The Tech Doctor: Better Work. Better Pay.

December 15, 2007
Bruce Kleaveland

EMRs may hold the key to helping you gain from pay-for-performance programs.


Pay-for-performance (P4P) sounds great at first. Perform better and earn more money.

But then you realize that every payer has its own definition of what constitutes “better performance,” and you really have no objective way of proving your quality of care is superior to that of your peers. Some states, like California, are attempting to standardize the yardsticks different payers use to evaluate physician performance. But that’s the exception.

Although the nation’s largest insurer - the federal government - is experimenting with P4P programs in four states as a precursor to a possible nationwide program, most P4P plans are defined and deployed by individual payers. And they vary widely.

P4P programs typically hold physicians to a mix of preventive care and chronic disease management benchmarks. For example, California’s standards evaluate clinical performance by reviewing within individual practices:

  • The percentage of children up to date on their vaccines;

  • The percentage of women who’ve recently had mammograms or Pap smears; and

  • The percentage of cardiac patients who’ve had cholesterol screenings and have kept their cholesterol levels under control.

The EMR/P4P connection

All of this is fertile ground for EMRs, which help physicians both at the point of care and from a patient-population perspective. EMRs give users the capability to mine data on all their patients who fall within a specific category (e.g., all patients with congestive heart failure). An EMR makes it easy to determine the disease management status of those patients by tracking specific measures, such as cholesterol levels.

At the point of care, EMRs can provide reminders and easy access to patient information as you deliver treatment and dispense advice. If one of your P4P criteria is controlling the HgA1c levels of your patients with diabetes, you can configure your EMR to remind you to request a lab test if you lack recent data. You can also review patients’ former lab results to evaluate how well they are doing. Or you can print out a flow chart of a patient’s historical HgA1c levels with a click of your mouse.

The patient encounter itself can trigger your EMR to issue such prompts and reminders. In fact, you can customize your EMR to prompt you for whatever information a particular P4P program requires, relieving you of the burden of having to remember the specifics of each one.

And since P4P programs reward physicians for influencing the behavior of patients after they leave your office, an EMR can help you generate convenient patient motivators. For example, you can use it to print a graph of a patient’s historical LDL levels, either as a nice visual reward of a patient’s progress or as a strong reminder of the consequences of noncompliance.

To reinforce patient education, EMRs also put a comprehensive, multilingual medical education library at a clinician’s fingertips. And because electronic charts are available wherever there is a workstation, EMRs can empower nurses and medical assistants to help manage P4P criteria as well. Any member of your clinical staff can access a patient’s chart and then easily screen for P4P performance measures.

Is it worth it?

Of course, to make all this happen, you and your staff must develop the appropriate procedures, templates, and protocols. Sound daunting? Remember that an EMR makes it possible to engage staff in preventive care in a way that’s virtually impossible using paper charts. Once they realize the more powerful role they can play, your staff members may start exploring EMR capabilities you never knew you had.

Finally, an EMR gives you the capability, at least in theory, to compile patient data that can either confirm or refute a payer’s assessment of your performance. But in practice, the data P4P programs use to reward physicians are typically compiled using the payer’s own claims and patient data. And individual P4P programs typically have elaborate rules and qualifications that are often beyond the standard reporting capabilities of most EMRs. To level the playing field, some practices will program their EMRs to feed patient information to a third-party registry or to a custom reporting tool that they can then use for their own P4P statistical analysis and reporting.

Even with these caveats, some payers are so convinced of the positive effect EMRs can have on quality of care, they’ve made simply having an EMR part of their P4P criteria - regardless of what you do with it.


Bruce Kleaveland is president of Kleaveland Consulting, a management consulting firm focused on healthcare IT. He can be reached at 206 527 6633, bkleaveland@msn.com, or via editor@physicianspractice.com.