In the fall of 2009, the American College of Cardiology (ACC) launched the Practice innovation and clinical excellence (PINNACLE) Network™.1 The foundation of the PINNACLE Network rested on three observations by ACC membership and staff:
- The medical profession is in the midst of unprecedented social, political, and economic change that dramatically impacts how cardiovascular specialists provide care.
- The ACC is a recognized leader in the development and implementation of quality initiatives, practice guidelines, appropriate use criteria (AUC), and clinical data registries.
- These abundant materials, services, tools, and programs remain underutilized by ACC membership.
With these observations, it became clear that several challenges lie before the ACC. These challenges are:
- to uphold the value of ACC membership and ensure its continued relevance as the marketplace rapidly evolves due to health system and payment reform;
- to foster the development of a culture of continuous quality improvement founded on a commitment to lifelong learning and the on-going acquisition and use of clinical data for the benefit of patients;
- to provide physician and practice support for innovation and transformation and to thereby enhance professional satisfaction and longevity; and
- to create efficiencies by organizing ACC programs for easy and logical member access and by ensuring inter-program communication and coordination.
It became clear that the response to these challenges was for the ACC to provide the leadership necessary to help members transform their practices during these turbulent times, and the PINNACLE Network was created to be the vehicle for that response.
The PINNACLE Network
The PINNACLE Network is an interactive community of cardiovascular professionals who are committed to the delivery of coordinated, efficient, safe, and effective cardiovascular care for their patients. Network members use the resources of the ACC to systematically measure, review, and improve their performance (through registries and quality improvement [QI] initiatives); to continuously learn and teach (through the ACC Learning Portfolio and patient-centered care programs); and to design or redesign care to meet the needs of their patients and the new realities of healthcare payment reform. The PINNACLE Network makes the direct connection between data, performance improvement, and the economics of cardiovascular care.
Member Benefits of the PINNACLE Network
The PINNACLE Network is comprised of three components. The PINNACLE Registry™, with more than one million patient records, is the nation’s largest cardiovascular ambulatory quality improvement registry. The PINNACLE Network Portfolio provides an organized set of programs, tools, and services for cardiovascular practices. At its core is a community of peers who share a common commitment to individual and practice measurement, thoughtful review of those data, and action based on their review. They also share a commitment to learn, teach, and practice the principles of continuous quality improvement, and to share experiences with others to help transform cardiovascular practice.
The PINNACLE Registry is one of five registries of the ACC’s National Cardiovascular Data Registry (NCDR®).2 The primary purpose of the PINNACLE Registry is facilitating improvement in outpatient cardiovascular care quality and, by extension, improving patient outcomes. The PINNACLE Registry captures clinical data of participating practices related to the outpatient care provided to patients with coronary artery disease (CAD), atrial fibrillation, heart failure and hypertension. Using established guidelines and performance measures, the PINNACLE Registry was designed to drive care improvement by reducing inappropriate variations in care, eliminating gaps in care, and improving care coordination for patients with cardiovascular diseases. The Registry assists practices in understanding and improving care through the production and distribution of quarterly performance reports for data-submitting practices and physicians. These reports, covering all valid patient encounters, detail adherence to 25 cardiovascular clinical measures at the physician, location, and practice levels.
Figure 1 gives an example of a PINNACLE Registry quarterly report for one performance measure, beta-blocker therapy—prior myocardial infarction (MI) (ACC/American Heart Association [AHA]), for the first quarter of 2010. This includes practice performance for the individual practice compared with the national average for all practices in the registry, for the site locations within each practice compared with each other and with the practice average, as well as for individual physicians compared with each other and with the practice average.
PINNACLE Registry data collection is based in the outpatient electronic health record (EHR) systems of practices, allowing for data typically collected in EHR systems to automatically populate and match with required PINNACLE Registry data elements. This method vastly reduces duplicative data entry, minimizes workflow interruption, and provides maximum clinical value to the participating practices. In addition to QI applications, NCDR and PINNACLE Registry data are used by researchers and clinicians for novel scientific output, including submissions to peer-reviewed medical and academic journals.
PINNACLE Network Portfolio
There are currently seven areas in which participants can benefit from programs, tools and services offered by or distributed through the PINNACLE Network.
- Network participation provides the opportunity to practice with increased adherence to published national clinical standards. One example is the FOCUS program.3 The online collection of tools and resources developed for FOCUS is designed to aid in the implementation of the College’s appropriate use crtiteria (AUC). These resources have been centralized in one place and offer access to an AUC QI listserv, pocket cards, best practices, webinars, and a performance improvement module. These resources can support a practice in evaluating AUC, as well as documenting QI activities for laboratory accreditation and maintenance of certification (MOC). In the coming year, additional tools will be added to FOCUS supporting additional AUC documents and point-of-care electronic decision support. These additional enhancements will be available on a subscription basis and can be packaged with PINNACLE Network membership once they are available. Lastly, updates on efforts by the ACC to package these resources for health plans, the Centers for Medicaid and Medicare Services (CMS) and Accountable Care Organizations (ACO) in ways to be used in lieu of radiology benefit managers (RBMs) will be posted on the FOCUS site. Partnerships with health plans and ACOs to use FOCUS would alleviate practice administrative burdens and the ‘black box’ rules of RBMs while providing member practices with tools to demonstrate appropriate use.
- Through the ACC’s Practice Management program, the PINNACLE Network also offers services to help office practices stay up-to-date with key issues in the field and succeed at the interface of practice management and quality cardiovascular care.4 Tools developed by the Network target all members of the cardiac care team including physicians, nurses, and practice administrators. Resources include webinars, live programs, and communities in critical areas such as buying and selling medical practices, guidelines for developing strategic alliances, physician employment contracts, working with health plans, and providing updates on coding and billing issues. At the annual scientific session meeting in April of this year, the ACC will feature the first Practice Management Spotlight Session with sessions driven by the Network including topics such as disease management, physician leadership, and innovative payment models. White papers on physicians as leaders of cardiovascular service lines are being developed and designed to provide guidance to cardiac care team members whose work environment has changed in recent years.
- Participants can benefit from lifelong educational and performance improvement activities through the Network. The Cardiology Practice Improvement Pathway (CPIP) is a practice-level performance improvement program designed specifically to enhance and instill quality in cardiovascular practice. The CPIP is approved through the American Board of Internal Medicine’s (ABIM) Approved Quality Improvement (AQI) Pathway and is eligible for 20 points towards the Self-Evaluation of Practice Performance requirement MOC. CPIP provides a platform for practices to evaluate themselves against a comprehensive measure set designed to support the delivery of cardiovascular care that achieves the six national quality aims identified by the Institute of Medicine (IOM): care should be safe, timely, effective, efficient, equitable, and patient-centered (STEEEP). The CPIP comprehensive measure set is currently organized within three domains—clinical, structural, and professional.
- Clinical—The clinical measure sets are developed and specified by the ACC with the AHA and the American Medical Association (AMA)’s Physician Consortium for Performance Improvement (PCPI). They are intended to improve patient outcomes by defining process and outcome measures for the ambulatory care of patients with one, some, or all of the following cardiac diagnoses: hypertension, stable coronary artery disease, heart failure, and atrial fibrillation and atrial flutter.
- Structural—The structural metrics identify and evaluate the implementation of practice-level systems that promote the delivery of STEEEP care.
- Professional—The professional metrics identify and evaluate each individual cardiologist’s achievement and maintenance of professional credentials; such commitment to professionalism at the practice level is believed to have positive effects on STEEEP care. CPIP offers practices opportunities to learn about their practice patterns at the group level and to understand how they measure up against the quality goals and targets established by their medical specialty society. Practices receive immediate feedback on their performance with recommendations for developing and implementing QI plans based on their results.
- Within three months of beginning the assessment phase (Stage A) of the pathway, practices complete data collection and submission requirements in order to attain their baseline performance.
- Practices will identify opportunities for improvement in the clinical domain and develop a QI plan. Practices will implement their QI plan over a six-month period (Stage B).
- Within three months of completing Stage B, practices will re-measure their clinical performance to determine whether the steps they have taken have resulted in an improvement (Stage C).
- The ACC’s performance improvement education follows the AMA Performance Improvement–Continuing Medical Education (PI-CME) three-stage process, which begins with data review and self-assessment, followed by developing a plan for improving performance and participation in at least one targeted educational intervention.5 Lastly, practitioners reassess their performance data to measure their progress and compare their results with other clinicians nationwide. The ACC’s PI-CME initiatives streamline practice review by allowing physicians to use NCDR registry data that have already been collected. Brief and easy-to-complete self-assessment questionnaires along with patient surveys supplement their clinical practice data, giving them a complete picture of how their practice matches up to evidence-based care. Their choice of educational activities, QI tools, and patient education resources helps them focus on specific performance measures to enhance their patient outcomes. ACC PI-CME initiatives provide 20 AMA Physician’s Recognition Award (PRA) Category 1 Credits™ for physicians and 20 contact hours for nursing professionals. In addition, ABIM-certified physicians who successfully complete one of the initiatives are eligible for 20 points towards the Self-evaluation of Practice Performance requirement of MOC.
- Participation in the PINNACLE Network provides opportunities to earn incentives for successful achievement of performance or reporting thresholds. The Bridges to Excellence (BTE) Cardiology Practice Recognition6 endorsed by the ACC is awarded to those cardiology practices that achieve performance thresholds for recognition established jointly by the ACC and BTE. Upon completion of CPIP Stage A, practices can choose to have their assessment data submitted to IPRO, BTE’s performance assessment organization, for evaluation against established thresholds. The quality indicators collected through CPIP are calculated and scored by IPRO for BTE recognition. As of this writing, practices that achieve the BTE Cardiology Practice Recognition will meet the 2011 quality criteria for inclusion in the Aetna Aexcel® and Anthem Blue Precision networks. In addition, these practices will be identified in the 2011 Blue Cross Blue Shield Association’s National Provider Directory. The PINNACLE Network has also demonstrated success in assisting participating cardiologists with receiving Medicare bonus payments for successful participation in the Physician Quality Reporting Initiative (PQRI).7 Early results indicate that participating cardiologists received between $7,000 and $10,000 for 2009.
- Network practices can also provide positive influence on local and national policy decision-making through affiliation with the ACC’s Advocacy Program. Participants in the Network will be enabled to demonstrate high quality and value to external stakeholders such as payers, government, referring providers and patients. Having the ability to demonstrate value will be critical as payment and delivery models evolve. In addition, network practices can work to influence health policy with data and outcomes that support high-quality, patient-centered care.
- Through the affiliation with the ACC’s Risk Management Institute (ACCRMI), Network members can benefit from medical professional liability risk management education and from insurance services provided through partnering liability insurance companies.8 The ACCRMI is designed to increase patient safety and reduce medical professional liability claims risks. The ACCRMI aims to provide cardiovascular practices with patient safety education they have confidence in and can trust. To that end, ACCRMI’s educational resources are created specifically for cardiovascular specialists. The ACC is partnering with medical professional liability insurance companies and the Physician Insurers Association of America (PIAA) to review closed cardiovascular claims and to identify trends. This information will be leveraged to provide practices with important information that can help improve patient safety, mitigate national cardiovascular liability, and lower insurance premiums.
Community of Peers
The PINNACLE Network further confers on participants the benefit of being part of a community of like-minded peers. These relationships are ideal for sharing best-practice information and for informally disseminating useful and practical information. These connections can, for instance, generate information that would be useful in the selection, purchase and implementation of office-based EHRs. The network’s community of peers can also be useful in generating a collective response to opportunities for comparative effectiveness research participation.
PINNACLE Network Governance
The PINNACLE Network is an informal group of participants united by the common desire to improve the quality of cardiovascular care. Its implementation has been guided by a work group whose members are appointed by the ACC President. The PINNACLE Network Work Group is comprised of current and former governors of ACC State Chapters and is supported by staff across several ACC divisions. The work group’s charge is to operationalize the PINNACLE Network and, by doing so, to make QI efforts easy, profitable, and rewarding for participating cardiologists.
Future Goals of the PINNACLE Network
In the very near future, several enhancements and additional portfolio products will be available to PINNACLE Network participants through the ACC website, CardioSource.9 Soon-to-be-added online discussion forums will encourage community building through such topics as practice vitality strategies, preparing for healthcare reform, and addressing the implementation of EHRs. Primers and select videos will help the cardiovascular healthcare team in such topics as performance measures, ACC guidelines and AUC, QI and EHR. Financial primers will offer assistance in such areas as fee schedule analysis. Legal issue briefs will provide guidance in such areas as buying and selling medical practices and physician employment contracts.
Over the course of the next year, monthly webinars will help inform and educate Network members on timely topics such as ACOs, payment models, team-based care, and the International Classification of Diseases, 10th revision (ICD-10) coding update. Case studies, live programs, and disease-specific clinical QI toolkits will also be provided as the year unfolds.
The medical profession is facing unprecedented social, economic, and political change. In these challenging times the ACC believes that the systematic practice of quality care is the foundation for practice success—clinically, financially, and professionally. Developed by cardiologists for cardiologists, the PINNACLE Network is a community and pathway to help ACC members achieve that success.
The PINNACLE Network promotes such cardiovascular practice success by providing service offerings in evidence-based medicine, practice management, QI, and education; supporting the application of systematic and accurate measurement, analysis, and feedback on performance; developing member-vetted programs and tools to help reduce the costs of practice, streamline work flow, reduce administrative burdens, and strengthen the business case for quality; creating a peer community to share pragmatic solutions to practice problems and common issues; and advocating, at federal, state, and local payer levels, enhanced recognition and reimbursement based on PINNACLE Network members’ commitment to the delivery of high-value cardiovascular care.