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Four changes that can improve the value of quality metrics.
Physicians across America are bogged down with paperwork. We are adrift in a sea of data without a common standard of meaningful metrics.
Unfortunately, many of the metrics we do collect do not measure meaningful measures of quality-not for physicians, not for the healthcare system, and certainly not for patients. Something needs to change.
The Council of Accountable Physician Practices (CAPP), a coalition of integrated medical groups and health systems involving 30-plus organizations and tens of thousands of physicians, believes there is a better way to arrive at the quality measurement goals our healthcare system needs-one that will lessen the burden on physicians and re-focus office visits on the patient, where the attention should be.
The current dilemma
According to a 2016 Health Affairs article, medical practices report that their physicians and staff spend more than 785 hours per physician per year dealing with external quality measures-an amount of time that would care for an additional nine patients per week. Physician organizations expend an astonishing $15.4 billion annually in the reporting function.
Unfortunately, most of this effort is spent complying with a potpourri of measurement requirements, which vary depending on the health plan or agency requesting the data. The burden of these administrative tasks not only contributes to physician burnout but can also harm patients. The pressure to document interferes with clinicians’ ability to relate to patients and attend to their needs during office visits and procedures. It can often replace the patient’s agenda for the visit with one of closing quality reporting gaps.
A brief look at the quality measure systems currently in place show the scope and variety of the data collected. The Healthcare Effectiveness Data and Information Set from the National Committee for Quality Assurance measures the quality of public and private sector health plans and their providers. Medicare’s measures set for physicians created under the Medicare Access and CHIP Reauthorization Act of 2015 is another reporting requirement. In 2019, most physicians who are not participating in an alternative payment model will report up to six measures chosen from a list of more than 200 provided by the Centers for Medicare and Medicaid Services. On a local and regional level, public/private collaborative and healthcare systems collect data for their local reports.
Perhaps this effort would be worth it if the end result provided meaningful quality measures. Sadly, this is often not the case. Instead we have a hodge-podge of reports and sites that are inconsistent in what they measure, what they report, and how this information is presented.
What we really need in quality metrics
Looking at the current state of quality metrics, CAPP found that the following issues decrease the value of current reporting systems. We then identified changes to improve the value of what is measured.
• Most quality metrics measure process, not outcomes. Physicians report the tasks that were completed- patients counseled about weight, blood pressure measured, etc. The actions that are measured should be those that are correlated to a clear improvement in population health and patient well-being. Examples of this type of measurement include immunizations, colon cancer screening rates, and control of lipids and blood pressure in diabetics.
• The impact of team-based care is not measured.The way a patient receives care is no longer limited to one-on-one visits with a specific physician. Patients may interface with chronic care nurses, diabetic educators, pharmacists, PAs, nurse practitioners and other physicians, who are all working together to optimize the patient’s health. Currently regulators and plans still define access to care as the ability to have a face-to-face visit with one particular physician. While continuity of care with a patient’s own physician is important, care is now delivered by this team approach, sometimes via phone or by video visits or electronically via a patient portal. Defining access as the ability to see one physician face-to-face is outdated, and misses the point about how team-based care is delivered today. Similarly, quality metrics must be expanded to be able to measure the outcome of this team approach – not just what happens with one doctor.
• Positive outcomes are assessed just in clinical or compliance terms, notin terms of patient function and well-being. What are patients able to do now that they could not do before? Have they returned to normal function after an illness? Are their risk factors significantly reduced overall? Are they engaged so that they are compliant with their course of care? These are the measures that are important to patients and ultimately, to the entire health care system.
• Updates to metrics must be made when there are new data which changes the treatment recommendations for a particular illness or condition. When the science changes what constitutes best practice, there should be a method in place to quickly update quality standards, so the measurement matches the new treatment recommendations.
Currently, there are efforts underway to consolidate, simplify, and reform data collection and reporting. The American Medical Group Association (AMGA) recently produced 14 consolidated quality measures that include process measures, like cancer screening, and also outcome measures, like hospital readmission rates, emergency department use per 1,000, and skilled nursing facility admissions per 1,000. The public/private Core Quality Measures Collaborative has identified seven domains, with multiple measures in each domain.
What can physicians do?
First, make workflow changes so that physicians are not the primary gatherer of data. In some practices, the medical assistant (MA) meets with the physician in the morning to go over the quality data that is needed for each patient scheduled that day. The MA can also acquire some, if not all, of this data before the physician sees the patient. That way, when the doctor walks in the room, the focus is immediately on “What brings you in today?”
Second, push EHR providers to improve interoperability, so that data does not need to be collected multiple times, and current information is always available to the physician during a patient encounter.
Third, recognize that the physician voice needs to be heard when designing quality metrics and reporting processes. Physicians are key stakeholders in the conceptualization, design, and implementation of quality reporting. By exercising their voice through organized physician and medical group organizations and participating in discussion and work groups, physicians can help shape the next generation of quality metrics to be meaningful, easy to record, and standardized.
Steven Green, MD, serves as secretary for the Council of Accountable Physician Practices (CAPP), a coalition of American multi-specialty medical groups and health systems. He is also the chief medical officer of Sharp-Rees Stealy Medical Group in San Diego.