EHRs: In Need of a PINNACLE Makeover?

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 - David May, MD, FACC
David May, MD, FACC
Cardiology practices now have opportunities to input their EHR data into clinical registries as U.S. healthcare moves toward a more accountable, quality-based model. The American College of Cardiology's (ACC) PINNACLE Registry could serve as a possible foundation for providers to gain a better understanding of their operations and ultimately help their bottom line.

Currently, the PINNACLE Registry, a cardiovascular outpatient database that is part of ACC's National Cardiovascular Data Registry (NCDR), has fully integrated or is in the process of integrating with 30 EHR systems, according to J. Brendan Mullen, BSFS, director of PINNACLE at ACC in Washington, D.C.

For PINNACLE-integrated practices, the ACC sends out quarterly reports on 26 performance measures under the categories of coronary artery disease, hypertension, heart failure and atrial fibrillation. The reports seek to demonstrate a practice's progression through the use of benchmarks, such as tracking lipids and blood pressure control for ischemic vascular disease.

"These metrics allow the outpatient setting to track patients over time and issue feedback to doctors and practices on how they're providing evidence-base care on a continuous basis," says ACC CEO Jack Lewin, adding that cardiologists can use PINNACLE data for practical purposes, such as a means to submit data to the Center for Medicare & Medicaid Services' (CMS) Physician Quality Reporting System (PQRS) or other pay-for-performance initiatives.

"The ACC wants to focus on systematic improvement in quality, safety and efficiency by collecting data and providing feedback," says Lewin.

While touted as a means to drive quality performance and pre-empt mandatory reform, such as in the Patient Protection and Affordable Care Act and the HITECH ACT's meaningful use requirements, some cardiologists question what they can gain from linking in if they purchase an EHR or retrofit their data to integrate with the registry.

According to Lewin, PINNACLE is approaching 1,000 users, and some users have seen gains in their budget line items due to the connection. For example, employing PINNACLE data to submit to the PQRS, Cardiovascular Specialists, a seven-physician practice in Lewisville, Texas, gained $100,000 in 2010, according to David C. May, MD, PhD, a cardiologist from the practice, which connected to the registry in 2009. "About 54 percent of our patients qualified for the PINNACLE Registry in 2010," says May, adding that the practice has not incurred any increased cost involved with collecting or transmitting data.

In addition to receiving the federal financial kickbacks, May attests that the registry allows the practice to transparently demonstrate superior patient care, especially for those at higher risk, which may have a future impact with payor incentives and reimbursements. "It's a reminder system which drives us to consciously document what we should be documenting already," says May.

There are two primary vectors of data flowing into the registry, notes Mullen. Currently, PINNACLE contains more than 1.5 million patient records driven by system integration technology. The data fields are designed to auto-populate into a PINNACLE form, which the physician sends to the registry, Mullen adds.

The second method is direct integration into an EHR. In this scenario, the EHR vendor prepares data export with the ACC, allowing PINNACLE elements to auto-populate from the system into the registry. "When integrating with an EHR, we can capture 60 to 70 percent of the intended data elements at first pass. With a little more work with the vendor, we can capture 80 percent of the data, allowing us to calculate the appropriate performance measures," May says.

He notes that the registry adds functionality in his practice by serving as a clinical decision support tool where he can, for example, query the risk factors for heart failure.

The administrators at Cardiovascular Specialists receive reports on performance metrics from the registry, including the volume of care for each physician, the percentage of those who comply with guidelines and how the practice compares with other U.S.-based PINNACLE practices. Another report shows patient encounter data from a geographical perspective, showing where and when patient encounters occurred from different locations within the practice's patient catchment area.

"From a business standpoint, that's useful because we can compare demographics and their different physical attributes. We can compare one quarter with previous sets. We directly employ these metrics to drive our business."

May has changed certain behaviors of his practice based on results from these quarterly reports. "For example, it's now our strict policy to take vital signs when a patient comes in because it could lead to quality improvements."

Tracking patients' vital signs drives home to providers and nurses that the acquisition of clinical data via a population-based approach will help the prevention of illness as opposed to a treatment/reaction model to illness going forward, May says.

Is PINNACLE pivotal?

Currently, PINNACLE is a free service to ACC members, but Lewin admits that a cost could be on the horizon. "There might be a modest monthly or subscriber fee, but there could be quality improvement benefits to using this kind of model," says Lewin. When the registry attains approximately 5,000 users, the ACC may begin charging for the service, he notes.

The emotional and time investment can add to the question mark looming over whether or not practices should undertake an EHR rearrangement or purchase. "PINNACLE is a powerful patient and practice monitoring tool," says Patrick J. Daley, MD, chair of the quality committee at Fort Wayne Cardiology in Fort Wayne, Ind. According to Daley, he has entered 700 patients each quarter into the PINNACLE Registry.

Yet, Daley acknowledges that having had to tweak his EHR was an initial barrier. "We had to reconfigure data because lipid profiles weren't being auto-populated or we had to keep checking patient demographic information when it didn't change," says Daley. "Once in place though, we could use the same EHR tool to allow the cardiologists to integrate PINNACLE into the workflow easily."

It took the Cardiovascular Group of Centra, a 19-provider practice in Lynchburg, Va., one year to construct an EHR to marry outpatient data in the office with the hospital's data via PINNACLE Registry integration as part of a pilot project. Another challenge of PINNACLE, says C. Michael Valentine, MD, a Centra cardiologist, concerns clinical data ownership. "Everybody wants those data so our first challenge was how to mine the EHR data and extract out reasonable, effective parameters," says Valentine. "A second issue was who will own the data, and a third challenge was how to construct an EHR that will appropriate the data. Payors and EHR vendors want the patient data so sometimes it's hard for them to support your efforts unless they get the data."

The struggles have paid off, as Valentine suggests his practice was able to recoup part of their EHR costs (about $200,000) through the PQRS by submitting PINNACLE data. "We hope that the return of investment is going to help us pay for the data programming employees working with us to improve data submission and abstraction," says Valentine. Data programming employees cost between $40,000 and $70,000 annually depending on experience, he reports.

Valentine advises the ACC to take written or electronic data, so even if a practice that hasn't set up an EHR, it could still connect into PINNACLE. He suggests other practices looking to buy an EHR "choose a vendor that will be able to get the patient data easily encrypted to the college." Investing time and data in PINNACLE—while initially time-consuming—could provide a strong organizational foundation.