Taking the wheel

By Victoria Houghton, managing editor

“As a small specialty, it may not come as a surprise when the valuable care we provide goes unnoticed,” said Henry W. Lim, MD, the Academy’s immediate past president in a From the President column. “Of course, we all understand the significance of the work that dermatology contributes to the health care world and so do our patients. However, there are policymakers, members of the public, and colleagues in other specialties who may not know what we do or the value that we add.”

Indeed, according to a study published in the European Academy of Dermatology and Venereology, 77% of 247 patients who received a medical consultation from a dermatologist were satisfied with their visit (doi.org/10.1111/jdv.13652). While patient testimonials indicate a clear satisfaction with the specialty’s care, information about the uniqueness of dermatologists’ expertise often flies under the radar.

Fortunately, in 2016, the Academy launched DataDerm™ — a clinical data registry — to fill the knowledge gaps about the breadth and depth of the specialty’s care. “DataDerm is a treasure trove of information for anyone interested in improving how they provide patient care,” said George Hruza, MD, MBA, Academy president-elect. Additionally, “It’s incredibly valuable not just to physicians individually, but it can inform how dermatology is perceived.”

Experts and users discuss how DataDerm has helped improve their practices and the role it can play in improving patient care and refining the narrative about dermatology.

What is DataDerm?

DataDerm is a clinical data registry developed by dermatologists for dermatologists. To date, the platform has been utilized by nearly 3,000 physicians and other providers in 1,020 active practices, submitting data encompassing 21.6 million patient visits and 8.1 million unique patients.

Working with both electronic and paper record practices, the registry connects data on millions of patients from thousands of dermatologists nationwide, eases the pain of reporting for programs, such as the Merit-based Incentive Payment System (MIPS), and allows physicians to demonstrate the quality of care they provide to payers, policymakers, and the medical community. The registry also offers participating physicians a private analysis of their practice’s data and compares it against national averages — down to the patient level.

“You have a dashboard, which tells you how you are doing in terms of the quality measures you want to report on — which of course is important to many of us,” said Dr. Hruza. “We also track other measures, which are not yet quality measures, but maybe will be one day and you can see how you are doing compared to other dermatologists.”

How is DataDerm being used in practice?

MIPS reporting

From increasing prior authorization requirements, to complex documentation standards, to heavy patient loads, it comes as no shock that the life of a physician is a busy one. Furthermore, a recent Mayo Clinic Proceedings study found that while overall physician burnout levels rose from 45% to 54% between 2011 and 2014, burnout among dermatologists during that same time frame rose from 32% to 57% (2015;90(12): 1600-1613).

Learn more about burnout and assess your own burnout level at staging.aad.org/dw/monthly/2017/september/feeling-the-burn.

Reporting requirements and their associated penalties have been identified as one of the many factors contributing to physician burnout. Indeed, the stakes are high: It is projected that the average dermatologist could lose about $200,000 in the next five years if they don’t report. Physicians can’t afford to not report, said Howard Rogers, MD, chair of the Academy’s Patient Access and Payer Relations Committee. “In general, being part of a clinical data registry really helps dermatologists on an annual basis to fully participate with the government mandates associated with MIPS. I think it’s a no-lose situation.”

Mary Barber, MD, at the Skin Cancer Center of Central Florida, used DataDerm to successfully report for MIPS in 2017 — reporting nine measures and earning a 2.1% payment bonus. “I thought DataDerm did a great job,” said Scott Kelley, MBA, practice administrator for the Skin Cancer Center of Central Florida. “Getting set up was just a matter of getting a hold of FIGmd [the Academy’s registry vendor] and having them set up the configurations and map out all of the fields. They did several mapping meetings with us where we would go back and look at the data for missing fields. All in all, the process was very good and they were very friendly and nice people to work with. They did a great job.”

All told, Dr. Barber and Mr. Kelley would recommend DataDerm for MIPS reporting. “DataDerm puts the data in a nice, graphical user-interface that makes it easy to follow and easy to deal with when the submission period comes around. I would highly recommend it,” said Kelley. “Anything that makes my job easier is favorable. The less paperwork that I have to do, the better.”

Quality improvements

In addition to easing the headaches associated with reporting, DataDerm has helped many take stock of the care that their practices provide. DataDerm currently provides individual benchmark reports on 27 dermatology-specific or applicable quality measures for all patients — not just Medicare — that allow physicians to drill down to the patient level, offering a complete profile of the care that they’re providing in their practice.

For Dr. Hruza, some of the quality measures from reporting programs of the past, such as PQRS, didn’t have any bearing on his practice. “For me, reporting how many of my patients have had the influenza vaccine has absolutely no relevance. But these dermatology-specific measures can be used to make meaningful improvements in your practice, and I would think the vast majority of dermatologists care about the quality of care they provide. DataDerm gives physicians the ability to see and focus on those areas where they can make improvements.”

How does this work in practice? Dr. Hruza — who has been using the registry for almost three years — says that his experiences with the quality tools in DataDerm have been eye-opening. As a surgeon, Dr. Hruza wanted to see how long it took for patients to be notified of biopsy results and how he compared to other dermatology surgeons. Using DataDerm, Dr. Hruza learned that it took more than a week for patients to be notified of results. “We figured out that the problem was getting lab results into the EHR in a timely manner and setting up a to-do list to flag incoming results for me to see. A few minor tweaks reduced our turnaround time of getting results to patients by 30%. To me, that made a difference, and DataDerm allowed me to follow our progress.”

Brent Moody, MD, chair of the Academy’s Resource-Based Relative Value Scale Committee, argues that DataDerm can help physicians see how they are faring against colleagues. “Being a nationwide database, it encompasses a large number of patients. By having those data points, it really allows a practicing dermatologist to understand if his or her practice pattern falls within the norm, or what their peers are doing. It will help people self-audit their practices.”

“Maybe it’s just me,” added Dr. Hruza, “but I think most dermatologists are competitive, and you want to see that you’re doing well on all these different measures. DataDerm tells you how you are doing compared to everybody else who is on DataDerm. It can tell you what you’re doing well or why you’re in the ‘yellow’ — right on the cusp of what’s considered standard. It may be there’s something you might want to change to make it better.”

For Marta Van Beek, MD, MPH, the Academy’s assistant-secretary treasurer and co-chair of the Academy’s Ad Hoc Task Force on Data Collection Platform and Registries, DataDerm’s current quality improvement tools have only just scratched the surface. “Right now, many measures that we report have been developed by somebody else, and not a lot of them are dermatology-specific. We’re going to start using the information we collect to develop quality measures that are meaningful to dermatologists and their patients. We need measures for general dermatologists, pediatric dermatologists, surgical dermatologists, and dermatopathologists.”

For a list of MIPS and QCDR measures, visit staging.aad.org/quality-measures.

HOW WILL DATA FROM DATADERM BE USED IN THE FUTURE?

With full integration with the medical record, DataDerm collects volumes of information beyond what is collected for MIPS reporting. Depending on the type of EHR and degree of integration, diagnoses, medications, disease manifestations, treatment plans, and utilization can be collected on patients. “Most of what we know about utilization has been taken from the Medicare population,” said Dr. Van Beek. “Using DataDerm, we can now measure Mohs surgery utilization in younger patients who have private insurance coverage. Thus far, the data indicates appropriate use of Mohs surgery and an average number of stages on par with the Medicare population. What’s even more exciting is that we can use some of this data to develop surgical-specific measures for quality reporting, allowing surgeons more choices in MIPS reporting.”

Additionally, “We’ve looked at what kinds of medications have been prescribed for atopic dermatitis, psoriasis, acne, and actinic keratoses. We’ve looked at the proportion of patients who have been prescribed field therapy for actinic keratosis — an indicator for skin cancer prevention,” said Dr. Van Beek. Now that this information is starting to take shape, what’s next?

Improve patient access

Dr. Rogers argues that these data can offer a new narrative about dermatologic care and demonstrate the complexity of conditions that dermatologists treat for payers. “One of the biggest problems is that, unfortunately, insurers basically have one blunt tool in terms of looking at quality: Cost. How much does a physician cost on a per-member, per-month (PMPM) basis?” As a result, payers may institute policies — such as physician tiering — that attempt to cut costs but inevitably reduce access to care to physicians who treat complex conditions. Since many dermatologists treat diseases that have widely varying severity, this is a problem.

“The most obvious example would be skin cancer, which ranges from small, easily treated lesions to a life-threatening cancer,” said Dr. Moody. “With psoriasis you may have very limited disease that can be easily treated with generic topical medicines, or you can have widespread disease refractory to topical medicine that requires a biologic. Currently, there is no way for a payer or anyone else by looking at claims data to know what disease you’re actually treating — how severe it is.”

“One of the most important things that we need to do is move things away from that PMPM basis to more of a risk-stratified, outcome-based measurement of how physicians work,” said Dr. Rogers. Going forward, Dr. Rogers is hopeful that the data will be useful in arguing for payer policies that improve access to care. “I think that’s one of the ways that we’re going to be able to use the data. We’ll be able to meet with insurers and say, ‘Our dermatologists dealt with one million people with psoriasis and it wasn’t just regular run-of-the-mill psoriasis. It was psoriasis that was head to toe and that’s why these patients needed biologics. Even though it seems like the dermatologist might be expensive, they’re treating patients in an appropriate manner that follows clinical guidelines and is appropriate.’”

“Private payers are eager to implement quality metrics,” said Dr. Van Beek. “It would be far better for the dermatology specialty to define those quality metrics than for an insurance company to define quality for us. As dermatologists, we know cost is not a surrogate for quality. Patients with more severe inflammatory disease or patients with more complex malignancies require a higher (and costlier) level of care. With DataDerm, our specialty can define quality, develop measures that are meaningful to patients, and offer them as an option for AAD members to use to prove their value to insurance companies with which they may contract.” Additionally, said Dr. Moody, these data can help ensure that dermatologists receive fair reimbursement for the care they’re providing. “Data can help make sure that we’re recognized for the importance of the diseases that we treat, the impact our care has on the quality of life of our patients, and in some instances — particularly with malignant conditions — the impact we have on their mortality. I think we all want fair reimbursement.”

However, in order to make measures and MIPS meaningful, everyone needs to lend a hand, advised Dr. Rogers. “Having the vast majority of dermatologists putting data in DataDerm increases the value of what we can offer insurers for potential access to performance measures or different risk stratification. If only 5% of our members contribute data, negotiating with DataDerm is less attractive to insurers. However, in an ideal world, the AAD would be able to say that most of our members participate in the registry, and we’d like to work with insurers to ensure measures of cost and performance are relevant and fully risk stratified. That would be very valuable to our interactions in advocacy with payers.”

Theodore Rosen, MD, the Academy’s vice president, agrees. “Massive nationwide data, when collected carefully so as to be truly representative of real-world practice, provides an opportunity to determine and help set realistic and optimum therapeutic standards of care. While a large number of dermatologists are participating in DataDerm, many more are needed.”

Define specialty value and standards of care

Why is it critical to join DataDerm now? “DataDerm will prove our value,” said Dr. Van Beek. “Frequently, insurance companies require a higher co-pay to see a specialist compared to a primary care provider. If we can prove our efficiency in getting patients better more quickly, with the correct diagnosis and treatment, that has potential to show value for the specialty. If a dermatologist can diagnose a patient with a skin disease and get them better within one or two visits, that’s more efficient than seeing their primary care physician six times and not receiving an accurate diagnosis or getting the proper treatment. In that case, a cheaper co-pay to see a dermatologist sooner, would be more cost effective for the insurance company.”

Dr. Moody indicates that data from DataDerm will be able demonstrate that dermatologists are uniquely qualified to diagnose and treat a number of complex diseases in a more efficient way than other physicians and providers treating skin conditions. “We can do it in fewer visits and with more precise therapy than anyone else. Having a good, robust data set will let us show that one visit to the dermatologist is more likely to solve the problem, than perhaps multiple visits to a non-dermatologist.”

In order to tell an accurate story about the specialty, dermatologists need to write the book, said Dr. Rosen. “If dermatologists don’t participate in a meaningful collection of real-world data, then other entities, government and insurance providers, for example, will set for us unsubstantiated and invalidated standards of care. The larger the cohort of participants, the more robust and accurate a picture can be ascertained regarding current intervention trends and outcomes.” dw

Dermatologists discuss how DataDerm™ drives their success — and the specialty's