Quality comparisons: 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

BY Brian Robinson, Published on Feb. 19, 2007 GovernmentHealth IT

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.”

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