Thursday, June 19, 2008

The Markle Connecting For Health Subcommittee on Quality and Cost Effectiveness

On June 19, 2008, the Markle Foundation Connecting for Health Steering Group met to discuss means of disseminating the Common Framework for Networked Personal Health Information and to discuss ongoing population health activities.

Now in its fifth year, the Markle Foundation has made remarkable contributions. Established in early 2004, the first public briefing on the Markle Agenda was held at the National Press Club on June 25, 2003.

Zoe Baird led the meeting discussing a meeting held last week by the Senate Finance Committee. Much was said about a universal health care financing vehicle and great attention was paid to costs. Although comprehensive legislation is not expected, incremental steps will be taken and information technology - wisely used - will enable better health care.

Some have lamented the lack of agreement that would allow the Government to use its market power as a payer for care. There is enough focus now with Congresional engagement and presidential campaigns that investments could be anticipated. One must make sure that the right kind of open markets are realized and, for this reason, both a consumer framework and a population health approach will be essential to the debate. There was significant discussion about the CBO report (2976) that pointed out where CBO believed additional congressional support could improve adoption and health.

Response to the CBO Report

Dr. Blackford Middleton noted the report gave a "reasonable review and summary of the literature on HIT value." Some CITL report aspects "were not represented well." These include:
  • A fundamentally different purpose for the report - the impact of funding
  • Value of un-standardized (level 3) vs standardized (level 4) interoperability.
  • They failed to note how CITL accounted for the current HIT context; CBO factored in existing provider-payer data exchanges, and existing lab and pharmacy integration
  • CBO treated costs of providers information systems but inadequately treated the internal benefits; their notion of data exchange was relatively restricted.
  • CITL differed with CBO on lab administration costs; phone call rates - but these were not key determinants of overall value
  • CBO's critique did not discuss some of the limitations of HIEI model limitations. The CITL model was more expansive and included realizing savings through quality improvements and the potential clinical benefit.
In the same discussion Zoe Baird noted that it isn't so much the report as how it is depicted to the public. Initial reports were rather unitarian in the view declaring that benefits are not there. CBO - recruiting a broad and talented array of health care economists - has emphasized a broader and more constructive mesage.

Subcommittee on Quality and Cost Effectiveness

One member of the committee expressed extreme frustration. After years of measurement, we haven't been able to "move the needle even one millimeter." People are "tired of it" and "it's time to move on." We need to measure something that counts and quite measuring for the sake of measuring. We do have measures that work - hospital infections, falls, and adverse events. There are very good programs on this focused primarily in hospitals - and this is done without "micro measurement" and by exploring different ways of including things into the processes.

To make an analogy, it is as if one measures the outcome of the Indianapolis 500 by measuring the piston characteristics, fuel injection performance, and, after adjusting for severity, develop an outcome metric!

It's time to re-think and move past the self-interest.

A second member empahsized the need to focus on a few simple things rather than continuing to expend energy as has been done over the past five years. Examples were providing a medication history for every American and better access to laboratory data.

One physician pointed out that "it isn't funny anymore" and spoke of an ongoing event concerning a relative where his personal presence was critical to pull together the various parties involved in the care of his hospitalized relative. Many providers stated "they really didn't have all the details" and depicted a number of clear outcomes that were the result of failures in the system. (The story rivalled that Regina Herzlinger tells in her recent book, "Who Killed Health Care.")

Five Potential High Impact Ideas

The Subcommittee currently is exploring five simple "high impact ideas"
for discusion as a sub-set of a more extensive list. They are:
  1. Measures that matter. Set big goals, like reducing cardiovascular events in the US over the next Y years by X%. Currently some measure for reporting rather than measure for improving. Measurement of "surrogate outcomes" should be abandon as "futile."

  2. Eliminate nosocomial blood stream infections in the US. This requires widespread adoption of evidence-based work flows involving every provider.

  3. Implement a national device registry. A simple correlation between surgeons and selected devices (e.g., hip prostheses, stents) would reveal variation.

  4. Make formularies on-line. (This writer would like to see no more than 50 formularies in the united states rather than thousands. In other words, "formularies that matter" not automating the thousand-plus variants of dubious value)

  5. Share a visit summary. Trials of interchange of CCR and CCD docments have been successful and hold great promise.
The overall approach is not to create another silo but rather to bridge with focus the gap between the many quality initiatives and the principles in policy and technology that are required to realize these objectives and improve them over time. The emphasis is on simplicity and evolution. Measures that matter, nosocomial infections, and visit summaries can be simplified by the maxim: "quit killing people" by focusing on a few systemic issues.

Some correctly point out that goals like elimination of nosocomial infections will result in part from the CMS regulations that prohibit payment for complications.

One strategy is to try to minimize rules that don't help. An example is the requirement for tamper-resistant prescriptions that require special paper and run counter to the technology imperatives expressed by this same government.

Rather than focus on delivery organizations, one should want to identify the four or five top diseases and measure what is required across the continuum of care. Instead, we get the "where do I fit in?" syndrome where roles are emphasized over results (e.g. "measures for anatomic pathologists").

These notes do not express the opinions of the Markle Foundation and may not accurately reflect the ongoing debate and discussions, but hopefully provide yet additional emphasis on why this vital organization's agenda should be supported.


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