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Explore This IssueJanuary 2014
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SAN DIEGO—As healthcare costs rise and market forces change rapidly in the wake of new laws, rheumatologists must adapt quality measurement techniques and care models, a panel of experts stated here at the 2013 ACR/ARHP Annual Scientific Meeting, held October 26–30. [Editor’s Note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org/sessionselect.]
Panelists discussed new techniques in measuring quality in rheumatology, contemporary attitudes in healthcare service delivery, and new rheumatology registries that physicians may access. The overarching theme of the panelists’ presentations is that change is inevitable, and rheumatologists must adapt and work together to ensure the specialty’s viability in the years to come. In addition, patients will benefit from more effective treatment models.
Put Your Data to Use
From the past few decades of collecting patient data, evidence shows large variations in the quality of rheumatologic care, said Janoos Yazdany, MD, MPH, associate clinical director of the Lupus Clinic at the University of California, San Francisco. “Our delivery system is fragmented, and payment is quality neutral. Can this change?” she asked the audience.
In the past, quality measures focused on the structure of care, such as the nurse-to-patient ratio, or on healthcare processes, Dr. Yazdany said. In the future, patient outcomes will be the focus. Rheumatology is ahead of the curve by implementing accessible online registries to measure outcomes, she said.
Disparities in care create an unfair playing field for patients, Dr. Yazdany noted. Better quality measurement efforts can highlight problem areas and help rheumatologists provide better care. She pointed to data collected on use of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients by the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set tool. Examining data on 90,000 RA patients throughout the United States found “there were widespread regional differences. There were lower rates of DMARD use in the South, and there were racial and ethnic disparities, too,” she noted.
The federal government’s Physical Quality Reporting System (PQRS) offers financial incentives and penalties to encourage rheumatologists to participate, and physicians may also use the ACR’s Rheumatology Clinical Registry (RCR) web-based tool to input data and submit to PQRS, Dr. Yazdany said. She encouraged rheumatologists to take the lead in developing their own quality measures and tools, she said.
“Seismic changes are ahead in how these measures will be developed and who will be steward of these measures,” she said. “I think many organizations will find themselves overwhelmed and rheumatologists won’t be their leading priority.”
Rheumatologists can and should leverage the investments that the ACR has already made in the quality area, including utilizing emerging technology, she concluded. “Quality-measure testing requires multidisciplinary input, and the information gathered must be feasible, valid, and useful,” she said. “Standardizing clinically rich data will minimize the burden for clinicians in chart review and will lead to quality improvement. Rheumatologists will be increasingly rewarded, and they will improve their patients’ outcomes.”
Rheumatologists should incorporate new quality measures to show their worth and respond aggressively to a financial healthcare crisis, said Eric Newman, MD, director of the department of rheumatology at the Geisinger Health System in Danville, Pa. Rising costs in healthcare will create a shift toward new, less costly models of care, Dr. Newman said. He described a future system where primary-care physicians might care for the bulk of rheumatology patients.
“Before you throw tomatoes at me, let me just ask: Are rheumatologists part of the team? Everything we do can technically be done by primary care. We prescribe drugs, they prescribe drugs. We inject joints, they inject joints,” said Dr. Newman. Successful rheumatologists will understand and respect healthcare systems, become a part of an involved healthcare team, implement problem-solving techniques, and measure quality, he said.
He urged his colleagues to create a team model to provide comprehensive patient care, and to utilize new technology. Dr. Newman helped developed the Patient Centric Electronic Redesign, a platform that collects and measures rheumatology patient data. Most importantly, rheumatologists must abandon the older, hierarchical model of care where the doctor sat at the top of a pyramid. This model creates separate reporting lines and no forum for quality and process improvement, he said. He advised the audience to embrace a new, collaborative model where problems are solved as a team. “Redesign your care team and empower them,” he said. “Your best ideas will not come from your physicians.”
Measuring patient outcomes will help rheumatologists and their teams improve patient care, Dr. Newman said. “You don’t understand what you don’t measure, and the pearl is that you can quantify success as you succeed.” Quality measurement tools can provide “real-time data, objective measures, and we get to see them in the context of the care we are giving,” he said.
Harness the Web
Rheumatologists must take advantage of the data from existing web-based tools to implement evidence-based quality measures, said Salahuddin Kazi, MD, associate professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas. More effective, rheumatology-specific electronic health record (EHR) programs or platforms are needed, he said.
“The ideal EHR would collect and measure quality measures at the point of care, trigger the rheumatologist with best practice alerts, and report outcomes to the reporting agencies,” said Dr. Kazi. The RCR helps to fill the gaps, providing members with quality reporting for several key health concerns, including osteoarthritis, RA, gout, osteoporosis, juvenile idiopathic arthritis, and drug safety, he added. The RCR is now in its fourth year, with data on 30,000 patients.
Rheumatologists may access the RCR and record data through a secure portal on the ACR website. The ACR also is working on adapting the system to synchronize with existing EHR programs. Information collected in the RCR may be submitted to PQRS to help rheumatologists meet meaningful use requirements, and make the submission process less cumbersome. In 2011–2012, PQRS reports showed encouraging patient outcome improvements in key areas like disease activity and functional status, Dr. Kazi said. “The idea that whatever you measure improves over time is supported by this limited but encouraging data,” he added. “I think this information tells you where your gaps in quality are, and where you can make improvements.”
The ACR’s newer Rheumatology Informatics System for Effectiveness, or RISE, provides another opportunity for measuring quality data and improving health outcomes, Dr. Kazi said. In the future, RISE will have secure, cloud-based applications. Rheumatologists will be able to find data on patients who share their own patients’ particular diagnosis and disease-activity measures to help guide rheumatologic care, for example. As RISE evolves, the goal is to ensure consistency in rheumatology measures across many different sites. “The RCR already records quality measures in RA and other diseases, and this information can assist with patient care, measures quality reporting, and maintenance of certification,” Dr. Kazi said. “But RISE will be the next step.”
Susan Bernstein is a writer based in Atlanta.