HEDIS measures can make practices almost perfect

Improvement effort involves all patients

When it comes to providing preventive care to patients, how good can your doctors be? Sharp Rees-Stealy Medical Group in San Diego discovered that some physicians are near-perfect. Now it’s trying to encourage other physicians to move closer to that performance.

By collecting data by physician, the group can reward those who are doing well and counsel those who are underperforming, says Richard O’Connor, MD, director of quality management.

"We focused quality improvement on the physicians who really need it," says O’Connor, who is also chief of the group’s division of asthma, allergy, and clinical immunology. "We also raised the ceiling [of performance]. I had assumed the upper limit [of percentage of patients receiving appropriate care] was somewhere in the low 80s. We had some physicians in the low 90s."

In 1993, the medical group began a program to monitor and improve performance in the Health Plan Employer Data and Information Set (HEDIS) of the National Committee on Quality Assurance in Washington, DC. Initially, the efforts focused on practicewide rates of cervical cancer screening, mammography, senior influenza vaccines, and pediatric immunizations.

Although the practice doesn’t yet have a complete electronic medical record, databases include much of the demographics, encounters, and ancillary services data. O’Connor compiles the information using codes designated by HEDIS. The practice has 230 full-time equivalent physicians caring for about 200,000 patients.

"We decided we wouldn’t get involved in the area of random sampling," he says. "We sample the entire patient population for whom we’re responsible. There’s no question about the validity of the data."

Focusing quality improvement efforts

In 1995, the group began reporting HEDIS data by health plan, so plans could see the care their own patients were receiving. "We realized all we had to do was add one other element, the patient’s physician, and we could track every physician in the group," he says.

The results of the first physician-specific HEDIS report were eye-opening. "The variability was truly astounding," says O’Connor. "The means [or average rates] for family practice and internal medicine are identical. We were really pleased with that. What was different is there is less variability among family practitioners than among internists."

For example, the mammography rates by internist ranged from 46% to 96%. "For the first time ever, we learned how to focus our quality improvement efforts," O’Connor says.

The annual HEDIS report became part of the practice’s assessment reports of physicians, which are essentially quarterly physician report cards. They consist of 34 indicators, including peer review, patient satisfaction, resource utilization, and productivity.

O’Connor plans to include specialists in the quality of care tracking with measures of beta blocker use after cardiac infarction [a HEDIS measure] and screening tests for diabetics. "We have set values beyond which we would consider physicians to be outliers," he says, although he adds that the performance assessment and HEDIS monitoring aren’t used in a punitive manner. Physicians who are outliers are counseled. Simply learning that they are underperforming among their peers is enough to prompt change, says O’Connor.

Positive experience for everyone

He also hopes to financially reward those physicians who are doing an exceptional job. O’Connor says he hasn’t heard any negative comments about the HEDIS tracking and performance assessment.

"Most doctors in the group realize we’re in a very competitive environment," he says. "Not only is this good medical care. This makes good sense for the medical group as a whole."

Meanwhile, O’Connor also discovered that the lowest rates of screening occur among patients who have listed the group as their provider but haven’t chosen a primary care physician. The group is contacting those patients and linking them with doctors. The importance of helping patients receive preventive care is stressed with the staff, as well.

"We’re trying to raise the level of cultural consciousness so preventive measures become a way of life for everyone," O’Connor says.