On April 25, the Washington, D.C.-based center for Studying Health System Change (HSC) released a new policy analysis, entitled “Hospital Quality Reporting: Separating the Signal from the Noise,” written by Emily R. Carrier, M.D., an HSC senior researcher, and Dori A. Cross, an HSC health research assistant. As HSC noted in a press release announcing the release of that policy analysis, “Amid the proliferation of quality measures, reporting requirements and transparency efforts, purchasers often find it difficult to separate the signal from the noise when determining what hospital quality measures are important, how to interpret and use quality information in a meaningful way, and how to present useful and actionable information to consumers.”
And, as authors Carrier and Cross note in the paper, “With U.S. healthcare costs high and rising, purchasers increasingly are seeking to identify high-value hospitals that deliver good care at a reasonable price. Some payers,” the authors note, “are incorporating clinical quality measures into health plan contracting, and benefit designs to alter provider networks and patient cost-sharing to drive patients toward higher-performing hospitals.” Yet a tremendous set of challenges exists in attempting to streamline provider reporting requirements and support consistency in definitions and practices, in the outcomes measurement arena.
There are many extremely useful elements in the paper, among them the first table, “Types of Hospital Quality Measures,” which summarizes all the different types of quality measures being used these days, with remarks on the “pros” and “cons” of each type of measure.
Shortly after the release of the policy analysis, Dr. Carrier spoke with HCI Editor-in-Chief Mark Hagland regarding the findings in the policy paper, and the implications of those findings for healthcare CIOs, CMIOs, and other IT leaders. Below are excerpts from that interview.
What was your overall goal in doing this analysis?
Our overall goal was to get a big-picture view of quality measurement for purchasers who might not really have been able to look at the issue in depth before, but who might be interested in picking it up.
Emily Carrier, M.D.
Were you surprised by anything, as you began to study all of this in depth?
Not really; I come at it from a clinical background, so experiencing this on a practice level, you sort of experience these coming in as different initiatives, coming one after the other. A performance measure becomes something important to your organization, and everyone’s thinking about it and working on it, and it becomes encrypted into your practice, and then another one comes along, and it doesn’t feel as though there’s a centralized approach to anything. And that reflects our health care system’s approach of “let a thousand flowers bloom.” There’s a national quality strategy that’s been developed by the national government, but it hasn’t yet been reflected in how these measurement efforts are implemented on the practice or organizational level.
Are clinicians faced with having to be graded on simply too many outcomes measures at once? That has been one of the biggest complaints from physicians for years now.
When you say too many, I ask, too many compared to what? Certainly there are a lot; and certainly there are subtle differences that would lead a provider to think that there are too many. Are we truly capturing the important dimensions of quality? That’s not clear. And there may be too many functionally, and yet we may still not be capturing the most important dimensions of quality. So rather than saying there are too many or too few, maybe we’re just not capturing the right dimensions. There’s a classic story about quality: you’re walking down the street and there’s a drunken man crawling around a lamppost, and you say, can I help you? And he says, I’m looking for my teeth, I’ve lost them. And you ask, are your teeth somewhere here around this lamppost? And he says, no, they’re further away, but he’s looking near the lamppost because that’s where the light is. And if what you have is medical claims, you’ll look at what you can capture in claims; if you have chart audits, that’s where you look. And now you have EHRs [electronic health records] to work with, and there’s great potential there, but there are questions also.
There is great potential in EHRs, but also, there’s a documentation burden on physicians, in terms of having to document so many things in the medical record; and there are the meaningful use requirements related to quality as well. Physicians are feeling particularly burdened these days, because of the combination of the meaningful use and value-based purchasing mandates.
Well, there are different ways of getting things done. And we may say that clinicians have to do the heavy lift; if we need a piece of information, we’re going to require that data be entered in a standardized way. Another way might be to say, we’re going to have the EHR developers do the lift, and work towards trying to create a 360-degree view beyond what can be captured through a single provider’s EHR, taking better advantage of what clinicians include in things they write down in freetext, things that are recorded automatically, etc., capture other aspects of care. And then there’s the full spectrum in between. To really fully realize the potential of EHRs, a lot of effort will be required, and it remains open as to on whom the main burdens will fall.
How should CIOs and CMIOs look at your findings and analysis?
There are a lot of things they could do; our analysis only speaks to a small aspect of their work. But maybe it would be helpful for them … They have the clinician perspective, and so they can share important information about quality measures that during the development process inevitably won’t come to light until these measures are adopted broadly. It’s just like medication: you can do all the testing you want, but things will become clearer when it’s used broadly. The CMIO can look at, for example, how the reporting is working within their EHR. And the thing is, EHRs are so customized now that the CMIO will be the expert on their organization’s EHR. And just more generally, thinking more about quality measurement—they may not necessarily interact with purchasers, but sort of taking a step back and thinking about it from the purchaser perspective and how they would want to put together a comprehensive approach to meeting performance measurement requirements—that will be important for CMIOs going forward.
They’ll have to help CMOs and CNOs develop an organizational strategy for all these requirements.
Yes, there are limits to being interactive. And if they know what the key purchasers in their community want—what our paper describes is the range of strategies out there, and one can look into approaches that would best meet the needs of both clinicians and purchasers. So being proactive—patient care organizations need to approach purchasers in their communities directly. What we talk about in our paper is that purchaser organizations are becoming increasingly interested in strategies around quality. And you could certain extrapolate from that, that if you’re a CMIO in a patient care organization, maybe it behooves you to get involved in the process early and see what you can offer.
I have seen in my reporting that there has been a reduction in some markets and states in the number of requirements/regimes.
Yes, and our paper does address that, that purchasers and providers could get together and meet and try to standardize an approach. And would a CIO or CMIO work with their peers in their market to promote that approach? But ultimately, the purchasers would have to be at the table as well.
What’s the future in this area?
I think the future is electronic health records; because of meaningful use, providers will be reporting quality measures directly through their EHRs. And some very innovative approaches to reporting may come from hospitals and health systems in terms of how they’re using their EHRs, and they may come up with a great idea.
Are you going to follow up with another study of some sort?
We don’t have immediate plans, but we’ll see whether our funder, the National Institute for Health Care Reform, will fund further study. They’re funded by the auto companies, so obviously, they’re very interested in the things purchasers can do around healthcare cost and quality.