After 50 years, physicians continue to struggle with quality metrics.
Fifty years ago, Avedis Donabedian, MD, MPH, of the University of Michigan, published his seminal paper, “Evaluating the Quality of Medical Care,” and created a framework that is still used to measure healthcare quality. Donabedian divided quality measures into three categories: structure, processes and outcomes.
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Efforts are now underway to expand his paradigm into a potent, data-driven network of quality measures, with the hope of streamlining and vastly improving America’s healthcare system.
In the short term, this initiative has turned into an expensive, burdensome, data-wrestling nightmare for many medical practices, says Lawrence P. Casalino, MD, PhD, MPH, a family physician who is a professor in the Department of Health Policy at Weill Cornell Medicine in New York, New York.
Casalino and associates published an article in the March edition of Health Affairs entitled, “U.S. Physician Practices Spend More Than $15.4 Billion Annually to Report Quality Measures.” The article is based upon a survey of about 400 primary care, cardiology, orthopedic and multispecialty practices, providing a “back-of-the-envelope” calculation of how much time and money is being spent to computerize quality data that are of very limited use, says Casalino.
After years of work, payers and providers still haven’t agreed upon common measures that would allow easy entry and use of data. There are now hundreds of quality measures. Clinicians and their staffs are spending about 15 hours per week, per doctor, to enter a hodgepodge of quality data into computers. That adds up to about $40,000 a year per physician, or $15.4 billion nationally, just for quality measures, according to the study.
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Having good quality measures is important for a variety of reasons, including the movement toward value-based medicine, in which quality and outcomes impact payment. Computerizing the information is part of an even more complicated and costly switch from paper to electronic health records (EHRs).
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“In the long run, we’re going to be glad we have EHRs, but we’re kind of sacrificing a generation of physicians to the transition right now,” Henley says.
Only 27% of survey respondents thought the quality data now being collected was moderately or very representative of the actual quality of care being delivered. “It’s pretty dismaying that the practices don’t see these measures as useful even though they see themselves putting in more time than ever,” says Casalino.
Coincidently, the Core Quality Measures Collaborative recently released a set of core measures to align and harmonize quality indicators used by all private and public payers. “It’s just a mess out there,’’ says Douglas E. Henley, MD, FAAFP, executive vice president of the American Academy of Family Physicians and a participant in that project. “Our involvement in the Core Measurement Collaborative was to work with public and private payers to see if we could get some order out of this chaos.’’ He is hopeful that the measures will be adopted in 2017, and private payers will adopt them as they renew contracts over the coming 18 to 24 months.
“As we get better measures, then we’ll swap out one measure for another and become more outcomes oriented, which is where everybody wants to go,” Henley says. “Eventually, we’ll get to the point with technology and electronic registries where a lot of this burden, which is now very manually orientated, can occur by simply extracting data directly from EHRs, rather than somebody in the clinic having to key in all this information.”
The system will allow doctors to manage populations of patients, while improving the quality of care. “That’s the Holy Grail we’re moving toward,” Henley says.
Meanwhile, the movement to data-driven systems has created enormous job growth in one particular area-medical scribes who often tail behind physicians as silent partners to input data. Kristin Hagen, executive director for clinical informatics/wellness at the American College of Medical Scribe Specialists, says there are already about 15,000 scribes working in the nation’s health system, and predicts that by 2020, there will be 100,000.
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Her organization is working to improve the education, training and certification of scribes, which she sees as essential to relieving physicians of data-entry duties so they can focus on patient care. “It allows doctors to focus forward,’’ she says.
As for Donabedian, before his death in 2000 he expressed a deeper view of medical quality, one that went to the foundation of structure, processes and outcomes. “UItimately, the secret of quality is love,” he said in an interview published in Health Affairs in January 2001. “You have to love your patient, you have to love your profession, you have to love your God. If you have love, then you can work backward to monitor and improve the system. Commercialism should not be the principal force in the system.”