Pinnacle Registry

Current Status of PINNACLE RegistryTM

Eleven Myths and Eleven Facts American College of Cardiology Board of Governors William J. Oetgen, MD, MBA, FACC Chair, PINNACLE Registry Steering Committee April 1, 2011

PINNACLE Registry • What does PINNACLE mean?

– Practice INNovation And Clinical Excellence

PINNACLE Registry • Where does the PINNACLE Registry fit into the ACC? – Two loci • NCDR® • The PINNACLE Network

PINNACLE Registry • Where does the PINNACLE Registry fit into the ACC? – NCDR – The PINNACLE Registry is one of six NCDR clinical registries • • • • • •

ACTION-GWTG – acute coronary syndromes CATH-PCI – diagnostic and interventional procedures CARE – carotid artery revascularization ICD – implantable cardioverter-defibrillators IMPACT – pediatric and adult congenital heart disease PINNACLE – outpatient performance improvement

PINNACLE Registry • Where does the PINNACLE Registry fit into the ACC? – PINNACLE Network – Community of CV professionals dedicated to: • Performance and quality • Data and measurement • Incentives and rewards

PINNACLE Registry • Where does the PINNACLE Registry fit into the ACC? – PINNACLE Network – developing services for members • • • • • • •

PINNACLE Registry FOCUS Practice Management Program Cardiology Practice Improvement Pathway Performance Improvement – Continuing Medical Education ACC Advocacy Program ACC Risk Management Institute

– http://www.cardiosource.org/Science-And-Quality/Quality-Programs/PINNACLENetwork.aspx

PINNACLE Registry • Why was the PINNACLE Registry created?

PINNACLE Registry • Why was the PINNACLE Registry created?

– Predictions about the future of CV care – ca. 2005: the New Reality • • • •

Medical records will be electronic Quality of care will be paramount Documentation of quality will be mandated Public reporting of individual provider performance will be de rigueur • Financial sanctions will be imposed for non-participation • Compensation will be based on quality of care and its documentation, not on volume

PINNACLE Registry • Why was the PINNACLE Registry created?

– The PINNACLE Registry was created to help participating ACC members to: • Document and improve the quality of the care that they provide • Benefit from using a trusted source for data analysis and reporting • Survive and thrive in the New Reality of health care

PINNACLE Registry • Review of PINNACLE Registry Functions – Conditions of interest – CAD, hypertension, HF, atrial fibrillation, cardiac rehabilitation – Data consists of ~150 elements from which 27 guidelines-based performance measures are calculated – Data are automatically collected from the EHR, analyzed against guidelines-based performance measures, collated, and reported back at the practitioner, site, practice and national benchmark levels – Using these data, practitioners create performance improvement plans – Results of the improvement plans are evaluated with data from the next report

PINNACLE Registry • PINNACLE Registry Eleven Myths

PINNACLE Registry • PINNACLE Myth #1 – The PINNACLE Registry is a massive burden to participating practitioners

PINNACLE Registry • PINNACLE Fact #1 – The massive burden is actually the rapidly changing set of societal expectations imposed on ACC members under the New Reality – The PINNACLE Registry is not perfect or easy, but it is the ACC’s response and potential solution to the New Reality; it is not the problem itself – Ten facts support this

PINNACLE Registry • PINNACLE Myth #2 – The PINNACLE Registry severely interferes with the provider’s office workflow

PINNACLE Registry • PINNACLE Fact #2 – The PINNACLE Registry was initiated with a 2-page paper collection form which added 5 – 10 minutes per encounter to the provider’s workflow – not sustainable – Since July 2010, all new PINNACLE participants (except for interested fellowship programs) must have a functioning EHR – The current estimated practice time to add the PINNACLE System Integrator to a practice EHR is 10 hours per week for 4 weeks (down from 80 hours; goal is 10 hours) – The current estimated additional time per encounter is ~1 minute using SI technology

PINNACLE Registry • PINNACLE Myth #3 (a and b) – The PINNACLE Registry only works for large CV practices (a) – The PINNACLE Registry only works for small CV practices (b)

PINNACLE Registry • PINNACLE Fact #3 PINNACLE Registry Practice Sizes 25

Number of practices

20

15

10

5

0 1

2-5

6-10

11-15

Providers per Practice

16-20

21-30

>30

PINNACLE Registry • PINNACLE Myth #4 – The PINNACLE Registry patient encounter and CV practice uptake has been abysmally slow

PINNACLE Registry • PINNACLE Fact #4 PINNACLE Registry Patient Encounter Records

1,491,122

1,400,000

Unique Records in Data Warehouse

1,200,000 961,959

1,000,000

System Integration (SI) Solution

800,000

705,851

600,000 462,378

505,186

400,000 213,799 200,000 0

2,466

5,722

11,150

Mar-09

Jun-09

0 Sep-08

Dec-08

Sep-09 Dec-09 Month

Mar-10

Jun-10

Sep-10

Dec-10

Geographic Distribution of PINNACLE Registry Practices – March 2011

WA (2;9)

VT ND

MT

NH MN

OR

WI (1;4)

SD

ID WY

IA (2;68)

NE (1;1)

NV UT CA (1;1)

CO (3;15)

KS (1;3)

NY (4;54)

MI (3:24)

IN IL (3;59) (6;95)

KY (3;31)

MO (2;84)

WV (2;2)

NM (1;5)

MS TX (4;101)

AL (2;24)

VA (3;38)

SC (2;33) GA

LA (1;16) FL (6;42)

AK HI

NJ (1;14) DE

NC (2;8)

AR (1;17)

Key: (Practices; providers) States = 28 Practices = 58 Providers = 780

MA RI (1;7) CT

PA (1;8)

OH (2;32)

TN OK AZ

ME

MD (3;14) DC

PINNACLE Registry • PINNACLE Myth #5 – PINNACLE Registry participation is “just not worth it” to CV practices

PINNACLE Registry • PINNACLE Fact #5 – PINNACLE Registry participation has many potential benefits • • • • •

Providing optimal care to patients Maintenance of certification credit Pay-for-performance programs of commercial payers Possibly maintenance of licensure credit in the future Possibly fulfillment of meaningful use criteria in the future • PQRS – proven efficacy

PINNACLE Registry • PINNACLE Fact #5 – PINNACLE Registry PQRS participants -2009 • • • •

14 practices in 14 states, 172 providers AL, AR, FL, IL, MD, MO, NC, NE, NJ, NY, SC, TX, VA, WA 100% received PQRI payments 13 practices, 171 providers reported results to ACC

PINNACLE Registry • PINNACLE Fact #5 – PINNACLE Registry PQRS participants -2009 • • • • • • • •

$1,495,029 received in payments Providers per practice 1 to 50 (mean = 13; median = 7) ~$8,352 received per provider ($3,817 to $21,667) 239,280 total PQRS encounters = additional $6.28 per encounter Or, ~ 130,408 Medicare encounters (54.5%) = additional $11.52 per Medicare patient encounter Additional time per patient encounter < 1 minute PQRS revenue for additional time devoted to PINNACLE = $375/hour PINNACLE-PQRS for 2010 ~500 physicians

PINNACLE Registry • PINNACLE Myth #6 – The PINNACLE Registry is too expensive for the ACC and will require invasion of cash reserves

PINNACLE Registry • PINNACLE Fact #6 – From 2007 to 2010, PINNACLE (R&N) was actually cash flow positive to the ACC PINNACLE Income Statements $3,000,000

ACC-Contribution Registry-Contribution Network Contribution Registry Expenses Network Expenses Net Contribution

$2,000,000

$1,000,000

$0

2007 - 2010 Net Contribution = $1,095,702 or $273,926/year ACC = $1,000,000 or $250,000/year ACC Surplus = $95,702 or $23,926/year

($1,000,000)

($2,000,000)

($3,000,000) 2007

2008

2009

2010

PINNACLE Registry • PINNACLE Myth #7 (a and b) – The PINNACLE Registry is only for research and publication (a) – The PINNACLE Registry data are not good enough for research or publication (b)

PINNACLE Registry • PINNACLE Fact #7a – The PINNACLE Registry case created to help participating providers measure and improve performance. Performance improvement, not research, has always been the main purpose of PINNACLE (See fact #1) – Nevertheless, it is important to do research and to publish on performance improvement topics and to use our experience to generate new knowledge and new measures

PINNACLE Registry • PINNACLE Fact #7b – PINNACLE Publications and Submissions – – – – – – – – –

Chan PS, et al. Am J Med. 2010;123:217-9.

Chan PS, et al. JACC. 2010;56:8-14.

Oetgen WJ, Mullen JB, Mirro MJ. JACC. 2011; 57:1560-3.

Erb BD, et al. US Cardiology. 2011;8(1):12-5.

May DC, et al Phys Exec J. In press 2011.

Arnold SV, et al. Circulation. Submitted 2010.

Chan PS, et al. Am Heart J. Submitted 2010.

Oetgen WJ. Circ Cardiovasc Qual Outcomes. In press 2011.

Oetgen WJ, Mullen JB, Mirro MJ. Arch Int Med In press 2011.

PINNACLE Registry • PINNACLE Fact #7b – PINNACLE Publications and Submissions – – – – – – – – –

Chan PS, et al. Am J Med. 2010;123:217-9.

Chan PS, et al. JACC. 2010;56:8-14.* Oetgen WJ, Mullen JB, Mirro MJ. JACC. 2011; 57:1560-3.

Erb BD, et al. US Cardiology. 2011;8(1):12-5.

May DC. Phys Exec J. In press 2011.

Arnold SV, et al. Circulation. Submitted 2010.* Chan PS, et al. Am Heart J. Submitted 2010.* Oetgen WJ. Circ Cardiovasc Qual Outcomes. In press 2011.

Oetgen WJ, Mullen JB, Mirro MJ. Arch Int Med In press 2011. » * Data-driven manuscripts

PINNACLE Registry • PINNACLE Fact #7b – PINNACLE Publications and Submissions • Chan PS, Oetgen, WJ, Buchanan D, Mitchell K, Fiocchi FF, Tang F, Jones PG, Breeding T, Thrutchley D, Rumsfeld JS, Spertus JA. Performance measure compliance. (JACC. 2010;56:8-14.)

– 7/1/08 – 6/30/09 – Patients = 14,464 – Atrial fibrillation = 2,786 – Coronary artery disease = 8,132 • Chan PS, Maddox TM, Spinler S, Spertus JA. Warfarin use. (Am Heart J, submitted December 2010) – 7/1/08 – 12/31/09 – Patients = 136,796 (>900%) – Atrial fibrillation = 18,393 (>600%) • Arnold SV, Spertus JA, Tang F, Krumholz HM, Borden WB, Farmer SA, Ting HH, Chan PS. Statin use. (Circulation, submitted December 2010) – 7/1/08 – 6/30/10 – Patients = 179,608 (>1200%) – Coronary artery disease = 39,601 (~500%)

PINNACLE Registry • PINNACLE Myth #8 – The AHA’s GWTG-OP will “bury” the PINNACLE Registry

PINNACLE Registry • PINNACLE Fact #8 – It is unfortunate that there is any competition between AHA and ACC in outpatient CV quality registries – There have been no peer-reviewed publications from GWTG-OP – In November 2010, the AHA reported informally on GWTG-OP • • • •

2 practices (vs ~35 in PINNACLE) 235 contributing physicians (vs ~450 in PINNACLE) 95,593 patient encounters (vs 961,959 in PINNACLE) “Launch” planned in January 2011 (vs October 2009)

PINNACLE Registry • PINNACLE Myth #9 – The PINNACLE Registry is incompatible with most EHRs

PINNACLE Registry PINNACLE Fact #9 • PINNACLE Registry is running on: – – – – – – –

Nextgen GE Centricity GE Logician GEMMS Allscripts Greenway Medical Misys

– – – – – – – –

Medisoft Clinical MIE Soapware gMed Amazing Charts Universal EMR PrimeSuite These represent >60% of CV practices with EHRs

PINNACLE Registry PINNACLE Fact #9 • PINNACLE Registry team is mapping: – – – – – – –

MDrec NextTech eMD MyWay EPIC Pronto EMR eClinical Works

– – – – – – – – –

Med Informatics Cerner Infinity Alteer Visionary Health Care Springcharts DigiDMS Athena Intergy / Sage These represent >30% of CV practices with EHRs

PINNACLE Registry • PINNACLE Myth #10 – The PINNACLE Registry does not collect enough data from EHRs to be worthwhile

PINNACLE Registry • PINNACLE Fact #10 – With reasonable, (i.e. cost effective) system integration efforts, the PINNACLE Registry can capture 75% - 80% of the required data for calculation of 27 performance measures for most EHRs (some EHRs are much higher) – With these data, 75%-80% of performance measures can actually be calculated and reported – Before the PINNACLE Registry and systems integration, zero outpatient CV performance measures were being calculated and reported – The PINNACLE Registry is not perfect, but the glass is 75% full, not 25% empty

PINNACLE Registry • PINNACLE Myth #11 – The PINNACLE Registry data are “stale” when practitioners receive their reports because they only are available quarterly

PINNACLE Registry • PINNACLE Fact #11 – With the ongoing deployment of the PINNACLE Dashboard, providers can instantaneously review their data – Custom reports can be created by providers on an ad hoc basis

PINNACLE Registry Summary • Workflow efficient • Practice size • Brisk uptake • Beneficial to practices • Economical to ACC

• • • • •

Supports research Competitive EHR agnostic Robust data Timely reports

PINNACLE Registry Summary • Not perfect

PINNACLE Registry Summary • Not perfect • But functional and useful

PINNACLE Registry Summary • Not perfect • But functional and useful • And something to be proud of

PINNACLE Registry • Contact Information – Brendan Mullen • bmullen@acc.org • 202-375-6464

– Bill Oetgen • oetgenw@georgetown.edu • 301-535-2493

PINNACLE Registry