Federal health officials are calling for a new framework in quality measurement, as the U.S. healthcare system prepares for what is hoped to be a new era of accountability.
“Meaningful quality measures increasingly need to transition from setting-specific, narrow snapshots, such as use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with congestive heart failure, to assessments that are broad based, meaningful, and patient centered in the continuum of time in which care is delivered,” wrote CMS Chief Medical Officer Patrick Conway, MD; National Health IT Coordinator, Farzad Mostashari, MD; and AHRQ Director Carolyn Clancy, MD, in the Journal of the American Medical Association.
The confluence of health reform, the transition to digital health records and the problems of high healthcare spending may suggest that the time is ripe to create a new measurement system with a “parsimonious set of core measurements,” they added.
As a guide, Conway, Mostashari and Clancy point to the Affordable Care Act-directed National Quality Strategy, which specifies performance priorities in six areas: clinical care, patient experience and engagement, population and community health, safety, coordination, and cost and efficiency.
The goal, they wrote, should be to “identify important measures” and “discontinue using those of little value.” For instance, in safety, they suggest that rather than just measuring central line infections, future measurements might report all patient harm, whatever the cause. For population and community health measurements, instead of just recording data such as smoking status and immunizations, providers might include data of the likely determinants of health conditions and progress in disparity reductions.
The larger goal is to move beyond the traditional measurements established by federal health programs (often established by statute), which has tended to be too setting-specific, they noted.
With CMS, the National Quality Forum recently launched a measures application partnership, to identify the next generation of measures and align measurement across the public and private sectors. Conway, Mostashari and Clancy argue that the newly aligned model must capture data at three main levels: the individual clinician, the group or facility and the population or community. And the measurements must allow for “roll-up,” an ability for results to be calculated and available at each level, for providers and communities to see their progress, or lack thereof.
Quality measurement in itself needs to change, too, beyond just collecting new information with easier workflows, they contended.
For one thing, the complexity of clinical data requirements and their workflows “may need to be reduced,” or at least considered early on the development of new measurement standards. “Quality measurement implementation needs to be easy in routine practice for clinicians with measures captured as part of the clinical workflow…and should minimize the burden of data collection,” they wrote.
Automated systems should be established for patient-reported outcomes and experiences, they explained, and be made available in consumer-friendly formats, like mobile or text messaging. Increased interoperability and data liquidity — like structured laboratory data — also need to be expanded, along with “increased reliability of quality measure calculation” in IT systems.
“Quality measures need consistent definitions of clinical concepts and to be based on defined electronic data elements. Standards are needed for unambiguous representation of quality measures and also for increased rigor of testing and certification of EHRs and intermediaries,” they wrote. Quality measurement systems would also benefit from new feedback features, they added, such as data visualization tools and clinical decision support.
Clinicians currently have three mandatory CMS quality programs to participate in — quality reporting system, the physician value-based modifier for Medicare, and the EHR incentive program for Medicare and Medicaid — which can be burdensome. So CMS is promising to consolidate those into a single set of measures for all three programs for 2014.
Looking ahead, and considering that the average cycle time for federal programs is about three years, the authors concluded that quality measurement development and implementation might be made more fluid and agile. There, they put forth three suggestions: the “measurement enterprise must move beyond identification of gaps to a collaborative model of planning and executing,” "value sets must be separated from measure definitions that permit electronic measures to be updated within shorter sub-regulatory timeframes,” and “testbeds” should be created to “foster new patient-centered, high-impact e-measures.”