Learning From the Past to Measure the Future

Comparison of Approaches for Aggregating Quality Measures in Population-based Payment Models

OBJECTIVE

To assess the impact of alternative methods of aggregating individual quality measures on Accountable Care Organization (ACO) overall scores.

DATA SOURCE

2014 quality scores for Medicare ACOs.

STUDY DESIGN

We compare ACO overall scores derived using CMS' aggregation approach to those derived using alternative approaches to grouping and weighting measures.

PRINCIPAL FINDINGS

Alternative grouping and weighting methods based on statistical criteria produced overall quality scores similar to those produced using CMS' approach (κ = 0.80 to 0.95). Scores derived from giving specific domains greater weight were less similar (κ = 0.51 to 0.93).

CONCLUSIONS

How measures are grouped into domains and how these domains are weighted to generate overall scores can have important implications for ACO's shared savings payments.

Physician Engagement With Metrics in Lean Primary Care Transformation

OBJECTIVE

Data and metrics play important roles in quality and process improvement efforts. For one specific process improvement method, Lean or Lean health care, data and metrics are central components, allowing users to identify areas that need improvement and to assess the degree to which improvements have been realized. This article explores the role that metrics and measurement played in a wide-reaching "Lean"-based continuous quality improvement effort carried out in the primary care departments of a large, ambulatory care health care organization.

METHODS

This article is based on qualitative data collected through in-depth interviews with physicians, staff, and health care leaders.

RESULTS

Suggestions for improving the ways that metrics may be optimally used, presented, and approached while carrying out health care improvement efforts include having accurate and compelling data throughout the improvement process, ensuring that metrics are professionally meaningful to physicians, and presenting metrics in a manner that increases the likelihood that they will be digested and ultimately used to improve health care.

CONCLUSIONS

Effective strategies for selecting and presenting metrics to practicing physicians are an important part of a successful quality improvement effort.

Enhanced Quality Measurement Event Detection: An Application to Physician Reporting

The wide-scale adoption of electronic health records (EHR)s has increased the availability of routinely collected clinical data in electronic form that can be used to improve the reporting of quality of care. However, the bulk of information in the EHR is in unstructured form (e.g., free-text clinical notes) and not amenable to automated reporting. Traditional methods are based on structured diagnostic and billing data that provide efficient, but inaccurate or incomplete summaries of actual or relevant care processes and patient outcomes. To assess the feasibility and benefit of implementing enhanced EHR- based physician quality measurement and reporting, which includes the analysis of unstructured free- text clinical notes, we conducted a retrospective study to compare traditional and enhanced approaches for reporting ten physician quality measures from multiple National Quality Strategy domains. We found that our enhanced approach enabled the calculation of five Physician Quality and Performance System measures not measureable in billing or diagnostic codes and resulted in over a five-fold increase in event at an average precision of 88 percent (95 percent CI: 83–93 percent). Our work suggests that enhanced EHR-based quality measurement can increase event detection for establishing value-based payment arrangements and can expedite quality reporting for physician practices, which are increasingly burdened by the process of manual chart review for quality reporting.

Expanded roles of registered nurses in primary care delivery of the future

BACKGROUND

Primary care in the United States is changing: practice size is increasing, there is a growing shortage of primary care practitioners, and there is a heightened prevalence of chronic disease. Given these trends, it is likely that registered nurses will become important members of the primary care team.

PURPOSE

This paper explores the challenges and opportunities in primary care delivery in the 21st century and examines the likelihood of expanded roles for RNs to improve quality and add capacity to the primary care workforce.

METHODS

We searched the peer-reviewed and gray literature for publications on primary care, primary care workforce projections, the future of nursing, and team-based care.

DISCUSSION

The number of primary care physicians is expected to decrease in relation to the US population while the number of nurse practitioners is increasing, with the result that more and more patients will see nurse practitioners as their primary care practitioner. However, the primary care practitioner (physicians, nurse practitioners and physician assistants) to population ratio is dropping. As a result, other professionals will be needed to deliver primary care. As the nation's largest health profession, registered nurses (RNs) are in sufficient supply and have been shown to improve the care of patients with chronic conditions. It is likely that primary care practices of the future will include an enhanced role for RNs, particularly in chronic disease management.

CONCLUSION

For RNs to assume an expanded role in primary care, several barriers need to be overcome: (1) the widespread introduction of payment reform that reimburses RNs to independently provide care for patients, and (2) nursing education reform that includes primary care nursing skills (3) scope of practice clarification for non-advance practice RNs working under standardized procedures.