While the specific content of national healthcare reform legislation and even its ultimate passage remain uncertain, several related initiatives that affect neurosurgeons have been well under way for some time. PQRI, MOC and CER are among the alphabet soup of initialisms related to healthcare quality improvement as a high-profile component of reform.
“A common feature of all healthcare reform initiatives is the focus on how to improve quality,” said Robert E. Harbaugh, MD. “For surgical specialties the only reliable way to do it is to track individual outcomes.”
Dr. Harbaugh is in a unique position to know. He chairs the AANS/CNS Washington Committee, which spearheads neurosurgery’s advocacy efforts in the nation’s capital, serves on that committee’s Quality Improvement Workgroup, which he previously chaired, and is a veteran of numerous efforts within neurosurgery and related disciplines to track outcomes and improve quality. He is the director of the Penn State Institute of the Neurosciences, chair of the Penn State Department of Neurosurgery and a professor in the Department of Engineering Science and Mechanics at Penn State University. He also serves as a director of the American Board of Neurological Surgery. For many years he has tracked the surgical outcomes of his own patients with a database he developed, a practice he has found valuable in a personal quest for achieving professional excellence.
Now he is leading a new endeavor, development of a single data portal for neurosurgeons to use in meeting all of the reporting requirements associated with the various quality initiatives. The project is led by NeuroPoint Alliance Inc., a nonprofit company established by the AANS in early 2009. Dr. Harbaugh serves as the company’s president, Tony Asher, MD, as secretary, and Paul McCormick, MD, as treasurer. David Adelson, MD, Kevin Cockroft, MD, Anil Nanda, MD, and Eric Woodard, MD, serve as directors.
NeuroPoint Alliance contracted with Outcome Sciences Inc. to manage data collection and to collaborate in neurosurgical outcomes research. Outcome has more than 10 years of experience in study design and management, biostatistics, opinion research and survey methodology, and Internet and wireless data collection. The AANS previously contracted with Outcome to handle recent projects such as Neuro-Knowledge and the lumbar spine outcomes pilot study. Outcome principals Richard Gliklich, MD, and Nancy Dreyer, MPH, PhD, literally wrote the manual on patient outcomes registries for the U.S. Agency for Healthcare Research and Quality.
“The timing is right for NPA,” said Dr. Harbaugh. “Past efforts in this vein haven’t attracted neurosurgeons’ widespread participation, primarily because there weren’t sufficient incentives to participate or penalties for lack of participation, but the climate has changed dramatically.”
Quality Initiatives
Maintenance of Certification exemplifies a quality initiative led by neurosurgeons. The American Board of Neurological Surgery requires its diplomates holding time-limited certificates to participate in MOC “to foster excellence in patient care,” according to the ABNS Web site. For these diplomates, failure to participate in MOC would mean no less than loss of certification. The ABNS site also notes that the program “provides an avenue for compliance with future state, hospital, and third party payers since these are expected to require either participation in an MOC process or periodic reexamination by state medical boards”; thus, participation in MOC offers the incentive of potentially meeting additional requirements simultaneously with fulfillment of MOC requirements. MOC participants submit operative data on key cases, and similarly applicants for initial ABNS certification submit data on operative procedures. NeuroPoint Alliance is working with the ABNS on streamlined data entry and data sharing measures that will build on the MOC process to increase the value of participation for neurosurgeons.
Another example is Medicare’s Physician Quality Reporting Initiative. Physician participation in PQRI has been voluntary, but it is widely expected to be required in the near future.
“Only about 1 percent of neurosurgeons have participated in PQRI, but the bonuses for participation are becoming more attractive,” Dr. Harbaugh said. “The new PQRI requirements will allow reporting of 30 consecutive cases, only two of which need to be Medicare patients. This will qualify the surgeon for a 2 percent bonus on all Medicare patients for the year. Streamlining participation through NPA tips the balance in favor of participation.”
Comparative-effectiveness research, while a familiar concept, is the new kid on the block in terms of quality initiatives. The American Recovery and Reinvestment Act of 2009 included $400 million for CER “to evaluate the relative effectiveness of different healthcare services and treatment options” and “to encourage the development and use of clinical registries, clinical data networks, and other forms of electronic data to generate outcomes data.” It designated the Institute of Medicine to advise how the funds should be spent, and the IOM report, Initial National Priorities for Comparative Effectiveness Research, strongly supports development of prospective registries and sets forth CEC priorities. The priority areas of particular interest to neurosurgeons are spine and imaging.
“These are the types of data requirements the NeuroPoint Alliance software is being designed to handle,” said Dr. Harbaugh. “NPA will make meeting all of these requirements a painless process with tangible benefit to neurosurgeons.”
Interoperability With EMRs
Another change from the past is that now many neurosurgical practices are equipped with sophisticated coding and billing software. Dr. Harbaugh noted that a key feature of the NeuroPoint Alliance software is its interoperability with doctorsâ electronic medical records systems.
“The interoperability built into NPA means that participation will simply require a data upload from a neurosurgeon’s local institution or office EMR,” said Dr. Harbaugh. “We’ll be looking closely at EMRs that are widely used by neurosurgeons such as NextGen, a ‘partner program’ of the AANS, to ensure broad-based interoperability.”
He cited the experience of Outcome Sciences as an advantage in establishing and maintaining interoperability. “Outcome not only has the infrastructure in place now, it also has a solid track record of continuous upgrades over the years,” he said. “We can move forward with confidence that interoperability is a mutually paramount concern from the project’s inception through the years to come.”
Long-Term Viability
Besides the demonstrated need for a data portal and the caveat that it be easy for neurosurgeons to use, it is clear that the company must be viable financially to be sustainable over time. Dr. Harbaugh described how the project will generate income and promote reliable, outcomes-based research.
“We want to be the main source for clinical data,” said Dr. Harbaugh. “The data itself is valuable and more so when we know, and can demonstrate, that it’s truly representative of neurosurgery as well as reliably collected.”
As such, the data can be generated for third parties for use in their research. NeuroPoint Alliance can ensure that the data is aggregated and that individual patients and neurosurgeons are not identified. In addition, it will be able to perform data collection and analysis for clinical trials and serve as a clinical trials organization for investigators from academia and industry.
“We would like NPA to become ‘the’ organization for neurosurgical trials,” said Dr. Harbaugh. “A distinct advantage is that the money comes back into neurosurgery.”
Recent reports in the media and in scientific journals alike have focused on inappropriate industry influence in clinical trials and bias toward publication of results favorable to pharmaceuticals or devices. Whether such conflict is real or perceived, the resulting climate change has paved the way for industry interest in a service like NPA to independently collect data, perform trials and publish results.
“We will do the trials that industry has previously done,” said Dr. Harbaugh. “We can build into the contracts that all results—positive or negative—will be published. Neurosurgeons who participate in such trials will contract with NPA, not with an industry sponsor, and will be vetted for any conflict of interest. Neurosurgeons who participate in an industry-sponsored NPA trial will be paid, by NPA, for their participation.”
Similarly, NeuroPoint Alliance could serve the needs of a company that must perform postmarket surveillance for a device or biological over several years or a surgeon who has a patent on a device and needs an unbiased evaluation of its merits.
True Quality Improvement
The incentives for participation, the ease of use, and a business plan that ensures sustainability might mask the underlying purpose of NeuroPoint Alliance.
“To truly measure quality, you need good data,” said Dr. Harbaugh. “Through NPA neurosurgeons can drive and achieve vigorous quality improvement, and that’s really what we all want for our profession and for our patients.”
Manda J. Seaver is staff editor of the AANS Neurosurgeon.
For Further Information
- AANS Partner Programs, www.aans.org/membership/mem_services.asp
- CER, Comparative Effectiveness Research; Institute of Medicine Report: Initial National Priorities for Comparative Effectiveness Research, www.iom.edu
- MOC, Maintenance of Certification, www.abns.org
- Outcome Sciences Inc., www.outcome.com
- PQRI, Medicare Physician Quality Reporting Initiative, www.cms.hhs.gov/pqri
- Registries for Evaluating Patient Outcomes: A User’s Guide, www.ahrq.gov (AHRQ Pub. No. 07-EHC001-1)