Measuring provider performance using claims data

Consumer-directed healthcare reform models, such as health savings accounts with high deductibles, depend on giving consumers the information they need to select the providers best suited to their needs and pocketbooks. This requires transparency of cost and effectiveness. In addition, such models are designed to rewards providers with incentives for doing good work, such as "pay for performance."

This post is not focused on the debate about whether providers' performance should be evaluated. Rather, it addresses the issue of using insurance claims (administrative) data to evaluate provider effectiveness and improve the quality of care.

Claims data provide some useful measures of clinicians’ performance, including mortality rates, complications, and cost of care. These data are grossly inadequate metrics, however, for incentives, transparency of cost & effectiveness, and continuous quality improvement.

This is because claims data do not include information necessary to determine, for example, how much a patient improved after treatment, if errors were made, if lower cost treatments of equal or greater effectiveness could have been used, if the patient was educated adequately in self-care and complied with the prescribed plan of care, and if coexisting conditions affected results. Without such clinical outcomes data, it isn't possible to evaluate a provider's performance accurately nor gain the knowledge needed to improve healthcare effectiveness and efficiency.

So, instead of using claims data in isolation, they should be augmented with detailed clinical outcomes data that (a) offer more valid measures of performance, and (b) enable researchers to establish and evolve evidence-based practice guidelines.

For an in-depth technical discussion of these issues, see this WellnessWiki page.

Filling the HIT Gap by Satisfying the Unmet Needs

We present the Patient Life-Cycle Wellness™ (PLCW™) system at http://wellness.wikispaces.com/Filling+the+HIT+Gap.

It is the first comprehensive health IT (HIT) blueprint to address the six unmet needs of mainstream HIT.

The PLCW system overlaps some other HIT systems in that it:

• Provides a collaborative space with single sign-on portal technology supporting EHR/EMR/PHRs, CPOEs, e-mail, forums, HIPAA compliant file transfer, voice over IP, and end to end encryption
• Promote secured access to specific patient data using authorization rules for Trusted Partners, as well as biometrics scans and SMART Cards for authentication
• Protects patient privacy by allowing only the information a patient permits to be shared with each authorized recipient (i.e., “Trusted Partner”)
• Interoperates with third-party applications.

But what makes the PLCW blueprint unique, is it is the first to satisfy the following six unmet HIT needs:

1. Bridging the Knowledge Gap
2. Managing Plan of Care Execution
3. Coordinating Care
4. Protecting public health
5. Enabling complete connectivity
6. Management of extensive data sets.

Defining the HIT Gap

In my prior post, I discussed what HIT is now and what it needs to be. I now define the HIT Gap.

The HIT gap is a result of not making six essential needs a top priority; that is, current HIT does not adequately focus on:

1. Bridging the knowledge gap — using comprehensive, detailed knowledge of each person and the scientific research to (a) make the best possible treatment decisions within a personalized care framework, (b) deliver that care efficiently and effectively, and (c) enable all consumers to be informed participants in the healthcare decision process and in promoting their own health.
2. Managing care execution — Helping providers execute their plans of care.
3. Coordinating care — Coordinating care across multiple providers in the healthcare continuum, so such tools are needed.
4. Protecting public health — Implementing processes for ongoing biosurveillance, post-market surveillance, and first-responder assistance in case of emergencies, so such tools are needed.
5. Enabling complete connectivity — Enabling all stakeholders — patients, providers (including RHIOs, facilities, and individuals across all healthcare specialties/disciplines), purchasers, and payors — to compile and share all the data they need for which they are authorized.
6. Managing extensive data sets — Fostering the fluid access, exchange, analysis and reporting of an enormous diversity of healthcare data sets, including a wide range of physiological (medical and non-medical) and psychosocial data, across patients’ entire lifetimes, about (a) people's disease/dysfunction-specific symptoms and functioning levels; (b) treatment-specific process, clinical outcomes, and practice guideline variance data; (c) genetic data; and (d) expense/financial/utilization data.

Next time I'll present an innovative solution for filling the HIT Gap by satisfying these six unmet needs.

What HIT Is Now and What it Needs to Be

Health information technologies (HIT) are improving, but there is still a huge gap between what HIT needs to be and what HIT is now. Only by closing this gap can HIT deliver what’s needed.

What it Needs to Be

As the USA struggles to deal with the healthcare crisis, mandates for change — such as the National Health Information Infrastructure (NHII) initiative — focus on the use of HIT to help increase healthcare effectiveness and safety, and reduce errors and costs, by:

• Deploying decision support tools with guidelines and research results


• Fostering collaboration and accelerating diffusion of knowledge


• Improving use of resources
• Increasing workflow efficiencies
• Reducing variability in care quality and access


• Advancing the consumer role
• Strengthening privacy and data protection
• Promoting public health and preparedness.

Achieving these objectives requires changes in healthcare policies and practices, as well as interoperable HIT that:

• Helps people know the safest and most cost-effective ways to care for each patient and deliver that care in a coordinated manner across the entire healthcare continuum with minimal error and omissions (see Consumer-Centered Care).


• Helps people understand each patient’s health problems and needs in fine, clear detail, to support accurate diagnostic and treatment prescription decisions (see Personalized Care).


• Helps people create and use evidence-based practice guidelines.
  Helps people know how to prevent illness and promote wellness for each person, and deliver such wellness/prevention programs.


• Promotes consumer/patient participation through increased knowledge and decision-support, which benefits them by increasing their ability to select the right providers and health plans, prevent illness/complications/accidents by focusing on self-care and wellness, and reduce complications of chronic disease by complying with plans of care.


• Promotes provider participation through increased knowledge, decision-support, and workflow efficiencies, which benefits them by increasing their ability to deliver more cost-effective treatment and increase patient safety (reduced errors and omissions).


• Promotes payer participation through increased knowledge, decision-support, and workflow efficiencies, which benefits them by increasing their ability to contain costs and take advantage of new business opportunities.


• Promotes purchaser participation through delivery of more cost-effective care to employees, which benefits them by reducing healthcare expenditures, absences, and turnover, as well as improvements on-the-job productivity.


• Enables collaborative networks to improve healthcare quality by helping them;
  
  • Perform clinical research in the field and lab through streamlined collection, sharing, and analysis of large quantities of diverse clinical outcomes data
  
  
  • Build evolving health science knowledgebases based on the clinical research and transform this knowledge into evidence-based practice guidelines
  
  
  • Disseminate, implement, and evolve the guidelines
  
  
  • Communicate easily and efficiently to share observations and lessons learned, handle disputes, and help run collaborative organizations.
  
  
  
  
• Protects populations by offering an efficient and effective way to obtain, transmit, and analyze biosurveillance and post-market surveillance data and by assisting first responders in the event of a wide-spread emergency (e.g., bioterrorism, epidemic).


• Helps utilize resources more efficiently.
• Helps people transfer data and information in a shared environment.


• Helps people use scaleable, integrated software applications.

What HIT is Now

Efforts these days focus on the most basic functional level of HIT, i.e., the development of interoperable architectures and the use of applications for inputting, validating, storing, securing, and exchanging basic patient data. Current HIT also offers some decision-support through reminders (e.g., of follow-up appointments, inoculations, etc.) and alerts via medication prescription checks, and streamline certain workflows. All this is a necessary first step, but it is grossly insufficient.

Does anyone disagree?

In my next post, I define the HIT gap and what can be done to bridge it.