Cardio-Hit Phase II

Quality measure exceptions are defined by the Physician Consortium for Performance Improvement® (PCPI) as reasons why patients who are eligible for a measure based on a broad criterion such as diagnosis (the patient has coronary artery disease) or age may not be candidates for a particular aspect of care because of a medical (allergy to drug), patient (preference), or system (shortage of influenza vaccine or inability to pay) reason. With the growing levels of public and private clinical performance measurement activity in the United States, the use of exceptions has received increasing attention from varying stakeholders, including consumer and patient groups, physicians, payers, policymakers, performance measure developers, and product vendors of electronic health records (EHRs). In the context of physician performance measurement, exceptions are an element of physician performance measure design that is intended to fulfill four functions: promote appropriateness of care, facilitate quality improvement and patient management, track variations, and prevent unintended penalization of physicians.

This project investigated and validated the prevalence and patterns of exception reporting among physicians participating in the Cardio-HIT collaborative, a practice-based research network. The overall objectives of this study were to assess the prevalence of exception reporting, document specific reasons for exceptions, evaluate the relative accuracy of reported exceptions, and identify the location of exception data in EHRs.

The Cardio-HIT Phase II collaborative was formed as a research network of five independent physician group practices to demonstrate the feasibility and value of implementing national performance measures for coronary artery disease (CAD) and heart failure (HF) within existing practice site EHRs. The five groups comprising the collaborative are Fox Prairie Medical Group, Midwest Heart Specialists, North Ohio Heart Center, Physicians Health Alliance, and the University of Pittsburgh Medical Center.

Two sources of data were used for this study: PCPI physician performance measure data that were collected by all Cardio-HIT sites, and detailed data on reported performance and exceptions that were extracted from the practices' EHRs. The practices reported data on 47,075 CAD patients for four CAD drug therapy performance measures and 13,985 HF patients for three HF drug therapy performance measures, including exception reasons. Retrospective manual reviews of the EHRs were conducted on a sample of 538 CAD and 559 HF patients with reported exceptions.

Performance rates were generally high with exception reporting generally low. Agreement rates between automatic submission and manual review were also high. The high rates of agreement support the use of exceptions in quality reporting.