- Email: [email protected]
Physician survey of dermatology quality reporting initiatives in Colorado
RESEARCH Physician survey of dermatology quality reporting initiatives in Colorado To the Editor: Recently there has been increased emphasis on healthcare quality. In 2006, the Centers for Medicare and Medicaid Services implemented an annual physician quality reporting initiatives (PQRI) system as part of an incentive payment process for providers of Medicare patients. In 2010, there were 375 measures published in the Federal Register covering a large range of medical conditions and specialties including, but not limited to, primary care, cardiology, the surgical specialties, and neurology.1 Of these measures, only 3 (measures 136, 137, and 138) directly applied to dermatology practices and related to care given to melanoma patients (Table I). We performed an observational study to assess how the 2010 PQRI measures were used in Colorado dermatology practices. The survey (Colorado IRB Protocol #10-0989) consisted of 18 questions (Table II) and was distributed to dermatologists who attended the 2010 Colorado Dermatological Society Annual Meeting. No identifiable information was collected and all responses were anonymous. Questions asked attendees if they used measures 136, 137, and 138; it also covered counseling for melanoma patients and sought feedback regarding PQRI measures. Of the 107 dermatologists who attended the meeting, 32 completed the survey, yielding a response rate of 30%. The majority of responding
LETTERS dermatologists (56.2%) did not use an electronic medical record (EMR) system. Even fewer of the respondents (34%) practiced electronic prescribing (e-prescribing). The group was evenly split (50%) between those who used measures 136, 137, and 138 and those who did not. Only 34.4% thought the CMS measures were worth the time, as opposed to 65.6% who responded either ‘‘No’’ or ‘‘Do not know.’’ Even fewer respondents (12.5%) felt that reimbursements were adequate (see Table II). The low response rate to this survey (30%) may have resulted from a low level of interest in the topic. Interest in the PQRI process may increase as physicians who fail to report PQRI data starting in 2015 will incur penalties up to 2% of their total allowed charges.2 Low levels of interest may have also resulted from the paucity of dermatology quality measures compared with the abundance for primary care and other specialties. For the past 4 years, PQRIs have been voluntary, and reimbursements for specialties such as dermatology have been minimal. By 2015, medical practices that care for Medicare patients will be penalized for nonparticipation and dermatologists will need to report measures using an electronic system. In addition, there have been concerns that current measures used by CMS do not adequately assess quality of care and better ways to improve clinical care are absent. Given the significance of quality care and the limited number of studies on this topic, more work needs to be done to guide clinicians on how to manage this process.
Table I. 2010 CMS PQRI measures 136, 137, and 138 Measure No.
Measure title
136
Melanoma: Follow-Up Aspects of Care
137
Melanoma: Continuity of Care e Recall System
138
Melanoma: Coordination of Care
Description
Percentage of pts w/ a new diagnosis of melanoma who receive all of the following aspects of care within 12 months: (1) pt was asked about new or changing moles AND (2) a complete PE was performed noting morphology, size, and location of new or changing pigmented lesions AND (3) pt was counseled to perform monthly self-skin examination Percentage of pts w/ a current diagnosis of melanoma or history of melanoma whose information was entered, at least once a year, into a recall system that includes (1) a target date for next complete skin exam AND (2) a process to follow up w/ pts who did make an appointment or missed an appointment Percentage of patient visits w/ a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician providing continuing care within 1 month of diagnosis
PE, Physical examination; pt(s), patient(s); w/, with.
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Table II. Questions 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, and 17 Question
Yes
No
4) Use CMS measures 136, 137, 138* 5) Use an e-prescribing system 6) Use an EMR 7) Counsel about sun protectiony 9) Counsel about self skin examsy 11) Is measure 136 easy to understand 12) Is measure 137 easy to understand 13) Is measure 138 easy to understand 14) Report non-dermatology CMS measuresz 15) Report measures in a system other than CMS 16) Are measures worth the time to practice 17) Does CMS provide adequate reimbursement
14 11 14 32 31 28 27 23 2 1 11 4
14 21 18 0 1 2 3 7 30 30 5 8
I don’t know
Did not answer
3
2 2 2 1 16 20
Question 1 surveyed the number of patients that respondents saw per week. The average was 109 patients a week. Question 2 asked for the focus of the dermatology practice, which more than 90.6% said ‘‘general dermatology’’. Other responses included Mohs, pediatric dermatology, cosmetic dermatology, and dermatological pathology. Question 3 asked for the type of practice (ie, solo, group, academic, etc): 66% were group, 22% solo, and the remaining were academic, managed care, or government practices. Questions 8 and 10 asked for explanations to the answer to the previous question and are described in the text. Question 18 asked for general comments and is described in the text. CMS, Centers for Medicare and Medicaid Services; EMR, electronic medical record. *One respondent reported using measures 136 and 138, but not 137. y Counsel for high-risk patients. z Respondents reported tobacco and alcohol measures.
Bryan T. Alvarez, MD,a Cory A. Dunnick, MD,b,c and Robert P. Dellavalle, MD, PhD, MSPHb,d
Mobile teledermatology in Ghana: Sending and answering consults via a mobile platform
Colorado School of Public Health, Preventive Medicine, Auroraa; Department of Dermatology, University of Colorado Denver, Aurorab; University of Colorado Denver School of Medicine, Aurorac; and Dermatology Service, Department of Veterans Affairs Medical Center, Denverd
To the Editor: ‘‘Mobile teledermatology’’ uses mobile devices to provide dermatologic services at a distance. It has demonstrated high levels of diagnostic concordance when compared with traditional faceto-face (FTF) dermatology clinicebased visits.1-5 Ghana, an African country of greater than 20 million inhabitants, has limited access to dermatologic care; however, access to mobile communication has become increasingly readily available. To bridge the gap between the limited supply of dermatologists and the great need for their services, it is important to use the already existing and successful mobile telecommunications infrastructure in Ghana. This pilot study was developed to evaluate the concordance of diagnoses made by 3 Ghanaian dermatologists examining patients FTF compared with that of a distinct remote Ghanaian teledermatologist exclusively using a mobile platform and a US teledermatologist using a desktop computer. In all, 34 patients with skin symptoms were randomly selected from 1 family medicine and 2 dermatology outpatient clinics in Accra and Kumasi, Ghana. Each patient had an initial FTF visit with 1 of 3 Ghanaian dermatologists who made a diagnosis of a primary skin condition. At this same FTF visit, data and images were collected by a US medical student who was part of the research team using the mobile application ClickDoc [ClickDiagnostics, Cambridge, MA] (used for data
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Cory A. Dunnick, MD, Associate Professor of Dermatology, 1665 Aurora Court Mail Stop F703, PO Box 6510, University of Colorado Denver, Aurora, CO 80045 E-mail: [email protected] REFERENCES 1. Centers for Medicare and Medicaid Services (CMS). ‘‘Roadmap for Quality Measurement in the Traditional Medicare Fee-forService Program.’’ Available at: https://www.cms.gov/Quality InitiativeGenInfo/. Accessed September 2010. 2. Gallego E. ‘‘Quality Reporting (PQRI) Case Study: Cardiology Consultants of Philadelphia (CCP): Team Delivery of Care.’’ Healthcare Information and Management Systems Society. Available at: http://www.himss.org/content/files/quality101/phase2/ 19_Quality101_PhaseII_CCP_CaseStudy_qualityreporting11-162010.pdf. Accessed September 2010. http://dx.doi.org/10.1016/j.jaad.2011.09.036
LETTERS dermatologists (56.2%) did not use an electronic medical record (EMR) system. Even fewer of the respondents (34%) practiced electronic prescribing (e-prescribing). The group was evenly split (50%) between those who used measures 136, 137, and 138 and those who did not. Only 34.4% thought the CMS measures were worth the time, as opposed to 65.6% who responded either ‘‘No’’ or ‘‘Do not know.’’ Even fewer respondents (12.5%) felt that reimbursements were adequate (see Table II). The low response rate to this survey (30%) may have resulted from a low level of interest in the topic. Interest in the PQRI process may increase as physicians who fail to report PQRI data starting in 2015 will incur penalties up to 2% of their total allowed charges.2 Low levels of interest may have also resulted from the paucity of dermatology quality measures compared with the abundance for primary care and other specialties. For the past 4 years, PQRIs have been voluntary, and reimbursements for specialties such as dermatology have been minimal. By 2015, medical practices that care for Medicare patients will be penalized for nonparticipation and dermatologists will need to report measures using an electronic system. In addition, there have been concerns that current measures used by CMS do not adequately assess quality of care and better ways to improve clinical care are absent. Given the significance of quality care and the limited number of studies on this topic, more work needs to be done to guide clinicians on how to manage this process.
Table I. 2010 CMS PQRI measures 136, 137, and 138 Measure No.
Measure title
136
Melanoma: Follow-Up Aspects of Care
137
Melanoma: Continuity of Care e Recall System
138
Melanoma: Coordination of Care
Description
Percentage of pts w/ a new diagnosis of melanoma who receive all of the following aspects of care within 12 months: (1) pt was asked about new or changing moles AND (2) a complete PE was performed noting morphology, size, and location of new or changing pigmented lesions AND (3) pt was counseled to perform monthly self-skin examination Percentage of pts w/ a current diagnosis of melanoma or history of melanoma whose information was entered, at least once a year, into a recall system that includes (1) a target date for next complete skin exam AND (2) a process to follow up w/ pts who did make an appointment or missed an appointment Percentage of patient visits w/ a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician providing continuing care within 1 month of diagnosis
PE, Physical examination; pt(s), patient(s); w/, with.
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Table II. Questions 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, and 17 Question
Yes
No
4) Use CMS measures 136, 137, 138* 5) Use an e-prescribing system 6) Use an EMR 7) Counsel about sun protectiony 9) Counsel about self skin examsy 11) Is measure 136 easy to understand 12) Is measure 137 easy to understand 13) Is measure 138 easy to understand 14) Report non-dermatology CMS measuresz 15) Report measures in a system other than CMS 16) Are measures worth the time to practice 17) Does CMS provide adequate reimbursement
14 11 14 32 31 28 27 23 2 1 11 4
14 21 18 0 1 2 3 7 30 30 5 8
I don’t know
Did not answer
3
2 2 2 1 16 20
Question 1 surveyed the number of patients that respondents saw per week. The average was 109 patients a week. Question 2 asked for the focus of the dermatology practice, which more than 90.6% said ‘‘general dermatology’’. Other responses included Mohs, pediatric dermatology, cosmetic dermatology, and dermatological pathology. Question 3 asked for the type of practice (ie, solo, group, academic, etc): 66% were group, 22% solo, and the remaining were academic, managed care, or government practices. Questions 8 and 10 asked for explanations to the answer to the previous question and are described in the text. Question 18 asked for general comments and is described in the text. CMS, Centers for Medicare and Medicaid Services; EMR, electronic medical record. *One respondent reported using measures 136 and 138, but not 137. y Counsel for high-risk patients. z Respondents reported tobacco and alcohol measures.
Bryan T. Alvarez, MD,a Cory A. Dunnick, MD,b,c and Robert P. Dellavalle, MD, PhD, MSPHb,d
Mobile teledermatology in Ghana: Sending and answering consults via a mobile platform
Colorado School of Public Health, Preventive Medicine, Auroraa; Department of Dermatology, University of Colorado Denver, Aurorab; University of Colorado Denver School of Medicine, Aurorac; and Dermatology Service, Department of Veterans Affairs Medical Center, Denverd
To the Editor: ‘‘Mobile teledermatology’’ uses mobile devices to provide dermatologic services at a distance. It has demonstrated high levels of diagnostic concordance when compared with traditional faceto-face (FTF) dermatology clinicebased visits.1-5 Ghana, an African country of greater than 20 million inhabitants, has limited access to dermatologic care; however, access to mobile communication has become increasingly readily available. To bridge the gap between the limited supply of dermatologists and the great need for their services, it is important to use the already existing and successful mobile telecommunications infrastructure in Ghana. This pilot study was developed to evaluate the concordance of diagnoses made by 3 Ghanaian dermatologists examining patients FTF compared with that of a distinct remote Ghanaian teledermatologist exclusively using a mobile platform and a US teledermatologist using a desktop computer. In all, 34 patients with skin symptoms were randomly selected from 1 family medicine and 2 dermatology outpatient clinics in Accra and Kumasi, Ghana. Each patient had an initial FTF visit with 1 of 3 Ghanaian dermatologists who made a diagnosis of a primary skin condition. At this same FTF visit, data and images were collected by a US medical student who was part of the research team using the mobile application ClickDoc [ClickDiagnostics, Cambridge, MA] (used for data
Funding sources: None. Conflicts of interest: None declared. Correspondence to: Cory A. Dunnick, MD, Associate Professor of Dermatology, 1665 Aurora Court Mail Stop F703, PO Box 6510, University of Colorado Denver, Aurora, CO 80045 E-mail: [email protected] REFERENCES 1. Centers for Medicare and Medicaid Services (CMS). ‘‘Roadmap for Quality Measurement in the Traditional Medicare Fee-forService Program.’’ Available at: https://www.cms.gov/Quality InitiativeGenInfo/. Accessed September 2010. 2. Gallego E. ‘‘Quality Reporting (PQRI) Case Study: Cardiology Consultants of Philadelphia (CCP): Team Delivery of Care.’’ Healthcare Information and Management Systems Society. Available at: http://www.himss.org/content/files/quality101/phase2/ 19_Quality101_PhaseII_CCP_CaseStudy_qualityreporting11-162010.pdf. Accessed September 2010. http://dx.doi.org/10.1016/j.jaad.2011.09.036