Clinical data should contribute to practice-based learning and improvement, resulting in improved patient care as well as meeting increasingly rigorous physician accountability requirements.
The movement toward improvement in healthcare quality and patient safety has led to greater emphasis on practice performance measurement and physician accountability. Health information technology provides clinical data for quality measurement but hasn't provided the link to practicebased learning and improvement. An electronic portfolio for practice-based learning and improvement (ePortfolio) that combines practice data for identification of competency and performance gaps along with learning and process interventions offers true practice-based learning and performance improvement. Automated reporting can assist in the ever-increasing burden of documentation for maintenance of licensure, maintenance of specialty board certification, credentialing, payer recognition programs, and other physician accountability requirements.
(Am J Manag Care. 2010;16(12 Spec No.):SP57-SP61)
Use of practice data that are collected and analyzed through health information technology will lead to practice-based learning and improvement resulting in:
The turn of the 21st century brought a new focus on healthcare quality and patient safety. Drivers of this movement included reports by the Institute of Medicine and RAND, which revealed a healthcare quality crisis.1,2 These early reports ignited a firestorm that led to the recent passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act and national health reform through the Patient Protection and Affordable Care Act (PPACA). Inherent to these acts is the premise that quality improvement is the key to the transformation of the US healthcare system.3,4
Although many interventions have been proposed to advance quality, information technology has emerged as the chief vehicle for driving change.5 A well-articulated blueprint has been developed by the health information technology (HIT) community, which focuses primarily on electronic health records (EHRs) and health information exchanges (HIEs).6 However, a vital piece of the HIT framework is missing: the electronic portfolio for practice-based learning and improvement (ePortfolio). The ePortfolio supports physicians in their mission-critical role as champions for continuous quality improvement (CQI). It bridges the divide between practice performance assessment and medical education to connect physicians to interventions based on performance patterns and actual gaps in their delivery of care. Studies have shown that linking learning and performance in just such a physician-centric format leads to improved quality and health outcomes.7-9
To date, use of ePortfolios that link performance and learning has been limited, in part because of the unavailability of rich patient-level data sets attributable to the physician and the lack of awareness of their potential and value. With the widespread adoption of EHR and HIE systems on the horizon, access to this crucial data is finally within reach. Once ePortfolios are fully operational on a continuous basis, the value to physicians, patients, and other stakeholders will be realized. The key to rapid, meaningful increases in quality improvement may be the ability to deploy ePortfolios between health plans (including managed care organizations), providers, and provider organizations for quality initiatives that include pay-for-performance (P4P), appropriate use, and clinical pathway implementation.
In this article we provide a brief history of the convergence of medical education and quality management so that readers can understand the need for a provider-centric ePortfolio that supports both performance and learning. In addition, we describe general characteristics and required features of the ePortfolio, as well as touch pointsfor the physician-authorized exchange of information among systems. The value and impact of this platform for managed care organizations, their provider networks, and various other stakeholders within the healthcare community will be evident through increased quality, efficiency, and provider satisfaction.
INTEGRATION OF MEDICAL EDUCATION AND QUALITY MANAGEMENT
Medical education and quality management have been traditionally siloed in medical schools, medical specialty societies, hospitals, and other healthcare organizations. Therefore, use of performance measurement in the development of medical education specific to addressing gaps in performance was rarely considered. The continuum of medical education has not provided for continuous performance measurement and improvement.
In the past, the provider’s professional responsibilities related to licensure, specialty board certification, and credentialing were relatively easy to understand and straightforward to maintain. Learning, in particular the need to accumulate continuing medical education (CME) credit, was a “check the box” requirement. In addition, tracking compliance often was accomplished using simple data systems, manila folders, or the proverbial shoe box full of paper certificates of participation. The traditional concept of CME, however, has been exposed as having little value in changing physician behavior or healthcare outcomes.10 The forward-thinking concept of continuous professional development and its focus on lifelong learning emerged from the void left by CME. Where CME was characterized by intermittent activities that were focused on global needs, continuous professional development is learner-centric, focused on the lifelong learning needs of the individual physician.
Prior to 2001, quality management was primarily a focus of hospitals and health systems interested in emulating the quality improvement efforts found in other sectors, such as
the automotive industry.11 The Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties shifted the focus of quality management to physicians’ training and practice when they defined the 6 core competencies, including the addition of practice-based learning and improvement.12,13 Similar to continuous quality improvement models, practice-based learning and improvement has been defined as the ability of a physician to (1) monitor practice, (2) reflect on or analyze practice to identify learning or improvement needs relevant to improving practice, (3) engage in learning or plan improvement, (4) apply new learning or improvement to practice, and (5) measure and monitor the impact of the learning or improvement on performance.14
The forces of reform are driving the convergence of quality management and medical education, and significantly raising the stakes surrounding the physician’s professional accountability. The transition of CME to continuous professional development and lifelong learning, and the entrée of practice-based learning and improvement as a core competency, indicate how the professional landscape has been altered as a result of healthcare reform.
The impact of this revolutionary change and its meaning to providers can be tracked along 2 axes. The first is the integration of quality management requirements, including practice-based learning and improvement, into high-stakes professional programs, which include maintenance of licensure and maintenance of specialty board certification. These new requirements reflect a fundamental change in philosophy in the “house of medicine” from a focus on cognitive learning and assessment through CME and written examinations to ongoing assessment, lifelong learning, and improvement in practice.
The second axis of change is linkage of practice-based P4P initiatives to professional certification programs. The Centers for Medicare & Medicaid Services (CMS) provides an additional bonus incentive for completing the Physician Quality Reporting Initiative through a medical specialty board’s program for maintenance of specialty board certification.15 Private payers such as Highmark BlueCross and BlueShield also have begun to merge practice and professionalism, as evidenced by their QualityBlue P4P Program.16 In that case, a section titled “Best Practices” provides physicians with points toward an incentive bonus for completing performance improvement activities through national organizations including the American Board of Internal Medicine, the American Osteopathic Association, the National Committee for Quality Assurance, and others.
These new concepts will require much more than a 1-time chart abstraction for quality review or reporting of CME credit. Various stakeholders will be requesting that physicians participate in ongoing performance improvement through practice measurement, analysis of practice data, and implementation of interventions for improvement that include education and systems-based process improvement, followed by remeasurement to continuously assess change and measure performance in practice. Other changes include reporting requirements for maintenance of specialty board certification and maintenance of licensure, multiple P4P and reporting programs, the Joint Commission’s Ongoing Professional Performance Evaluation, Risk Evaluation Mitigation Strategies mandated by the Food and Drug Administration, accountable care organizations, and others. Although these comprehensive changes will help bring provider accountability in line with public and provider stakeholder expectations, they also will bring a new level of complexity. Significant efforts to align these various programs are under way, driven by stakeholders such as the American Board of Medical Specialties, CMS, and progressive health plans. However, there remains an urgent need for HIT to support physicians in their continuous quality improvement efforts and to help them manage an ever-increasing reporting burden.
ELECTRONIC PORTFOLIO: THE MISSING PIECE IN HEAlTH INFORMATION TECHNOLOGY
Electronic portfolios are a key theme in higher education due to their ability to promote a learner-centered approach to education with a focus on reflection and outcomes.17 As a
“learning portfolio” their primary function is to store documents, complete assessments, identify learning goals, build personal development plans, and present educational programming, combined with the ability to reflect on these activities, track their outcomes, and share the results with mentors. For practicing physicians, these would be welcome tools to assist them with their continuous professional development and lifelong learning needs.
On the other hand, performance assessment portfolios (often referred to as performance scorecards, balanced scorecards, or benchmarking systems) are used within the healthcare industry to calculate performance measures and present performance scores to providers on behalf of payers or their health systems. This form of portfolio is considered to be targeted to the physician, but in actuality it is most frequently presented within administrative systems used by practice managers and other nonphysicians.18
In order to support the emerging needs of today’s practicing physician engaged in continuous performance improvement and outcomes reporting, a more robust notion of the ePortfolio is required, one that joins the performance portfolio with the learning portfolio. By integrating performance and learning within a single information system and personalizing this system for the physician, practice-based learning and improvement and CQI can be realized. Performance assessment, although of some value, is not enough to guarantee improvement. By linking performance and learning on a continuous basis, the ePortfolio can inform the physician of gaps related to practice performance in real time. Gaps in practice performance, knowledge assessment, regulatory requirements, and self-directed needs all can be addressed using this approach. Physicians can see how their improvement efforts affect their personal performance, and stakeholders gain access to evidence of the interventions that are most effective.
CHARACTERISTICS OF THE ELECTRONIC PORTFOLIO
Personalization to the Physician
The physician-centric aspects of the ePortfolio will help achieve the transformative mind-set needed to merge practice with professionalism for physicians. Few practicing physicians have been trained to consider practice performance and professional requirements in a unified way. The ePortfolio will achieve this goal by providing the physician with a personal view of his or her world.
Access to practice-level data is important for driving CQI through the ePortfolio. The ePortfolio should be flexible in its approach to data aggregation. If data are readily available from external systems, standardized methods for importation should be available. In those cases where external data are unavailable or incomplete, Web-based tools should be provided for chart abstractions or registry development.
Monitoring of Performance
Standardized performance measures must be supported. The ability to periodically calculate and present the results to the physician in the form of an actionable measure monitor or dashboard is an essential component.
Identification of Performance Gaps
The link between performance and learning becomes real when gaps in performance or knowledge can be determined and acted on to drive CQI. Physicians are given the opportunity to measure performance based on predetermined goals, benchmarks, or personal goals.
As data flow is enriched, it becomes feasible for physicians to determine how various elements of their practice (eg, disease, disparity, safety) are affected by performance gaps. Access to this information will help provide the physician with direction for performance improvement.
Traditionally the learning objectives for CME were developed based on perceived needs and interests with vague, global learning objectives. In the ePortfolio, performance gaps represent learning objectives. A system that can intelligently and dynamically connect the learner with personalized pathways for performance improvement will be invaluable for CQI.
The ePortfolio should provide the physician with flexible reporting tools and services to generate physician-authorized outbound reports to a variety of stakeholders. These might include regulators, health plans, CMS, and other organizations for the purposes of credentialing, P4P, maintenance of specialty board certification, maintenance of licensure, and so forth.
ePortfolio Information Exchange
Portability of data across the continuum of the physician’s training and professional career, from undergraduate medical education through emeritus, should be a goal of all ePortfolios. Efforts are under way to define a standard for this exchange of information by the medical education technical standards development organization MedBiquitous, as well as others.
VALUE PROPOSITION FOR STAKEHOLDERS
Widespread adoption of a practice-based performance and learning ePortfolio will enable meaningful physician participation in CQI. However, achieving this objective will require support from a broad spectrum of important stakeholders. Fortunately, there is evidence that suggests that CQI leads to better patient outcomes and improved processes, as well as lower costs, across a variety of care settings.8,19 A significant value proposition exists for all of the following stakeholders: regulatory organizations, health plans, hospital systems, physicians, and most importantly, patients. For managed care organizations in particular, supporting solutions like ePortfolio, which will help scale and spread CQI initiatives, can address a number of quality, safety, and financial issues. PPACA contains several health policies that will revolutionize the nation’s payment structure, from fee-forservice to value-based purchasing. As a result, the demand for provider participation in CQI will shift from a quest for improvement to a mandate that has substantial financial implications.
However, stakeholders must address certain current limitations. The HIT community must ensure that appropriate data are accurately collected and shared to ensure effective measurement. Measure developers must focus on practice-relevant, evidence-based clinical measures. Physicians and other healthcare professionals must develop skills in practice measurement and improvement. Without meaningful practice data, measurement, and improvement, healthcare delivery cannot improve.
IMPLICATIONS FOR MANAGED CARE
Under the Medicare Advantage CMS Star Rating System Medicare Advantage plans face an average 12% decrease in revenues by 2017.20 However, PPACA provides the opportunity to recoup these losses based on quality performance as indicated by the health plan’s CMS Star Rating. Managed care organizations must immediately set in motion initiatives to ensure that they are able to achieve the highest possible Star Ratings, as millions of dollars are at risk. The Star Rating has 4 components: (1) quality of care, (2) access to care, (3) responsiveness of care, and (4) member satisfaction with the plan.21 Through CQI, plans have the opportunity to drive considerable improvement in these metrics that directly affect their bottom line. PPACA also mandates quality improvement throughout the Standards for Participating Health Plans under the rules for Health Insurance Exchanges. Managed care organizations must be able to drive a strategy for quality improvement and to track the performance of providers in their networks to participate.
The ePortfolio, as described here, can provide the platform for a confluence of individual clinical performance assessments, healthcare delivery quality goals, and documentation for physician accountability. It has the potential to enhance practicebased learning and improvement not only for physicians, but also for other healthcare professionals involved in the delivery of patient care. Further, it can inform healthcare administration and policy through ongoing measurement and improvement.
Implementation of the ePortfolio no doubt will lead to additional questions. What data are meaningful to stakeholders? How much of this process can be embedded in practice to reduce the burden of data collection and reporting for physicians? Can the ePortfolio be coordinated across the healthcare delivery team? Practical application of the process followed by effective study of its impact will result in continuous improvement of patient care.
The authors wish to acknowledge the thoughtful review and insights of David Davis, MD, Senior Director, Continuing Education and Performance Improvement, Association of American Medical Colleges.
Author Affiliations: From the National Institute for Quality Improvement and Education (NLD), Homestead, PA; CE City (LM), Homestead, PA; and Northwestern University (ZEM), Evanston, IL.
Funding Source: The authors report no external funding for this work.
Author Disclosures: The authors (NLD, LM, ZEM) report being employed by CECity, a provider of continuous quality and performance improvement technology. Dr Davis is also employed by the National Institute for Quality Improvement and Education (NIQIE), and reports her membership on the board of NIQIE and the Executive Committee of MedBiquitous. Mr L Myers reports holding stock in CECity and having a patent pending for "Systems and Methods Related to Continuing Performance Improvement". Mr L Myers also reports being a board member of CECity, NIQIE, and MedBiquitous.
Authorship Information: Concept and design (NLD, LM, ZEM); acquisition of data (NLD, LM, ZEM); analysis and interpretation of data (NLD, LM, ZEM); drafting of the manuscript (NLD, LM, ZEM); critical revision of the manuscript for important intellectual content (NLD, LM, ZEM); administrative, technical, or logistic support (NLD, LM); and supervision (NLD).
Address correspondence to: Nancy L. Davis, PhD, Executive Director, National Institute for Quality Improvement and Education, 285 Waterfront Dr E, Ste 100, Homestead, PA 15120. E-mail: firstname.lastname@example.org.
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