Beyond Process Towards Patient-Centered Outcomes
The long-awaited paradigm shift from reimbursement for volume to value for medical services is accelerating. This week, the Core Quality Measures Collaborative (CQMC) released seven sets of standardized clinical quality metrics for practitioners. Significantly, the collaborative represents a broad coalition of stakeholders:
- Center for Medicare and Medicaid Services (CMS)
- Americas Health Insurance Plans (AHIP)
- American Academy of Family Physicians
- American College of Gynecology and Obstetrics
- American College of Cardiology
- American Academy of Orthopedic Surgeons
- Consumer groups
In the past, physicians, payers, and certainly patients have defined quality using multiple different metrics resulting in burdensome and unnecessary complex reporting by providers. There is now general acceptance that so-called "meaningful use" of the EMR bears little relationship to the quality of care. In addition, the focus has shifted from process measures of care to a search for clinically relevant metrics.
The seven sets of standardized measures address the following areas:
- Accountable Care Organizations, Medical Homes, Primary Care
- HIV and Hepatitis C
- Medical Oncology
- Obsterics and Gynecology
Most of the measures are familiar to physicians. For example, cardiac outcomes include readmission rate within 30 days after hospitalization for congestive heart failure and prescription of a B-blocker in patients with a previous myocardial infarction and ejection fraction < 40%. For orthopedics, readmission after total hip or knee replacement is a consensus metric. For primary care physicians, annual eye exams and HbA1C measurements in diabetic are familiar standards. What's new is the alignment of measures among different public and private payers, presumably simplifying reporting requirements.
While these measures arguably define evidence-based quality care from the perspective of the payer, some physicians object that many (e.g. blood pressure or glucose control) depend on patient adherence to treatment and are really out of the provider's direct control. Improving performance in some of these metrics probably requires a team approach with the capacity to influence the psychosocial factors which are frequent barriers to a successful outcome.
Harmonizing the quality standards across multiple payers and providers is an important step forward. However, with few exceptions, the collaborative measures are "doctor-centered." Most are based on "hard" medical data such as utilization of imaging or lab tests, prescriptions, and readmissions. Moving to the next level in quality measurement will require incorporating the patient's perspective. Patients want to know if and when then can return to work or recreational activities. Their motiviation for care is usually symptom-driven, e.g., chest pain or shortness of breath.
International Consortium for Health Care Outcomes Measurement (ICHOM) co-founder Michael Porter points out in the current issue of The New England Journal of Medicine (N Engl J Med 374; 2016: 504-506) that including patient-reported measures provides outcomes which fully encompass the full spectrum of care. For example, the ICHOM outcome set for coronary artery disease incorporates patient reported functional status, quality of life measures, and depression as well as surgical and interventional complication rates. As of this date, ICHOM has completed work on 13 sets of standardized outcomes for conditions including lung cancer, stroke, hip and knee arthritis and low back pain.
Defining the numerator of the equation ( quality / cost ) represents a crucial step on the journey to clinically meaningful, measurable patient-centered value in health care. Standardization of outcomes increases the chances of greater physician engagement in the process. Building technology which facilitates seamless capture of both patient-centered and clinical data into the EMR workflow is an important next step.
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