Tweetstorm: Quality Measurement in Healthcare is at a Crossroads
A summary of Dr. Mostashari’s remarks at #NQF17
It was raining cats and dogs in DC all day today, so I nearly missed Dr. Farzad Mostashari’s tweetstorm this evening. Over the course of 20-some-odd tweets, he summarized remarks and discussion from his panel at the National Quality Forum. Dr. Mostashari is the former National Coordinator for Health IT (read: the nation’s health IT czar behind today’s widespread adoption of electronic health records, or EHR.) He currently leads Aledade, a firm that helps physician practices become value-driven healthcare organizations.
Needless to say his insights, drawn from a career in medicine, policy, technology, and business, are worth some consideration for would-be health reformers across the land. Even in tweet form. I’ve copied and pasted the full thread of tweets at the end. What follows is a summary of his comments — Please note that the prose interpretation and reorganization below is my own; Any error or oversimplification is mine alone, anything that sounds insightful came from him.
Quality measurement in US healthcare is broken.
A chief complaint is that quality measurement today is far too labor-intensive for clinical staff, health systems, third party vendors, and most others involved in the process. Another is that most of today’s measures were designed for the transactional reimbursements of the FFS era — what do they really mean in a world of value-based contracts?
The industry collectively missed a big opportunity to automate how we gauge “quality” over the last several years of federally-driven reforms. EHR vendors are partly responsible for this, but so too are the quality measures themselves, whose design, selection, and deployment are quickly proving their outdatedness for how medicine is practiced and how healthcare is delivered and paid for in 2017.
Moving beyond the blame game, health systems that are truly value-oriented have an opportunity here to step up and demonstrate leadership. One way might be to help to define measures that truly matter in this brave new world of value, e.g. episodic variation, costs, outcomes. This is especially true in specialties like oncology or surgery.
For example, hospitals are still measured by a litany of yes/no process measures, such as flu shot vaccinations or putting patients on a particular clinical protocol. If a hospital really wants to keep people healthy, they’ll do this stuff anyway — if we’re collecting this data in the patient record anyway, do we really need to make them a reporting requirement? Moreover, giving systems the flexibility to select which measure they report undermines the central goals of quality improvement— to improve accountability, reduce variation, and promote the comparison of outcomes.
One idea for how to improve all of this is the use of data registries or intermediary groups that can ease the reporting burden faced by doctors, practices, hospitals, and other provider groups. Another might be to pause, look at the data that *is* being captured in EHR as part of routine care, and work backwards from there to define metrics that gauge the quality of that care.
For example, some measures are well-intentioned but poorly designed for the modern 12-minute visit. Body-mass index (BMI) is part of a two-part reporting scheme that replaces a potentially split-second automatic calculation (height & weight) with a two-part metric that involves collecting patient data, recording them, reporting them, counseling the patient, and reporting that too.
Smaller practices are less able of being self-deterministic, so their frustration with measurement-heavy “reforms” like MACRA is understandable. Hypothetically, if value-based contracts worked as originally intended, then doctors could simply focus on their patients and get paid more for taking good care of them. It’s not impossible, nor easy; it will take time, patience, and meaningful reforms to workflow, measure design, technology, and more to get there.
The Tweetstorm
…we’ve found a middle ground. Or a Medium ground.
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