The Tech Doctor: EMRs & P4P: A Perfect Match?

January 1, 2007
Bruce Kleaveland

Why an EMR is essential in the new world of pay-for-performance.


As we all know, pay for performance (P4P) is a payment scheme that rewards physicians for meeting a payer’s predefined clinical or patient satisfaction benchmarks. Some states, like California, are attempting to standardize the yardsticks different payers use to evaluate physicians. But they are 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 national program, most P4P programs are defined and deployed on a payer-by-payer basis. And they vary widely.

P4P programs typically base their incentives on a mix of preventive care and chronic disease management benchmarks. For example, California’s standards (see www.iha.org for full details) evaluate clinical performance measures by looking at benchmarks including:

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

  • The percentage of women with recent mammograms or Pap smears; and

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

Where do EMRs fit in?

All of this is fertile ground for EMRs, which help physicians both at the point of care and from a patient-population perspective, allowing you to easily mine data on all patients who fit a certain class (e.g., all patients with congestive heart failure). An EMR makes it simple to determine those patients’ disease management status by tracking specific measures, such as cholesterol levels.

At the point of care, the beauty of an EMR is that it provides 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; give you a record of a patient’s last measurement to evaluate how well he or she is doing; or quickly generate a flow chart of historical HgA1c levels for individual patients.

The patient encounter itself can trigger your EMR to issue prompts and reminders. 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 particulars of each one.

And since P4P programs reward physicians for influencing patient behavior after they leave your office, an EMR can also help you provide convenient patient motivators. For example, you can use it to issue 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 can 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. Any member of your clinical staff can access a patient’s chart and easily screen for P4P performance measures.

How useful are these tools?

To make this happen, templates, procedures, and protocols must be put into place. But an EMR makes it possible to engage staff in preventive care in a way that’s virtually impossible using paper charts.

An EMR also gives you the capacity, 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 a payer’s own claims and patient data. In addition, individual P4P programs typically have their own elaborate set of rules and qualifications that are often beyond the standard reporting capabilities of most EMRs. In response, some practices will program their EMRs to feed patient information to a third party registry or custom reporting tool that they use for P4P statistical analysis and reporting.

Nevertheless, some payers are so convinced of the connection between EMRs and quality of care that they have 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.

This article originally appeared in the January 2007 issue of Physicians Practice.