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doi: 10.1097/01.NT.0000428474.31149.52
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IN PRACTICE: Donald Iverson, MD: What You Can Do to Improve Your Practice

Rukovets, Olga

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Keeping up with practice trends and improving your performance as a neurologist are not just personal responsibilities to yourself and your patients, they are also mandated by the American Board of Medical Specialties. Two years ago, at the request of the American Board of Psychiatry and Neurology (ABPN), the AAN launched NeuroPI, its Performance in Practice (PIP) program, to help neurologists achieve these goals.

“The mandate is to do performance improvement units in 10 years. Each unit includes both a clinical and feedback module component,” Donald Iverson, MD, the editor of the AAN Performance in Practice modules and a neurologist with Humboldt Neurological Medical Group in Eureka, CA, said. “We recognize the increasing demands on practicing neurologists, and we want to make something that is truly useful and relevant without being too onerous,” he added.

Dr. Iverson, who also serves on the editorial advisory board of Neurology Today, talked to the publication about how the AAN chooses and develops PIP modules, the newest modules on the market, and what topics you can expect to see in the future.

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HOW DO YOU CHOOSE THE TOPICS FOR NEUROPI MODULES?

Our goal is to develop at least one module for the 13 or so major subspecialties, and several “universal” modules that can apply to almost any specialty. We use AAN measure sets, which are a product of years of work and vetting, when available; otherwise we derive them from specialty societies' guidelines, AAN practice parameters, other high-level evidence, or inference.

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WHAT IS THE GOAL OF THESE MODULES?

These modules — all available online — serve as a checklist and a resource for improving neurological care by highlighting or emphasizing issues that may go underappreciated or overlooked.

One of the goals is to identify measures or tasks that absolutely have to be done and belong on any neurologist's checklist. Then, we also try to find items where there may be gaps in practice, so there's room for improvement.

For example, every neurologist has to do a history and physical examination. But there are other things, such as providing education to women about reproduction and epilepsy, which some neurologists may not already be doing. Addressing those potential gaps in practice — that's an opportunity for improvement.

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WHAT DOES THE MODULE CONSIST OF? WHAT KIND OF RECORD KEEPING IS NEEDED ON THE NEUROLOGIST'S END?

Each of the modules is structured in three parts: stage A) assessment, where you assess your performance via a chart audit using a select set of criteria; stage B) intervention, where you will have access to a selection of resources to support areas of growth and assist you in constructing an effective improvement plan; and stage C) evaluation, where you will reassess your performance and determine whether you have achieved your improvement goals.

The module includes patient demographic information, the checklist of measures, case studies and rationales/didactic information supporting the measures, suggestions for creating an improvement program, multiple choice questions, and clinician and patient resources. The “record keeping” is limited to entering the above information.

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HOW DO THESE MODULES REFLECT “BEST PRACTICES”? DO THEY ADDRESS CHANGES IN PRACTICE?

DR. DONALD IVERSON: ...
DR. DONALD IVERSON: ...
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There is a greater emphasis on patient education these days, and we address that and provide resources for patients. “Best practice” has acquired some negative connotations to the extent that it implies “expert opinion” rather than “evidence-based medicine.” That said, patient education, for example, falls under a “best practice” because it is a reasonable inference that it will lead to better outcomes.

Every time a new article or study comes out, we won't necessarily change a module. But if there are high-level recommendations from the AAN, for example, or a major FDA missive, then we may modify a module. We've only been doing this for two years, but I suspect that there will be more changes over time and we're able to update the modules as needed.

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CAN YOU DESCRIBE THE NEW MODULE FOR STROKE?

The “Acute Stroke Care” module is based on the American Medical Association/American Stroke Association measure set that the AAN helped to develop (aan.com/globals/axon/assets/8248.pdf). It is a robust measure set that was the basis for Medicare's Physician Quality Reporting System (PQRS) program. Some of the featured quality measures in the module include: Deep Vein Thrombosis Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage, Anticoagulant Therapy Prescribed for Atrial Fibrillation, Screening for Dysphagia, Consideration of Rehabilitation Services, and Avoidance of Intravenous Heparin.

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FOR THE NEW MODULE ON CHRONIC OPIOID THERAPY, HOW HAVE YOU ADDRESSED INCREASED CONCERNS OF OVER-PRESCRIPTION AND ADDICTION?

The issue of over-prescription and addiction has had widespread media attention — a five-fold increase in prescriptions and overdose deaths in the same 10-year time period. In our new module, we address those concerns and offer the tools to deal with them. For instance, we include recent FDA safety measures on narcotic prescribing, such as issues of diversion of medications, patients receiving medicines from multiple prescribers, informed consent for prescribing the medications, and compliance.

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WHAT FEEDBACK HAVE YOU RECEIVED FROM PARTICIPANTS?

The feedback has been good so far — 90 percent have reported NeuroPI is “helpful” or “very helpful” on program evaluations. We've had participants tell us, “I will use this in my practice” because “I have been giving women with epilepsy short shrift,” or “I have not been providing education on risk of falls,” and so on.

We want to emphasize that we are sensitive to the demands that are being put on neurologists. For example, some of the measure sets are potentially labor-intensive (e.g. Patient Safety: Falls, Parkinson's); so we created questionnaires that can be completed “off line,” which saves the clinician a lot of time and improves the accuracy of patient reporting.

I am a private practice general neurologist, so I'm in the trenches and I understand the constraints. So far, from the feedback we're getting, it seems that we've been successful.

My staff person extraordinaire, Tracy King, the associate director of education at the AAN, has been the real engine behind this operation. We always welcome comments and feedback from neurologists. We actually brought two people on as faculty who just started out asking us questions about the recertification process.

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FUTURE MODULES?

Future modules include: headache, ALS, spine, intracerebral hemorrhage, and multiple sclerosis.

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FOR FURTHER READING:

• From the AAN, NeuroPI: Performance Improvement in Neurology: Dr. Donald Iverson's video introduction of NeuroPI and other program information is available at www.aan.com/view/neuropi.
Neurology Today's coverage of practice improvement measures for neurology: http://bit.ly/XTOUYq, http://bit.ly/UtuJWV
• From the ABPN, Maintenance of Certification requirements for neurology/child neurology: www.abpn.com/moc_neuro.asp

©2013 American Academy of Neurology

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