Organized osteopathic medicine, embracing what its leaders foresee as the inevitable future, has required its two largest physician residency specialties to adopt evidence-based clinical benchmarking and physician-specific reporting for accreditation.
On July 1, the American College of Osteopathic Internists mandated participation in the American Osteopathic Association's Clinical Assessment Program, which is based on a database of process measurements taken from abstracted medical records of participating ambulatory-care osteopathic physicians.
As a requirement for accreditation, 66 osteopathic internal medicine residency programs must use the assessment program, known as CAP. The internists join 144 family medicine residency programs, which have been required to participate in CAP since July 2003.
There were 230 osteopathic physicians in internal-medicine residency training programs and 536 physicians in family-medicine residency programs out of 2,408 physicians-in-training in all osteopathic residencies during the 2004-05 academic year, according to Mike Campea, a spokesman for the Chicago-based AOA.
Going forward, all osteopaths in the two CAP-mandated residencies will be required to participate in some form of data-driven self-analysis. About a dozen other residency programs in other osteopathic medical specialties are participating in CAP voluntarily.
Seven areas targeted
CAP uses 84 ambulatory-care measures culled from physician performance-measurement sets in seven areas most commonly encountered by osteopathic physicians: adult immunizations, coronary artery disease, childhood immunizations, diabetes mellitus, hypertension and metabolic syndrome, lower back pain and women's health screening.
An eighth measurement set -- for asthma and other chronic obstructive pulmonary diseases -- may be added by fall. The indicators were for the most part taken from the Health Plan Employer Data and Information Set developed by the not-for-profit National Council for Quality Assurance, according to George Thomas, D.O., director of quality and patient safety at 226-bed Marymount Hospital
in suburban Garfield Heights, Ohio, and immediate past president of the AOA. Thomas chaired the AOA committee that set up CAP in 1998.
The database project was originally launched because AOA leaders believed that it was only a matter of time before physicians would be required to meet performance measures as part of their HMO contracts, Thomas says.
Martin Levine, D.O., is a Bayonne, N.J., family medicine physician and chairman of the AOA's Bureau of Osteopathic Clinical Education and Research, which oversees CAP. Levine says the new requirement makes accreditation for an osteopathic family-medicine residency program conditional on using at least the metrics for diabetes control and lower back pain.
Internal-medicine residency programs are required to use at least the metrics for diabetes and coronary artery disease, Levine says.
Richard Snow, D.O., is medical director for performance improvement at 216-bed Doctors Hospital in Columbus, Ohio, and the principal researcher for CAP.
Beyond exposing new physicians to self-reporting, Snow says two other goals of the program are to give residents an opportunity to match population-based medicine with their daily practices and to develop a database for research.
"Fundamentally, when physicians are trained, they're trained to treat the patient, not so much the population," Snow says. "When you bring the national numbers in, there is a disconnect. We're trying to tie that in with their daily practice. And when they do come out of training, measurement is going to be a part of it, whether it is pay-for-performance or something else."
Residents will be required to analyze a minimum sample of about 20 cases, Snow says. Most will abstract the data themselves by hand from patient charts because few residency programs have electronic medical-record systems. The data are submitted via a Web interface to the CAP database, where their results can be measured against national norms. The data also are used as the basis for a required paper presented by residents to their peers and attending physicians.
Also on July 1, practicing AOA member physicians not in residency training could begin registering online for CAP, though participation is voluntary. Data collection will start sometime this fall for those physicians, Levine says.
Participants will receive a performance report within about two weeks after first submitting data, comparing their work with that of other participants as well as with national benchmarks.
"We're being proactive in setting this up so physicians across the country can say they are participating in a performance-assessment program," Levine says.
Measure for measure
Nearly 8,000 allopathic residency programs training 100,000 physicians are coordinated by the Chicago-based American Council for Graduate Medical Education. Residents in these programs use online "case logs" maintained by the ACGME to help record information about patient encounters.
Program administrators and the council review the logs to ensure that the program provides sufficient depth and breadth, according to John Nylen, chief operating officer of the ACGME.
But the ACGME does not operate a database of clinical measures for residency training similar to the osteopaths' CAP, Nylen says. Given the exceedingly higher number of allopathic residency programs (compared with osteopathic programs), organizing and setting up a database in the allopathic world is an order of a different magnitude, Nylen says.
"We're not doing that right now, but that's not to say it won't happen," he says. In January urol-ogy residents began testing an online evaluation system in which a resident enters his or her cases into a Web-based database and the attending physician, based on the information entered, evaluates the resident.
The head floor nurse can provide input as can patients, Nylen says.
"The other specialties have looked at it, and we're looking at ways that we can make it available for the other residencies," he says. "We're getting there."
William Ervine, D.O., a third-year resident at Doctors Hospital, is doing his paper on the correlation between compliance with a diabetes-management program and healthcare coverage type.
Ervine presented an abstract of the study results, drawn from data in the CAP database, at an American Heart Association meeting earlier this year.
"I was surprised that Medicare patients had significantly better control," Ervine says. "With (Medicare patients) not actually having prescription coverage, you would have thought those (patients) in Medicaid and insurance would be" more compliant.
Ervine says abstracting data from his medical records for submission to the CAP database was "very time-consuming," which has already made him a fan from afar of electronic medical-record systems.
But, he says that despite that drawback, he still is a believer in self-reporting for performance improvement. "People with EMRs will find it easier to extract the data and check how their practice is doing," he says. "With the coming of pay-for-performance, (EMRs will be) a big portion of how we're going to be reimbursed, getting our patients to goals, and it's another way to improve our own level of performance."