Vital Signs Core Metrics for Health and Health Care Progress (2015) / Chapter Skim
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2 Health and Health Care Measurement in America
2 Health and Health Care Measurement in America
Pages 63-100
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From page 63... ...
Expanded measurement capabilities have helped focus a variety of interventions across the health system, thereby contributing to positive impacts on health and health care. As understanding has grown about the many factors shaping individual and population health and technical capacity for tracking has advanced, the scope of health measurement has broadened to include a large number of process and outcome targets relevant to health and health care, from social determinants and programs to physician and hospital performance, patient experience, and costs of care.
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From page 64... ...
Some new forces are encouraging the integration of clinical care, while others are driving a community or regional approach whereby stakeholders collaborate to improve health care quality while controlling costs, and partnerships are bringing together health care and community organizations with a broad focus on improving health. These initiatives are occurring at multiple levels -- national, state, regional, community, and institutional.
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From page 65... ...
At the vanguard of the myriad changes occurring in health care delivery is the widespread adoption of electronic health records (EHRs) and other health information technologies, enabling the gathering and use of measurements on a wide range of services, costs, and outcomes.
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From page 66... ...
. Similarly, two Wisconsin multi-stakeholder groups -- the Wisconsin Collaborative for Healthcare Quality and the Wisconsin Health Information Organization -- are working to increase the supply of data on health care quality and value to support value-based payment (Toussaint et al., 2011)
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From page 67... ...
(e.g., convening of National Priorities Partnership and Measure Applications Partnership, endorsement of population health measures) • Private insurers and health plans (e.g., United HealthCare Foundation's America's Health Rankings)
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(e.g., National Quality Healthcare Quality Report, National Healthcare Disparities Report, National Quality Measures Clearinghouse, Consumer Assessment of Healthcare Providers and Systems [CAHPS]
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From page 69... ...
One analysis found that measures are used most commonly in health care for quality improvement and public reporting; they are used for payment almost half as frequently, and an even smaller number of measures are used for accreditation, certification, credentialing, and licensure (Damberg et al., 2011)
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From page 70... ...
bears primary responsibility at the federal level for monitoring overall population health status. Its maintenance of vital statistics and data on reportable diseases is based on a blend of national standards and local application.
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From page 71... ...
The Network for Regional Healthcare Improvement (NRHI) serves as a national association of Regional Health Improvement Collaboratives, coordinating and advancing initiatives focused on improved health care quality and payment reform across the nation (Rosen et al., 2012)
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From page 72... ...
The Veterans Health Administration began electronic health monitoring a decade ago and in 2013 monitored more than 140,000 veterans with high-risk chronic conditions (i.e., diabetes, hypertension, chronic obstructive pulmonary disease [COPD]
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From page 73... ...
Working with the Agency for Healthcare Research and Quality (AHRQ) , NQF identified patient-reported outcomes and patient-generated data in EHRs as priorities for the 2012 National Strategy for Quality Improvement in Healthcare (HHS, 2012)
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From page 74... ...
Therefore, quality improvement initiatives can use measures that may not be appropriate for other purposes -- depending on the measure's accuracy, precision, evidence base, or representativeness -- and thus present an opportunity to test measures in practice without the consequences of changing financial incentives or impacting an organization's reputation. For example, Intermountain Healthcare has used care process measures embedded in its clinical data systems and applied across clinical units.
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From page 75... ...
IHI's formulation of the Triple Aim of better care, lower cost, and better health has become a standard reference point for many health improvement efforts. The Joint Commission also plays an important role in assessment of care quality.
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From page 76... ...
, Medicaid health homes, and Innovation Center projects; public reporting programs, such as Hospital Compare, Physician Compare, and Medicare Advantage Star Ratings; and quality tracking, such as Medicaid Adult Health Care Quality measures and Medicaid/CHIP Children's Health Care Quality measures. Moreover, CMS provides technical assistance on measurement through the Quality Improvement Organization program and coordinates with a variety of measurement organizations on measure development and accreditation.
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From page 77... ...
. Transparency, Public Reporting, and Benchmarking Comparisons offer inherent motivations and focus for progress, and measurement is a key tool and incentive for understanding and addressing variations within and among local clinical care practices, health care organizations, and the broader care system, enabling individuals and organizations to identify best practices in terms of positive patient health outcomes and improved value.
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From page 78... ...
. The number of such programs has continued to grow, and half of all states now sponsor a program for public reporting on care quality (Ross et al., 2010)
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From page 79... ...
The Joint Commission accredits approximately 20,000 health care organizations and programs, while NCQA accredits health plans and offers voluntary programs for new delivery models (Berenson et al., 2013)
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From page 80... ...
One prominent example is the Preventive Health and Health Services block grant, which allows states to pursue projects aligned with the Healthy People program. The program incorporates a variety of standardized measures of performance (CDC, 2011)
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From page 81... ...
Other limitations in the ability to use the measures gathered relate to the capability to sustain data collection, the availability of and linkage to accountability levers, data quality and availability, and the programmatic distortions that may occur when an organization's TABLE 2-2 Key Considerations in Addressing Statistical and Analytical Challenges of Measurement Statistical or Analytical Challenge Key Considerations Attribution When essential, can patient health outcomes, such as for acute or chronic conditions, be attributed to a specific clinician or health care organization? Data sources Can a measure be calculated from existing electronic health records or related sources such as survey, claims, and laboratory data?
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From page 82... ...
. Examples of the many gaps in current measurement efforts include • Patient engagement -- few capabilities to assess patient-centered care and patient engagement; • Care quality -- limited scope of quality measurement for certain areas, such as special populations (e.g., children/adolescents, pa tients with multiple chronic conditions, patients with rare diseases, patients dually eligible for Medicare and Medicaid)
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From page 83... ...
What may be useful to payers, regulators, accreditors, and others concerned with compliance and with broad mandates may be of limited utility for patients, providers, and other stakeholders for use in health decision making and quality improvement programs. Even data available for assessing similar parameters may have been analyzed or presented in ways sufficiently different to limit comparison.
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From page 84... ...
For example, a hospital serving a relatively low-income community may have lower scores on quality measures than a hospital serving a relatively high-income community because of differences in the populations served rather than meaningful differences in the quality of care provided. At the same time, differences in quality may be at work: failure to communicate or engage patients effectively, provision of different services to those with less ability to pay, or other reasons for suboptimal delivery of care.
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From page 85... ...
Measurement data coupled with supportive financial incentives can be a powerful motivator for system-wide improvements. Recent payment reforms include a shift away from the fee-for-service model through the development of ACOs and other models that reward value rather than volume in health care, and they may encourage more meaningful patientprovider interactions beyond the provision of billable tests and services.
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From page 86... ...
. Limitations in Data Quality and Availability Critical to any effort to measure performance over time or compare health outcomes or care quality across groups is the availability of highquality, consistent standardized data.
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From page 87... ...
Furthermore, making useful comparisons at different levels throughout the health system will require a standardized approach to data collection, reporting, and use. Limited Measurement of Cost and Affordability A significant challenge for the growing health measurement enterprise is the capacity to assess cost and price variation and affordability of care meaningfully and to identify sources of waste.
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From page 88... ...
Yet many public reporting sites focus on performance for specific clinical processes. If measures are not centered on the most important concepts, improvement will be elusive (IOM, 2006; Werner and Asch, 2007)
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From page 89... ...
others ... future fall risk POPULATION HEALTH - Atrial fibrillation and HS: life expectancy atrial flutter: chronic anti HS: perceived health coagulation therapy HS: days with physical or mental illness - Maternity care: elective Beh: fruit/vegetable consumption delivery or early induc Beh: activity levels tion without medical Soc: income/child proverty indication at greater than or equal to 37 weeks and Soc: neighborhood crime less than 39 weeks Env: air particulate matter And many more...
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From page 90... ...
Implications for Care Organizations Without reorientation, the proliferation of measures is likely to continue, with associated opportunity costs impacting the ability to meet other needs in the health care system. A variety of consequences could result, including the erosion of internal measurement activities and inefficient approaches to improving on measures without improving the measures'
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From page 91... ...
Preliminary results from a survey of leadership in 20 health care organizations, ranging in size from 180 to 3,000 beds, suggest that measurement activities may require the equivalent of 50 to 100 full-time employees, at estimated costs ranging from $3.5 to $12 million per year. While the providers consulted in the development of these preliminary findings believe that quality reporting is valuable and should continue, it was also suggested that reporting large numbers of measures may be overwhelming, such that resource-intensive reporting activities may crowd out efforts to improve based on the data produced (Dunlap, 2015)
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From page 92... ...
However, the costs and benefits of measurement activities are difficult to quantify. Many powerful, high-quality measures are already in use, but the lack of alignment and coordination discussed above limits their potential.
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From page 93... ...
To avoid the natural tendency to focus on physiologic parameters at the expense of broader dynamics, patients with diabetes could instead be monitored on the key elements of the core measures, including healthy behaviors, receipt of preventive services, affordability of care, and their own and their community's engagement with their health care. A conceptual aim of payment reform is to link financial incentives to performance at the population level.
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From page 94... ...
2013. National Quality Measures Clearinghouse.
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From page 95... ...
1979. Healthy people: The Surgeon General's report on health promotion and disease prevention.
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From page 96... ...
2013b. Toward quality measures for population health and the leading health indica tors.
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From page 97... ...
2010. The triple aim journey: Improving population health and patients' experience of care, while reducing costs.
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From page 98... ...
2007. Closing the quality gap: A critical analysis of quality improvement strategies (Vol.
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From page 99... ...
2004. Paying for quality: Providers' incentives for quality improvement.
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