HIMSS: Dr. Smith, you get an Fwill you change your practice now?
ATLANTA—Disseminating physician scorecards within a healthcare facility can be a powerful tool to drive clinical practice change, if the cultural barriers can be overcome, according to a presentation by an informatics executive from M.D. Anderson Cancer Center in Houston Monday at HIMSS10.

“Scorecards are not the answer, they are an answer to effective practice change,” began John C. Frenzel, MD, director of peri-operative and critical care informatics at M.D. Anderson.  However, he said that scorecards can have a role in the practice change continuum.

“Forces are coming to bear on medicine causing provider practice and institutional performance versus specific measures to be openly shared with patients and payors,” Frenzel pointed out as a reason for implementing such methods as scorecards. Also, he said that the “reimbursement environment for providers is becoming more challenging,” adding it will be soon driven by data to improve quality of care for the lowest amount.

Many providers do not change their practices that much over the years, but these additional pressures are causing facilities to re-examine their internal processes, such as CMEs. Nationally, physician recertification is getting a “new look,” according to Frenzel.

For instance, in 2000, the American Board of Medical Specialties completely overhauled certification requirements, adding a fourth stipulation: “Implementation of evidence-based medicine is an aspect of individual practice and a part of practice change projects.” Recertification now requires addition requirements over the course of the same 10-year span.

However, Frenzel acknowledged the difficulty of keeping up with the newest evidence-based medicine. For instance, he said that to “maintain current knowledge, a general internist would need to read 20 articles per day, 365 days a year.”

This was one of the reasons they examined scorecards at M.D. Anderson, which as an institution asked: “How can we help physicians change their practice, which will allow them to meet these certifications,” Frenzel said. “Scorecards can do a lot of this work for them. Also, we used these increasing pressures as another means to get our physicians to buy into this method.”

He cited a 2001 Journal of the American Medical Association study that found internists know less than when they entered practice, only three to four years after their board certification. And, 14 to 15 years after board certification, 68 percent of internists would no longer pass the certification test, according to the study. Frenzel explains: “It’s not because they don’t know medicine, it’s because they are not practicing modern medicine. They are practicing what they learned in medical school.”

Additionally, CMS is also adding to the pressures, with the Physicians Quality Reporting Initiative (PQRI). In 2010, the federal government issued 149 PQRI best practices measures that need to be implemented, as well as the ongoing provider practice evaluation.

He cited the traditional models of practice change: communication, process re-engineering, education (CMEs) and competition.

“Coupled with traditional CME, scorecards serve as a mirror to the provider to see practice habits reflected via objective and un-biased data,” Frenzel said. “We invested a lot of effort and money into developing scorecards properly in our organization, but we had to justify them in other ways, including PQRI, ongoing professional practice evaluation in partnership with the Joint Commission and being able to show physicians how they were performing.”

In order to implement scorecards, the developers worked with various departments to identify “target processes and practices that needed to change.” They performed a literature search to collect EBM guidelines, which involved distilling input variables necessary to build the scorecard. They identified source systems that could feed the necessary data.

In addition, Frenzel and his colleagues performed a gap analysis of missing data, poor definitions and practice issues, thereby, creating working groups to address these issues.

“Scorecards do not exist in a vacuum,” he said. They worked with departments to create CME focus on the guidelines, enabling discussions and feedback to modify guidelines for local practices and identifying potential implementation roadblocks early on.

“I wouldn’t suggest a big bang rollout,” Frenzel said. “It’s a cultural change, as much as a practice change.”

They first worked with friendly respondents who were “fairly receptive and cooperative.” However, he said that all physicians initially had trouble accepting their shortcomings, and blamed the data for being inaccurate.

When the reporting process was being tested, the first pass data were presented to the department for discussion. They used scorecards to re-emphasize the guidelines in light of actual practice data, and data integrity was explicitly addressed. Based on the initial phase-in, additional views of the data were created to answer the questions on data validity

“Once final validation and acceptance of the process occurred, scorecards were managed by the departmental QI/PI committee,” Frenzel said. “To help understand process drift, a set of internal metrics for the QI/PI committee were created to view practice level performance, as well as enable drill down to individual provider level data.”

Frenzel reiterated that scorecards have been effective at M.D. Anderson, but acknowledged that is a gradual process required to enact change of practice, and accept shortcomings.