National CME pilot getting good reviews

Some 6,000 physicians have signed on to a quality improvement project.

By Myrle Croasdale, amednews staff. Dec. 15, 2003.

It's really quite easy. That's the verdict of two primary care physicians taking part in "Project in a Box," a quality improvement pilot that also offers continuing medical education credit, which the Centers for Medicare & Medicaid Services introduced in April.

Family physician Eric Paulson, MD, in Carroll, Iowa, says incorporating "Project in a Box" into his solo practice has been fairly painless.

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The project was initiated in Iowa two years ago before being rolled out by the CMS through state Medicare Quality Improvement Organizations everywhere except Alabama and the territories of Puerto Rico and the U.S. Virgin Islands.

The program is optional for physicians, but with the added incentive of CME credit, the aim is to increase the number of office-based physicians participating in quality improvement efforts.

Mike Speight, director of partnership development for the Iowa Foundation for Medical Care, Iowa's Medicare QIO, said the evaluations coming across his desk show doctors are giving the pilot top scores for ease of use and impact on patient care. This is anecdotal evidence at this point, but more formal results will be calculated when the American Medical Association performs an independent evaluation early in 2004.

Dr. Paulson's been keeping tabs on all three tracks -- diabetes management; influenza and pneumococcal immunization; and breast cancer screening -- for two years.

The national CME pilot has 3 tracks: diabetes management, flu and pneumonia immunizations, and breast cancer screening.

"To be perfectly honest, most of the work is done by my nurse, and she assures me it's not an undue amount of busy work," he said.

This sentiment appears to be shared by many of the physicians who've signed on.

To date, 6,000 physicians from across the country have agreed to participate, with that number expected to rise to about 10,000 by the end of the year as late starters such as California roll out the program. Up to 30 AMA Physician's Recognition Award Category 1 credits can be earned in the first year if doctors participate in all three interventions. The first quarter, 5.5 credits are awarded, with an additional 1.5 credits for each subsequent quarter. Physicians use performance measures to track the success of their programs and must adjust their interventions if no improvement occurs. The program is also being supported by the American Academy of Family Physicians.

"What I really like about it is getting the report back and seeing if I'm doing as well as I think I am," said Dr. Paulson. "It identifies areas where I could do better, and I appreciate that."

Dr. Paulson modified a version of the CMS flow chart, which lists recommended tests and services for patients with diabetes.

"It's just so easy to see what you haven't done for the year," he said.

His nurse copies the flow charts and sends them to the Iowa Foundation for Medical Care each quarter.

He's been surprised by what the tracking system has revealed.

"I found out I was not as compliant as I expected," Dr. Paulson said. "I expected to be 98% compliant, but in a couple of areas I was less than 90%. Everyone thinks they're perfect, but I found I didn't keep up with every single patient and missed some areas."

He sees several patients with diabetes every week and now can see in a glance if they've had their urine checked for protein this year or when they had their last lipid profile.

Speight said data from each state will be available eventually. For now Iowa is the only one to release hard numbers. Its diabetes track shows that the number of patients getting the hemoglobin A1c test rose from 87% to 90% from October 2000 to September 2001, lipids test compliance rose from 68% to 78% and eye exam compliance also rose from 68% to 78%.

Dr. Paulson said his results have steadily improved. His rate of eye exams jumped from 10% to 70%, mostly through better documentation, he said. He's seen the most real change in areas like testing patients' urine for microalbuminuria.

"I used to do that for specific patients, now I do it across the board," Dr. Paulson said.

David Carlson, MD, medical director for the Burlington Area Family Practice Center in Burlington, Iowa, said integrating the project into the daily routine of 11 physicians has not been overly difficult. His group has been participating for about a year.

"It hasn't really added much to our daily workload," he said. "We use the flow sheet to do some of our documentation that we would have done elsewhere, and periodically we photocopy the flow sheet and send it in to track our results." Since they've started they've seen a 15% to 20% increase in their hemoglobin A1c monitoring. They've also started to do more screening for microalbuminuria.

CME credits provided extra motivation for some in the practice, but, Dr. Carlson said, participating is part of the physicians' commitment to keeping current as medical professionals.

"Quality improvement is becoming a big issue politically and in terms of good patient care," he said. "One of the things I've found challenging is, in order to improve care over large numbers of people, you have to change the system, the way you approach it."

An unexpected by-product of using the flow sheets has been more efficient use of time with patients.

"If you don't have to spend your time looking up the routine things then you can focus on the problems," he said. "That's why changing systems can help, and 'Project in a Box' is a good example of finding a better system."

He's also found it has helped him stay motivated.

"From my personal experience, I can tell you when I'm seeing someone with diabetes, I'm reminded that we're tracking certain parameters, such as examining the feet," Dr. Carlson said. "Sometimes that's a deciding factor. I want a good report card, so take off your shoes and let's examine your feet. Those things benefit patients in the long run."