Few agree on how to measure health care performance. But experts say any answer will depend on using electronic health records to compare apples to apples
Does measuring medical performance lead to better patient health?
The short answer is yes — and just about everyone understands that, at some point, information technology will be vital to the widespread use of performance measures.
But the measures need to be smartly focused. A study published in the Journal of the American Medical Association in December, for example, found that measures used in a performance measurement project run by the Centers for Medicare and Medicaid Services (CMS) were specific but not meaningfully linked to patient outcomes.
Heart attack treatments, for instance, were rated on whether someone administers aspirin and beta blockers when a patient arrived and whether someone to tried persuade the patient to stop smoking, the study states, adding that those are not strong precursors of quality differences.
The relative performance of hospitals, clinics and physicians in delivering care to patients has been an ongoing health care question for years. But as it broadens into a national debate and the concerns become more focused, the conversation has centered on how to measure health care performance.
Many commercial and public interest groups are now attacking the problem. The American Medical Association (AMA), for example, is leading a project to develop standard performance measures that health providers and insurance plans nationwide can use, including the Medicare program. The project has already produced more than 140 measures.
At the same time, Congress is trying to push the envelope with enticements for physicians to use performance measures. President Bush signed bipartisan omnibus legislation in December that would provide physicians with a 1.5 percent bonus to their regular Medicare payments if they reported data to CMS based on measures that the AMA initiative is trying to develop.
The legislation, introduced by Sens. Charles Grassley (R-Iowa) and Max Baucus (D-Mont.), requires a quality reporting system for eligible physicians to begin using measures July 1 that CMS has already adopted to July 1. The law would initially last until Dec. 31, though Congress could extend it.
IT is essential IT will be vital to the widespread use of performance measures. More local programs, such as the statewide pay-for-performance program in California, created by the Integrated Healthcare Association, make the use of health IT part of their measures.
Although health IT vendors are starting to look at the ramifiactions of performance measures, most are reluctant to do much work until a consensus on nationally applicable measures is clearer.
“Vendors have been putting most of their time into developing the functionality of [health IT] systems, such as being able to write and send prescriptions, rather than the tools needed to do” this kind of performance-related reporting, said Charlene Underwood, chairwoman of the Healthcare Information and Management Systems Society’s Electronic Health Record Vendors’ Association.
The problem is not a lack of experience with programs that use such measures. There are scores of pay-for-performance programs nationwide, Underwood said. Estimates reveal that more than 100 such initiatives are operating, but most of them are local.
Furthermore, many of them are programs run by single hospitals or regional provider plans. Other than California, only Hawaii and Massachusetts have statewide programs. And they depend on performance measures that are specific to their programs.
“Vendors just can’t afford to spend a lot of money in producing tools to capture the data needed for all these programs,” said Underwood, who is also director of government and industry affairs at Siemens Medical Solutions. “It’s the focus on [the national consensus on measures] that will drive things in this area.”
Good or bad? The AMA-led Physician Consortium for Performance Improvement is addressing at least part of that first mandate. The group has been working for the past few years to develop a consensus on what national performance measures should contain and what goals they should target.
It has not been easy. The health profession has not yet decided whether performance measures overall are good or bad.
“If they act as proxies for the quality [of health care], then yes, it supports them,” said Dr. Nancy Nielsen, speaker of the AMA House of Delegates and the organization’s leader on quality issues. “If a patient has a heart attack and the performance measures say they should be given aspirin and beta blockers, then most physicians would say the measures are a good thing.”
However, doctors are wary that the measures will be used more as proxies for the cost of care, and that causes many medical professionals to balk at the notion of performance measures.
“True efficiency should be linked with value and whether patients are getting the same level of care for a lower cost,” Nielsen said. “The suspicion is that health plans will use performance measures simply to lower cost.”
Nancy Wilson, senior adviser to the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) and its leader for multistakeholder collaboration programs, said she thinks physicians have justifiably been suspicious in the past. She added that the current situation is an unprecedented opportunity to move the health system forward.
“I believe there really is a commitment by everyone to move forward for the benefit of the entire community,” she said. “That historically has not been the case as far as performance metrics are concerned.”
Embedding in EHR The use of performance metrics with health IT is one of the biggest upcoming challenges for health care planners. Metrics have not traditionally been designed with electronic health records in mind. There is a consensus that metrics specifications need to be developed for use with EHRs so the data needed for performance measurement can be automatically extracted from them, Wilson said.
With that in mind, the American Health Information Community and other workgroups focused on health care quality are looking to develop a starter set of performance measures and create EHR specifications for those.
EHRs inherently provide data for measurement, Underwood said. Siemens’ EHR product can extract as much as two-thirds of the data that performance measures need, she said. The problem comes in the software code that has to be written to provide the rest of the data. That’s unprofitable if vendors must develop code for all of the different performance measures, which is why they insist that agreement on nationally applicable measures is necessary.
Team sport Dennis Weaver, interim chief medical officer at the National Alliance for Health IT (NAHIT), a group of leaders from all health care sectors who work to promote the use of clinical IT systems, said he believes the push on performance measures is in its infancy, “until we see quality of care included as a systemic property” in those measures.
The industry is beginning to understand that quality of care is a team sport, he said, and relies on the input of many people across different settings. Future performance measures must become far more comprehensive and reach across multiple physicians and settings if they want to accurately reflect quality of care.
Scott Wallace, NAHIT’s president, said financial incentives should not be linked too quickly to the performance component of the project. “There has to be an incremental approach,” he said. “There’s no way that we can launch this [performance] system tied to quality improvement and expect it will all be done at once.”
But performance measures will press forward. Most people believe that the momentum behind performance measures is too great to stop, partially because of the pressure from the Bush administration and Congress to apply them to Medicare. Because Medicare accounts for more than 40 percent of physician reimbursements, it’s a powerful driver for adoption of performance-based measures.
“Most providers understand that performance measures are here to stay,” said Margaret VanAmringe, vice president of public policy and government relations at the Joint Commission on Accreditation of Healthcare Organizations. “There’s a concern over health care quality in general, and there’s a national interest in pay for performance. And Congress has now spoken” about their use in Medicare.
The question is how to best move that process along and how to promote the adoption of IT that most organizations will need to add before they can use performance measures.
VanAmringe said many organizations will wait to see if the Certification Commission for Healthcare IT adopts the performance measure recommendations that come out of the latest deliberations as part of its certification process for EHR vendor products.
After the tipping point However, it may not be a question of performance measures alone. Nielsen said physicians need to see improvement on other IT issues, such as interoperability and standards, before they will adopt EHR in droves, even if there is agreement on performance measures.
Others believe more money must be attached to the adoption of performance measures and pay for performance before they catch physicians’ attention.
“There has to be more of a market imperative for it,” said Bruce Bagley, medical director of quality improvement at the American Academy of Family Physicians. “Over the next three or four years, and as more payment plans demand some kind of clinical performance data, people will respond. By then the expectation is that [pay for performance] could make up from 20 percent to 30 percent of a physician’s total reimbursement.”
So many physician groups, hospital associations and other bodies are now at the table that the discussion about performance measures is probably already past the tipping point, Wilson said.
“Everyone realizes that performance measurement is moving forward, and now they just want to make sure that the metrics are as reliable and accurate as possible,” she said. “They know we are at a point in history where we have the chance to change health care in this country for the better.”
Government Health IT presents Liesa Jo Jenkins, executive director of CareSpark, in this recent eSeminar, where she shared her experiences and insight into building a health information exchange that enhances community health, rewards regional collaboration and drives economic progress.
