Published in the August 2007 issue of Today’s Hospitalist.
When meeting performance measures from payers like Medicare, such as giving CHF patients ACE inhibitors, one challenge is making sure that physicians do the right thing. But an even more vexing problem is making sure that physicians document what they’re doing so they “and their hospital “get credit for those actions.
Those challenges are made abundantly clear in research conducted by IPC-The Hospitalist Company. IPC, which has more than 600 hospitalists working in markets across the country, examined how often a sample of its physicians were prescribing “and documenting the use of “ACE inhibitors and ARBs in patients with CHF. Performance measures used by Medicare and other payers are tracking how frequently physicians prescribe these and other drugs to heart failure patients.
The bad news was that according to medical records, physicians in the study gave ACE inhibitors or ARBs to only 39% of their patients with congestive heart failure. The good news? By creating a relatively simple reminder system that was displayed at discharge, IPC was able to boost that prescription rate to 59%.
While IPC’s results should encourage hospitals that are looking for ways to quickly improve their standings on performance measures, the study also raises questions about how well physicians are meeting these measures. Perhaps even more importantly, the research points to obstacles that physicians who are meeting the measures face in documenting their compliance.
A technological advantage
IPC is in a unique position to influence the prescribing and documentation habits of its hospitalists because the company uses a unique software system called IPC-Link, which doubles as a clinical and billing database. At discharge, IPC hospitalists must use the system to update such items as the patient’s lists of diagnoses, medications and tests performed.
To examine how well its physicians were meeting the CHF performance measure, IPC added a reminder screen to its software that “popped up” when a patient with CHF had not received either of the two medications. That pop-up screen would ask physicians if they wanted to prescribe one of the medications. When doctors answered “no,” the system would ask them to choose a reason from a list.
In a control group that received no reminders to prescribe the drugs, only 39% of CHF patients had documentation of receiving a prescription for an ACE inhibitor or ARB. Of the physicians who received the pop-up reminder, that figure jumped to 50%.
IPC then crunched the numbers differently, eliminating patients who were ineligible for the therapies because of contraindications. When those patients were taken out of the equation, 59% of eligible patients with CHF had documentation of receiving one of the two drugs.
A case of contraindications
Kenneth R. Epstein, MD, IPC’s director for medical affairs, says that based on the literature he reviewed as part of the study, the IPC physicians were more or less in the national average. Most studies show that between 40% and 70% of physicians comply with heart failure measures. In one study comparing heart failure care in the U.S. to that in Canada, patients in the U.S. were prescribed ACE inhibitors at discharge in 54.3% of cases.
That still doesn’t explain why even with a reminder system in place, the medical records showed that only 59% of IPC’s CHF patients were receiving ACE inhibitors or ARBs. Dr. Epstein says he’s convinced that his physicians are doing the right thing when it comes to CHF patients, but that’s not coming through in doctors’ documentation.
He says that the study’s figures on patients who had a contraindication to the drugs likely are just the tip of the iceberg. Of the 1,477 patients in the intervention group who were discharged with a diagnosis of CHF, 220 “or nearly 15% “were not eligible for an ACE inhibitor or ARB.
“I think there are legitimate reasons why we’re not prescribing ACE inhibitors or ARBs to a lot of our patients,” Dr. Epstein says, “but the physicians are not documenting those reasons. I think a lot of our improvement came from the documentation of contraindications, not the actual prescribing of therapies.”
No standard for documentation
A big problem, he adds, is that it’s often difficult to document the reasons why patients aren’t receiving treatment. “We don’t have a uniform system throughout all our practices in terms of documentation,” Dr. Epstein says. “We need to improve the method of documenting contraindications.”
He gives this example: Suppose you have a discussion with a cardiologist or nephrologist, and you decide that a drug isn’t appropriate. How is the hospitalist supposed to document that decision so a payer like Medicare doesn’t assume that you’ve missed an opportunity to prescribe?
“We don’t have a uniform medical database where we can say, ‘You were at another hospital three months ago and this test was done’ ” that showed a contraindication.
“Even the person who extracts the data for the CMS criteria has no way to document that,” he says. “There’s no uniform way to document.”
Dr. Epstein says that he was surprised by the study’s results because they showed just how much of a disconnect there is between clinical practice and the performance measures being used by Medicare, known commonly as core measures. He also says that the findings show why physicians like hospitalists need to find ways to receive the credit they’re due on those measures.
“The core measures are important,” he explains, “but we have to constantly strive to look for better ways to tie into the actual documentation in the hospital and the fragmentation of care across hospitalizations.”
The value of reminders
If there’s good news to come out of the study, which has not yet been published, it’s that a reminder system is a good start. While being able to make use of an electronic system, as the physicians at IPC can, is the preferred way to prompt physicians to gather information on CHF patients, Dr. Epstein feels that a paper-based version can also be effective.
He says that “human factors” are often the most successful way to gather this information, a term that he says refers to either paper-based forms or a CHF nurse. “You need some consistent, uniform way throughout the hospital where there is either a form to be filled out or someone checking to make sure that we have documented reasons or contraindications that these medicines are not being prescribed,” Dr. Epstein explains.
The paper approach could be something as simple as a stamped form in the chart saying you documented reasons for not prescribing a medication. But you need to make sure any approach used does not interfere with physician workflow.
Because IPC hospitalists are so used to the IPC-Link software, Dr. Epstein said he received no negative feedback about the pop-up screens, even though the physicians have to check off a box to be able to continue through the discharge.
Adding reminders at admission
Moving forward, IPC is planning to add the pop-up screens at discharge so all its physicians, not just individuals who were part of a study, will see them. Dr. Epstein says IPC is also exploring the idea of having a version of the screen display at admission, when hospitalists still have plenty of time to change course and give patients appropriate medications.
“At discharge,” he notes, “there’s no real time to go back and add a medication, even if it’s appropriate. So we’re going to build a system that displays the pop-up screen at the time of admission.”
Dr. Epstein also says that while tools like automatic reminders will help boost physicians’ compliance with these systems “or at the very least, their documentation of that compliance “he expects to see compliance rise for other reasons.
He points to initiatives like Medicare’s Physicians Quality Reporting Initiative, which will pay physicians to report data on a select group of performance measures. He thinks that the program, which began last month, will help physicians become more accustomed to the idea of regularly reporting information on their patients. (See "New pay-for-reporting program sets its sights on individual physicians" in the July Today’s Hospitalist.)
In Dr. Epstein’s mind, hospitalists have a moral imperative to help hospitals succeed. Increasingly, that will mean doing well on performance measures.
“We have a responsibility to help the hospitals where we work comply,” he explains. “We have the responsibility to ensure the success of the hospital.”
Edward Doyle is Editor of Today’s Hospitalist.