid diseases or lower socioeconomic status). The recognition group served as a control. Both groups (control and incentive) received quarterly quality performance reports, telephone and onsite coaching on work flow redesign, and training on documentation, and were invited to a recognition program at the end of the year. The quality reports summarized practices’ progress on the ABCS and compared their performance with other practices in Health eHearts and trends over the previous 6 months.
Survey Administration and Instrument
Health eHearts was a 2-year program, with cohort 1 enrolled at the beginning and continuing for 2 years and cohort 2 enrolled at the beginning of year 2. Practices were surveyed before and after each program year. This study focuses on the survey administered to all participating practices at the end of Health eHearts. A 33-item survey (29 items in the control group version) was administered in October 2011. A lead clinician from each practice was invited to respond to the survey first by mail, followed by at least 3 reminder phone calls to nonresponding clinicians. Survey administration continued through February 2012.
The instrument was developed in collaboration between PCIP and researchers from University of California San Francisco (UCSF) who were contracted as evaluators for the overall evaluation of the program. The instrument focused on several aspects of the Health eHearts program: clinicians’ experiences and attitudes toward the selected quality measures (ABCS), training on use of the EHR or achievement of ABCS, QI visits, tracking patients for preventive services using the EHR, quality reports, incentive payments (incentive group only), recognition programs in general, and demographics. The survey was pretested with program staff and a clinician in PCIP. Items used in this survey were based on an earlier instrument co-developed with UCSF to assess barriers and facilitators for small practices to participate in P4P. Topics identified as barriers included: accuracy and regularity of reports relevant to the practice’s patient population, measurement targets that were meaningful to the practice population, availability of training or assistance to conduct QI activities, and use of practice tools, such as the EHR, to identify patients and document for quality measurement reports.
The survey was considered part of program evaluation activities conducted by PCIP and was deemed exempt by the Institutional Review Board at New York City Department of Health and Mental Hygiene. Clinicians in the control group were offered a $100 honorarium for participating in the survey.
Frequencies and averages were calculated for practice characteristics stratified by whether the practice was in the incentive or control group. All items in the survey were recorded into dichotomous variables and then stratified by incentive and control groups. Significant statistical differences between the incentive and control group were determined using χ2 tests. Data were analyzed using SAS software, version 9.2 (SAS Institute, Cary, North Carolina).
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