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As a result of participating in the Medicaid Medical Directors Learning Network—an ´óÏóÊÓƵKnowledge Transfer project—the Iowa Medicaid Enterprise, in consultation with the Iowa Foundation for Medical Care, used two Effective Health Care (EHC) Program guides and several Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey questions to influence Medicaid policy and improve quality.

When the Iowa Foundation for Medical Care—the State's quality improvement organization—began developing a patient registry in 2007, Thomas Kline, DO, Medicaid Medical Director and member of the AHRQ-sponsored Medicaid Medical Directors Learning Network, recommended that the developers consult an EHC Program guide, titled Registries for Evaluating Patient Outcomes: A User's Guide. This publication highlights issues for consideration in the design, implementation, and evaluation of effective registries for understanding patient outcomes.

Kline explains, "The guide was used to determine what should be included in the registry development process." Kline's suggestions helped ensure that the Iowa Foundation for Medical Care created a registry that drew upon the wisdom of numerous resources in its design.

Based on models in the guide, the Iowa Foundation for Medical Care created a registry for use by the Iowa Medicaid Enterprise to evaluate patient outcomes. The data collected are derived from and reflect the clinical status of the patient (e.g., history, examination, laboratory tests, or patient-reported data). The guide suggests that "registries include the types of data that clinicians would use for the diagnosis and management of patients."

The registry was developed to be compatible with electronic medical records. It also includes a physician tracking mechanism that indicates whether a patient made an appointment with a specialist, whether the patient attended the appointment, and whether information from the specialist came back to the primary care provider. The registry also includes a laboratory test tracking mechanism that monitors whether a lab test was completed and whether the results were reported back to the physician and the patient. These system checks and balances help capture a better picture of the patient experience.

Kline notes that while Iowa's urban providers may have the resources to develop registries, providers in rural Iowa—frequently working in one- or two-physician offices—typically have limited resources. For rural providers, he says, "The registry will go a long way in helping them achieve medical home status, as defined by the National Committee for Quality Assurance. That is a target goal of the Iowa QIO-to help rural Iowa."

Another EHC report that proved valuable to the Iowa Medicaid Enterprise is Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics. The Iowa legislature has previously denied attempts to restrict access to behavioral health medications; atypical antipsychotics now comprise a large part of the Medicaid pharmacy budget.

The State convened a mental health work group that includes adult and pediatric psychiatrists, pediatricians, and pharmacists who specialize in behavioral health drugs. The work group is charged with creating guidelines on preferred products and quantity limits that could achieve cost savings. Drawing upon the findings presented in the ´óÏóÊÓƵreport, the group refined coverage policy for atypical antipsychotics.

Kline says, "The ´óÏóÊÓƵreport raised a red flag for us by laying out a series of unknowns regarding the use of these medications in the pediatric population. As a result, Medicaid is working to gather as much information as we can to assure the appropriate use of off-label atypical antipsychotics in pediatric psychiatry."

He also reports that the Iowa Medicaid Enterprise has drawn upon other ´óÏóÊÓƵtools to enhance its examination of health care quality from the patient's perspective. Some of AHRQ's research on the CAHPSâ„¢ Clinician and Group Survey has been used to extract pertinent questions for a survey that is sent to new enrollees. The survey is intended to assess what aspects of the program are working, what is not working, and how best to make changes.

"Having access to these ´óÏóÊÓƵresources as a source of unbiased, authoritative evidence on our clinical priority issues has been invaluable," Kline concludes.