NQF Issue Brief on Measuring Elements of Care

The recently released issue brief from the National Quality Forum titled "Performance Measurement and Reporting at the Clinician Level" can be found here (pdf file) makes the case for clinicians reporting which like it or not is coming. While many resist and there are difficulties in comparing results in healthcare because of the many contributing variables to outcome it seems impossible for me to imagine the future without comparisons of quality by patients.

For heavens sake - I can compare the quality of a dishwasher, the performance of a store and customer service of a technology provider why should I not want or be able to compare the results of my hospital and clinical service provider.

It is important to remember a point I made before:

Millions of times each day, patients interact with the U.S. healthcare system. During these interactions, most patients receive the benefit of solid clinical judgment and technical expertise from their care providers and witness basic and state-of-the-art technology appropriately applied

And rightly they point out that

Current incentives encourage more care rather than the right amount of care

So the effort underway is to refine these measures to make them better and more helpful and specifically to address the charge of Apples to Oranges that we hear repeatedly when data is published showing poor quality in one institution over another. The current work seeks to address this:

Clinician-level measurement is undergoing refinement. The shortcomings of current measurements are driving concurrent efforts to more broadly define relevant, important, and measurable elements of condition-specific episodes of care and related accountability.

In the Charter they focus on the criteria and attributes that are desirable for measuring clinicians from a patient perspective:

1. Measures should be meaningful to consumers and reflect a diverse array of physician clinical activities.
   
2. Those being measured should be actively involved.
   
3. Measures and methodology should be transparent and valid.
   
4. Measures should be based on national standards to the greatest extent possible.
   

But to achieve this as they identify in their discussion paper (Rattray MC, Clinician Level Measurement and Improvement – Improving Reliability, Actionability, and Engagement, Washington, DC: National Quality Forum; 2008) and follow up discussions needs to:

Enrich clinical data. Accelerate efforts to capture relevant clinical data to augment administrative claims data.

To satisfy this need without weighing down the already over burdened clinician requires that this data is enriched as part of the clinical process and not by imposing new and difficult processes onto their current clinical activity. A recent example cited by one of my clinical colleagues had me truly surprised. In this implementation the new clinical system required the clinicians users to be shadowed 1 on 1 for 30 days to help them learn and use the system. If this is what is required there has to be something wrong with the approach and/or the system. Educators are told that if everyone fails their test on material they have delivered to their students then the chances are that there is a problem with the education method, format or delivery and not with 100% of the students. What is surprising to me is that a healthcare facility would consider the necessity to shadow clinicians for 30 days an acceptable aspect of any system..... and rest assured that the cost of this training must be an additional administrative burden on an already stretched healthcare system.

Enriching the clinical data is essential to our move to quality and getting maximum value from our stretched clinical dollars but we cannot capture and impose complex systems and requirements on clinicians to achieve this aim. Use existing processes, tools and resources that are already efficient and use technology to facilitate the enhancement and capture of this information. I am all in favor of new ways and technologies to be applied to healthcare and our lives in general but let's use what is in place and help improve efficiency without burdening the scarcest clinical resource we have - the clinical staff.

CMS Physician Quality Reporting Initiative - Breaking down the Resistance

CMS continues to push the Physician Quality Reporting Initiative (PQRI)
which represents the move towards quality measurement and comparison healthcare shopping for consumers. While there are many concerns related to the comparability of data and the different case loads and risks adversity fo different phsycians and thier patient load. But it is the burdensome overhead of collecting data

Participating in the program, established by a 2006 tax bill, will require time, resources and staff-something not all physician practices are willing or able to provide, industry experts say. As a result, the physicians that decline to participate in the CMS' Physician Quality Reporting Initiative will lose out on the 1.5% bonus payment the initiative pays.

That makes for interesting reading given the increasing number of factors to collect

2008 PQRI consists of 119 quality measures, including 2 structural measures. One structural measure conveys whether a professional has and uses electronic health records and the other electronic prescribing.

The measures include:

In Diabetics:

• Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
• Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus
• High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus

In Cardiac Disease:

• Left Ventricular Systolic Dysfunction (LVSD) - placed on ACE
• Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease
• Beta-blocker Therapy for Coronary Artery Disease Patients with Prior Myocardial Infarction (MI)
• Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction

You can see the complete list here

Capturing this data can be a burden but imagine if you were able to extract this information using the standard clinical documentation practice of dictation. With the addition of speech understanding and extracting this information to a CDA4CDT document that contains the detailed human readable narrative but is linked to the extracted machine readable semantically interoperable clinically actionable data this point of resistance should diminish and capturing this data should become part of the normal clinical documentation process.