Implementation of Specialty Society Performance Improvement (PI) CME How CME and Quality Improvement (QI) Can Collaborate to Improve Physician Performance December 10, 2007 2007 AMA Faculty Alejandro Aparicio, MD, FACP Director, AMA Division of Continuing Physician Professional Development (CPPD) 312.464.5531 alejandro.aparicio@ama-assn.org Sue Ann Capizzi, MBA Associate Director, AMA Division of Continuing Physician Professional Development (CPPD) 312.464.4230 sueann.capizzi@ama-assn.org Susan Richart, MBA, CPHQ Manager, Performance Assessment and Improvement American Academy of Family Physicians 913.906.6000 x4130 srichart@aafp.org Disclosure The content of this presentation does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose. 1
Objectives At the end of this presentation participants should be able to: Explain why participation in PI CME activities may become recognized as having increased value to physicians and accredited CME providers in the future Describe the components of a PI CME activity that meet the requirements for AMA PRA Category 1 Credit Identify at least two sources of evidence-based performance measures that can be the basis for a PI CME activity Describe how one specialty society has implemented a PI CME activity for physicians What is PI CME? Three stage learning model approved for AMA PRA Category 1 Credit, September 2004, as a result of pilot study done in collaboration with American Academy of Family Physicians (AAFP) and other stakeholders Structured long-term process developed by an accredited CME provider in which evidence-based measures and quality improvement (QI) interventions, not traditionally thought of as CME, are used to change physician performance What is PI CME? (continued) May address any facet of a physician s practice with direct implication for patient care Differs in structure from other CME learning models that may also use PI/QI data (live activities, enduring materials, etc) PI CME is not a PI project that can be approved for credit retrospectively 2
Why has PI CME become so important? Potential solution to meeting multiple physician reporting requirements (MoC, MoL, P4P) Brings the CME activity closer to the patient-physician interaction Facilitates what has long been a goal of CME: To have QI and CME work together in a more effective manner What is MoC? Maintenance of Certification (MoC) is a program adopted by the American Board of Medical Specialties (ABMS) in 2006 a program of continuous professional development ABMS MoC - as a formal means of measuring a physician s continued competency in his or her certified specialty and/or subspecialty Physicians who wish to maintain their specialty certification must meet MoC requirements on a periodic basis Components of MoC include: lifelong learning and self-assessment, and practice performance assessment For more information on MoC, visit the ABMS website: www.abms.org What is MoL? Maintenance of Licensure (MoL), as described by the Federation of State Medical Boards (FSMB) is the process by which a licensee demonstrates that he/she has maintained his or her competence and qualifications for purposes of continued licensure Involvement in MoC may become a requirement for MoL for certified physicians For non-certified physicians, MoL requirements may include reporting of CME credits and evidence of practice performance assessment For more information on MoL, visit the FSMB website at: www.fsmb.org 3
What is P4P? Pay for Performance (P4P) is a Centers for Medicare and Medicaid Services (CMS) initiative to encourage improved quality of care in all settings where Medicare beneficiaries receive their health care services The foundation of P4P initiatives is ensuring that valid quality measures are used for achieving actual performance improvement CME providers that wish to assist physicians who participate in P4P will need to learn more about how physicians may comply with P4P requirements For more information about P4P, visit the CMS website at: www.cms.hhs.gov Why should specialty societies consider producing PI CME activities? Unique opportunity work collaboratively with corresponding specialty certification Board New benefit that responds to members needs to demonstrate compliance with MoC Part IV Performance Practice Assessment and other reporting requirements Consistent with the spirit of the new ACCME criteria What should CME Providers do to get started in PI CME? Become familiar with PI CME requirements (PRA booklet, pages 10-11) and know how to find/use quality measures Explain to your PI/QI colleagues how PI CME activities present an opportunity to improve physician performance/patient care and help physicians meet reporting requirements Determine whether there are specific initiatives in which you can collaborate with PI/QI to implement a PI CME activity Enlist organizational support (CME committee, medical leadership, administration, etc.) Determine how to work with your corresponding certification Board to have PI CME approved for MoC Part IV 4
How to Structure and Award Credit for PI CME Sue Ann Capizzi, MBA How is a PI CME activity structured? Three stage process: Stage A - Learning from current practice performance assessment Stage B - Learning from the application of PI to patient care Stage C - Learning from the evaluation of the PI effort Stage A - Learning from current practice performance assessment Assess current practice using identified performance measures, either through chart reviews or other appropriate mechanism Participating physicians are actively involved in data collection and analysis 5
Stage B - Learning from the application of PI to patient care Implement PI interventions based on performance measures selected in Stage A, using suitable tracking tools Participating physicians should receive guidance on appropriate parameters for applying the intervention(s) and assessing performance change specific to the physician s patient base Sample interventions that might be included in Stage B Chart reminders Flow sheets Patient communications - postcards, emails, phone calls System changes Education Stage C - Learning from the evaluation of the PI effort Re-evaluate and reflect on performance in practice (Stage B) by comparing to the assessment done in Stage A Summarize any practice, process and/or outcomes changes that resulted from conducting the PI activity 6
What must a CME Provider do in order to designate AMA PRA Category 1 Credit for a PI CME activity? Be accredited by the Accreditation Council for Continuing Medical Education (ACCME) or a state medical society recognized by the ACCME Design the PI CME activity compliant with core requirements for designating AMA PRA Category 1 Credit Design the PI CME activity to comply with specific requirements for PI CME What are the core requirements for an AMA PRA Category 1 Credit CME activity? Refer to PRA Booklet (pages 4-5): Conforms to definition of CME Appropriate depth and scope Non-promotional Addresses an educational need Objectives/purpose communicated Core requirements (continued) Learning format appropriate to objectives Evaluation mechanism Means to record the actual credits claimed by the physician Designated for credit in advance Appropriate Designation Statement in activity materials 7
What are the additional requirements for a PI CME Activity? Design as a 3 stage learning activity Use evidence-based performance measures Provide background information on performance measures to physicians Provide clear instructions to learners Validate participation by reviewing PI documentation How is credit awarded for PI CME? Five credits for completion of each stage in which the physician actively participates Additional 5 credits for completion of all three stages 5 + 5 + 5 = 20 Points to remember when awarding credit for PI CME Credit is not based on time Credit is issued even if there was no change in practice Stage C could begin another PI CME activity, becoming Stage A of the next 8
Identifying and Using Performance Measures What is a clinical performance measure? Mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion (Institute of Medicine, 2000) Mechanism to measure the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in the optimal time period (National Quality Measures Clearinghouse) What types of information can be captured from performance measures? Access Outcome Patient Experience Process Structure Timely attainment of appropriate health care Health state of the patient resulting from the care provided Perspective on the quality of care Identify areas of care that may require improvement Feature of an organization relevant to capacity to provide care (eg. nurse/patient ratio) 9
What is important to know when selecting performance measures? Measures must be evidence-based* and well designed with clearly specified required data elements for feasible data collection Measures should not focus on cost of care separate from measurement of quality of care * integration of best research evidence with clinical expertise and patient values Where can we find evidence-based performance measures? 1) National Quality Measures Clearinghouse (NQMC) www.qualitymeasures.ahrq.gov 2) Physician Consortium for Performance Improvement (PCPI) www.physicianconsortium.org National Quality Measures Clearinghouse (NQMC) National repository of evidence-based measures sponsored by Agency for Healthcare Research and Quality (AHRQ) Good information that defines measures and how to use measures Easy to navigate site provides access to hundreds of measures across many diseases and conditions 10
Physician Consortium for Performance Improvement (PCPI) AMA convened organization governed by multiple stakeholders Goal is to lead in the development of performance measures for physicians to improve quality at the point of care and to make clinical guidelines quantifiable Comprised of over 100 stakeholders including specialty and state medical societies, medical specialty boards; experts in methodology and data collection, government, payers, employers and consumer groups Consortium activities are carried out through cross-specialty work groups 213 PCPI performance measures available for 31 clinical topics Acute otitis externa /otitis media with effusion Adult diabetes Anesthesiology and critical care Asthma Chronic kidney disease Chronic obstructive pulmonary disease Chronic stable coronary artery disease Community-acquired bacterial pneumonia Emergency medicine End state renal disease Eye care Gastroesophageal reflux disease Geriatrics Heart failure Hematology Hepatitis C Hypertension Major depressive disorder Melanoma Oncology Osteoarthritis Osteoporosis Outpatient parenteral antimicrobial therapy Pathology Pediatric acute gastroenteritis Perioperative care Prenatal testing Preventive care and screening Prostate cancer Radiology Stroke and stroke rehabilitation Etc. Access and use of PCPI measures Royalty-free permission to reprint and distribute Consortium measures are available to CME providers Available at: www.physicianconsortium.org 11
Sample PCPI Measure Set Chronic Stable Coronary Artery Disease (CAD) Provided by: American College of Cardiology, American Heart Association, and Physician Consortium for Performance Improvement Purpose, Statistics, Relevant Guidelines Designed for any physician who manages ongoing care of patients (=/>18) with CAD 9 clinical performance measures References Data Collection Flowsheet Sample performance measure from the CAD measure set Antiplatelet Therapy Measure description: Percentage of patients who were prescribed antiplatelet therapy Numerator: Patients who were prescribed antiplatelet therapy (aspirin, clopidogrel or combination of aspirin and dipyridamole) Denominator: All patients with CAD =/> 18 years old Denominator exclusions: Documentation of medical reason(s) / patient reason(s) / system reason(s) for not prescribing antiplatelet therapy How might the antiplatelet therapy measure be used in a PI CME activity? 12
Stage A: Learning from practice performance assessment Physician selects 10 charts of patients with a diagnosis of CAD Physician evaluates performance in relation to antiplatelet therapy recommendations If data is available from the institution, provider can have physician complete a questionnaire and then compare his perceived status with actual data Completion of Stage A Physician analyzes data comparing it to the performance measure Physician completes form indicating results of this assessment Stage B: Learning from the application of PI to patient care Interventions are put into place Contact patients not receiving appropriate antiplatelet therapy to schedule an appointment Implement a reminder system for patient visits Implement a system to monitor antiplatelet therapy for CAD patients Other interventions that are agreed upon 13
Completion of Stage B Could be based on number of patients seen with CAD Could be a predetermined time frame, e.g. six months Documentation should reflect the interventions that were used for different patients Stage C: Learning from the evaluation of PI effort Re-evaluate and reflect on performance in practice (Stage B) by comparing to the assessment done in Stage A Audit 10 additional charts Complete questionnaire indicating perception of performance; compare to actual data Summarize any practice, process and/or outcome changes that resulted from conducting the PI activity Other considerations for developing this PI CME activity Provide physicians with background information including needs assessment, objectives, requirements for completion, time frame Have a kick-off or orientation meeting with groups of physicians 14
PI CME in Practice Susan Richart, MBA, CPHQ Manager, Performance Assessment and Improvement American Academy of Family Physicians Case Study METRIC Measuring, Evaluating, Translating Research Into Care 44 The American Academy of Family Physicians (AAFP) The AAFP is an ACCME-accredited provider of CME and one of three national accrediting organizations for CME for physicians. In 2007 the AAFP was reaccredited with Commendation for six years by the ACCME. The AAFP produced 175 CME activities for a total of 2,452 credits in fiscal year 2007. The AAFP is the third largest medical specialty society representing nearly 94,000 family physicians, residents, and medical students. The AAFP is the only medical society devoted solely to primary care. 45 15
METRIC is an online performance in practice activity that meets Maintenance of Certification for Family Physicians Part IV (MC-FP Part IV) and awards 20 AMA PRA Category 1 Credits Five module choices are currently available: Diabetes, Coronary Artery Disease, COPD, Asthma, and Geriatrics 46 Background The AAFP has been formally committed to strategies that support continuing quality improvement in family physician practices since 1997. The American Board of Family Medicine set parameters for meeting MC-FP Part IV and implemented them in 2006. AAFP s METRIC provides a structure and process for purposeful change and improvement that fulfills the MC-FP Part IV requirement. 47 Current Levels of Performance Current performance shows that we give indicated care about 55% of the time - McGlynn (2003). If population health measure rates are to improve, the process changes must begin at the practice level, the smallest system of care. Bruce Bagley, M.D., Medical Director for Quality Improvement for AAFP, describes the need as a change from Pedigree to Performance by developing PI CME for physicians and their practice team. 48 16
Collaboration with QI A cross-divisional AAFP staff group from the following areas was initially responsible for the business plan for the METRIC Activity: Information Technology CME Scientific Activities Online and Custom Publishing Quality Improvement Bruce Bagley, M.D., Medical Director for Quality Improvement at AAFP, is involved in the METRIC module content development process. 49 Collaboration with QI (cont d) Each METRIC module has a multi-disciplinary faculty: a content expert, a medical editor, a guidelines/measures expert, and a quality expert. METRIC is managed by QI staff and has a physician advisory committee. AAFP has a Quality Team of six. The CME Division currently has a staff of 26. Other AAFP Divisions also produce CME activities. 50 Performance Improvement If a team is to accomplish its goals, it has to know where it stands. If you think you are the entire picture, you will never see the big picture. - John Maxwell From perception to reality, performance assessment is the heart of quality. 51 17
METRIC Objectives as a Performance Improvement Activity Expose physicians to a model of care that is patient-centered, team-oriented, and likely to lead to better patient outcomes. Assist physicians in assessing their current practice based systems from a structural, procedural, and outcome perspective. Provide interventions suited to the continuum of practice environments of the Family Physician. 52 Activity Objectives Example using Diabetes Module Learning Objectives After completing this module, physicians should be able to do the following: Assess current practice performance through chart audits that measure and remeasure key indicators of high-quality diabetes care. Evaluate the current office environment to determine whether and how it supports processes that lead to improved patient outcomes. Prioritize and implement practice changes using proven quality improvement methods. Identify and execute changes that consistently support patientcentered outcomes for patients who have diabetes. Summarize the effect of short-term changes on practice performance and select long-term changes that support ongoing, continued improvement 53 Evidence Based Performance Measures Chart review measures are from the AMA Physician Consortium for Performance Improvement. Measures are appropriate for the Family Physician practice environment. Measures are derived from evidence based guidelines. 54 18
PI CME: Stages of Activity Stage C Evaluation & Outcome Stage A Practice Assessment Stage B Intervention 55 Stage A: Learning from current practice performance assessment METRIC uses the Chronic Care Model as a basis for assessment of practice based systems of care for chronic illness. http://www.improvingchroniccare.org/index.php?p=chronic+care+model&s=124 56 Stage A: Example of Assessment of Practice Based Systems of Care In my practice, for patients with diabetes, planned visits for diabetes care are not used. are used if patients are not doing well or need refills. are implemented for certain patients. Reminder cards are used but there is no long-term planning for regular visits. Checklists and flow sheets are used, as well as other tools to assure that key elements of care are provided. are used for all patients and include regular assessment, preventive interventions and attention to self-management. are used systematically to optimize patient follow-up; in addition, missed elements of planned care are easily spotted through an alert system. 57 19
Stage A: Performance Measures Example Physician reviews 10 charts with online data entry. Program assigns a random identifier to each chart. Measure: Does the chart reflect a recommendation for aspirin therapy (dose >=75mg)? Education embedded in the Program includes: Clinical Recommendation: The use of aspirin therapy in all adult patients aged >=40 years with diabetes is recommended. Evidence: Level A (Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered; supportive evidence from well-conducted randomized controlled trials that are adequately powered) Aspirin therapy: The ADA recommends... References 58 Privacy of Data METRIC utilizes CECity s Performa platform. There are safeguards in place such as firewalls, encryption, and security at the data center. Physicians only see their data. IRB's have provided exemptions for these projects as quality improvement programs. CECity Performa Platform Other modules or programs CECity Performa Platform AAFP METRIC module Diabetes METRIC data is not transferred to the Board. Chart A METRIC USER 59 Stage B: Learning from the application of PI to patient care Compare your performance with peers (who have completed this Program). Patients Who Received Aspirin Therapy Recommendation - Baseline 90% Percent 80% 70% 60% 50% 40% 60% 70% 30% Baseline My Peer's Baseline Participant and Peer Basleine 60 20
Stage B: Design an action plan and implement Select interventions and develop an action plan for improvement based on assessment results Example: Delivery System Design Build a diabetes care team Flow sheets Group Visits Improve communication with other providers 61 AAFP Guidance Designing an Action Plan around an Intervention Flow sheets Short: this is the description that the learner sees as they are reviewing and choosing interventions. A flow sheet is a one- or two-page form that records all of the important data regarding a patient s condition. A diabetes flow sheet that s kept up-to-date enables the physician to determine at a glance what testing has been done and what s lacking. Flow sheets are especially useful in the management of chronic disease because they prompt care team members to address issues during every office visit, even if the patient is in the office for a sore throat or Pap smear. Additionally, the standardized nature of a flow sheet ensures uniform data entry for each patient. 62 AAFP Guidance Starting the Action Plan around an Intervention Flow Sheet information after selecting this intervention. Long: this explains a flow sheet s function. A flow sheet should display aggregated data (e.g., A1C) over time so the physician and patient can see whether treatment efforts are resulting in improvement. When used in this way, the flow sheet becomes a tool for interpreting historical data gathered during patient visits. In addition to collecting patient data, your flow sheet represents how your practice puts clinical data into practice. For this reason, you may prefer to customize your own flow sheet based on the guidelines you use. Etc. Resources: further reading, templates and examples of use http://www.aafp.org/fpm/20000600/diabetesflowsheet.pdf 63 21
AAFP Guidance Facilitating Ideas for Improvement Tips for making your flow sheet work (excerpt of a few of the tips) 1. Make it pertinent to treatment goals and diabetes care guidelines. If your flow sheet doesn t display critical data in a way that helps you make informed decisions about treatment, it isn t functioning as it should. 2. Consider it a work in progress. Use your flow sheet for a specific trial period and make note of what works and what s missing. Revise accordingly. If your flow sheet is missing key elements, or if using it is a hassle, it can t help you. 3. Share the responsibility. You may find it difficult to use this new tool consistently, especially at first. Adding a flow sheet to existing office processes works best when: filling it out is a team effort that includes the physician and other staff members; using it for each visit is office policy; and you follow a consistent procedure every time the flow sheet is used. 64 Stage C: Learning from the evaluation of the PI effort After a minimum of 3 months implementation time: Reassess practice based systems of care and conduct another chart review. Compare Baseline and Follow-up assessment results. Note any change in outcome. Summarize the learning experience. The METRIC Activity provides a longer term version of the specific interventions selected in order to encourage continued improvement efforts and to apply the intervention more broadly in the practice. 65 Stage C: Encourage continuous improvement Flow sheets Follow-up: Once you get in the habit of using the diabetes flow sheet, consider developing a system for reviewing flow sheets periodically and following up with patients who have missed needed services. If you have a patient registry, this review process can be fairly simple because you'll know exactly which charts to pull. With the needed information distilled to a single page, your chart reviews can become more manageable one-page flow sheet reviews. 66 22
Physician Engagement in PI CME As a membership organization, AAFP can create an expectation of participation. As a membership organization, AAFP can design PI CME programs that are easy to use and meet the physician at their level of understanding and use of Quality Improvement processes. Promote the data that shows its effectiveness. 67 Barriers to participation Physician awareness of the METRIC Activity is adequate, but physicians primarily seek it out because it is required, not necessarily because they see its value in improving patient care. PI CME takes more time than traditional CME. Physicians have expressed the feeling of being overwhelmed at the idea of having to do this kind of activity and put it off. PI CME is more complex: there are multiple steps and the need to engage members of the practice team. Some family physician are in a faculty position or other environment not suited to METRIC. 68 Results to Date Continuing with the Diabetes module as an example, the following are the top 6 interventions chosen as part of the action plan. 19% Put Guidelines into Practice 17% Flow Sheets 10% Build a Patient Registry 8% Planned Visits 8% Pt/Staff Reminders 7% Smoking Cessation 69 23
Participant Feedback METRIC program has helped me look closer at the quality of care I provide to my patients and how I can improve it. Very well organized, useful, self-motivating tool. METRIC helped re-emphasize the quality of care that all physicians should practice. The process is easy to follow and it s fast once you get the rhythm. This was a positive experience. We did it in conjunction with our residency. It gave everyone an opportunity to participate in a PI project, learn the recommendations, and experience how difficult it is to improve a large practice. We do plan to continue participating in additional METRIC projects. 70 What we are learning Change is hard Changing a system requires buy in from other staff and physicians in the practice and The Action Plan must maintain a high priority through implementation. Residency programs are finding value in METRIC Learning and system changes occur as a team. Faculty complete METRIC as well. METRIC meets the ACGME requirement relating to practice based learning and improvement. The AAFP is integrating METRIC with the Practice Enhancement Forum (PEF), another AAFP PI CME program. PEF provides QI mentors and coaches to each practice team (physician, clinical and non-clinical staff) to facilitate learning and change. 71 Advice Build initial PI CME around perceived needs or glaring gaps in performance on clinical topics Participation may be higher Perhaps use your annual needs assessment survey or other methods in place to identify a topic Design the program such that multiple physicians can participate More buy-in from stakeholders in the practice since system changes impact the practice 72 24
How to work with Your Board Parameters and physician accountability for PI CME are determined by the Board. Medical specialty societies can have valuable knowledge about their members for their Board. The PI CME Activity is developed around the principles of Performance Improvement and the Board s parameters (Stages A, B, and C). Each activity is submitted to the Board for certification for Maintenance of Certification Part IV or PI CME. 73 Questions? Recording of today s presentation If you would like to view the recording of this webinar at no additional cost registration will be available tomorrow at www.ama-assn.org/go/webinars In the On-demand section, select the recording of today s webinar, and enter Registration Discount Code: AMA2 This comp registration includes 2 views of the recording, and registration is available only for the person who registered for today s webinar (not each person participating at your site) 25
Final Thoughts PI CME is an opportunity for CME to increase its important role in improving healthcare The PI CME learning model is still new - AMA is here to help you as your organization starts into PI CME If you are interested in being part of a community of practice related to PI CME, please indicate this on your evaluation form Resources The Physician s Recognition Award and credit system: Information for accredited providers and physicians 2006 revision www.ama-assn.org/go/prabooklet www.ama-assn.org/go/cme www.physicianconsortium.org www.ama-assn.org/go/cmecppd Additional resources Performance Measures AQA Quality Measures: http://www.aqaalliance.org/performancewg.htm NCQA Performance Measures: Physician Recognition Program: http://web.ncqa.org/tabid/58/default.aspx CAHPS Survey Tool: http://web.ncqa.org/tabid/58/default.aspx The Chronic Care Model http://www.ihi.org/ihi/topics/chronicconditions/allcond itions/changes/ AAFP PI CME websites: http://www.aafp.org/metric http://www.aafp.org/online/en/home/practicemgt/quality. html 26
What resources does the AMA have for CME providers and physicians? CPPD Staff Thank you! 27