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Podcast Library > NextGen Advisors Podcasts > Quality Measurement in Healthcare

April 23, 2020

Quality Measurement in Healthcare

Join Graham Brown, Senior Vice President with NextGen Advisors, Dr. Martin Lustick, Senior Vice President with NextGen Advisors, and Dr. Betty Rabinowitz, Chief Medical Officer of NextGen Healthcare for an ongoing discussion about current healthcare topics and challenges. Today's topic: Quality Measurement in Healthcare.

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Transcript

Graham Brown:

Hello, this is Graham Brown, senior vice president with NextGen Healthcare and principal with NextGen Advisors. I'd like to welcome you to our new podcast series featuring senior leaders from the NextGen Advisors team. We'll use this series to address different topical subjects related to ambulatory care, exploring the successes and challenges that community providers experience from an operations' policy and strategy perspective. I'm joined today by my colleagues, Dr. Marty Lustick and Dr. Betty Rabinowitz. Welcome, Betty and Marty.

Dr. Martin Lustick:

Hi, Graham. It's great to be here.

Dr. Betty Rabinowitz:

Thanks, Graham. Happy to be here.

Graham Brown:

Good morning to you both. Today's topic is Quality Measurement in Healthcare. Quality measurement has evolved a great deal over the past few decades, with efforts introduced by Medicare, AHRQ, specialty medical societies, and commercial payers aimed at quantifying the quality of care being provided to patients. Each of you were practicing physicians, Marty as a pediatrician, and Betty in internal medicine. So my first question, then, would be when you first began clinical practice, what kinds of things were you required to track and report on as a measure of quality? Marty?

Dr. Martin Lustick:

Yeah. Well, that's an interesting question that my age, when I first started in practice, there really were no standard quality measures. What would happen is that if one of the clinicians in the practice had a particular interest... Like I was interested in Attention Deficit Disorder, so I would create a manual tracking tool that we would all agree were the important things we wanted to keep track of with kids that were being evaluated or treated for that. We had someone in our practice who was really interested in asthma and drove the creation of an asthma program. And so we had metrics associated with that, like reducing emergency room visits for children with asthma, avoiding hospitalizations for children with asthma, but they were all self-generated metrics. There was no external body saying, "You need to meet this measurement."

Graham Brown:

Betty, how about you?

Dr. Betty Rabinowitz:

Similarly, there were no formal programs. We had a clinician in our group who was passionate about immunization. So very early on, we were tracking a percentage of patients who got flu shots in flu shot season. There was very little data available to us to do any of this measurement. We were still on paper charts. Many of our listeners had started practicing in a time where they went right onto electronic records, but some silver-haired clinicians listening will remember the time when we were in paper, there was very little ability to aggregate this information. So there was actually very little. I think Marty's description is actually ahead of its time. We did very little quality measurement, per se, in that regard.

Dr. Martin Lustick:

Well, to your point, though, when I started a program on Attention Deficit Disorder, it started with a card file where we had three-by-five cards that we would fill one out for each patient as they were coming in and being evaluated and diagnosed. And that was our tracking tool. Everybody had to have a card filled out and kept in the file-

Graham Brown:

So-

Dr. Martin Lustick:

...so it was pretty primitive.

Graham Brown:

Yeah, primitive and rudimentary, but at the same time, function for the priorities that, as a practice, you were trying to focus on. So that's really contrasted very much to today's environment, where providers are being asked to track hundreds of different measures for different types of populations, for different types of payer relationships. So how have things evolved from the beginning of your career and what providers are required to measure today? Betty?

Dr. Betty Rabinowitz:

I actually think that this is an area where we have completely lost our way. We are over measuring, assuming that measurement is synonymous with quality or generation of quality. Many of the programs are partially overlapping, creating great misunderstanding, chaos, confusion amongst providers of what actually needs to be measured. And very few of the measures out there, in spite of the huge efforts and resources devoted to supporting them, very few of them actually measure true, real, positive patient outcomes.

Dr. Martin Lustick:

It's interesting. In some ways, I would describe it as now that we have electronic information, we got stuck in a very early phase. I mean, back in the '90s, when I was in practice and we had our first database that told us every diabetic, we could see if they were due for a hemoglobin A1C or everyone who was due for colonoscopies. When we first got that information, we just gave it over to the practices. And within six months, they made dramatic strides in getting patients in to fill the gaps. And it had a huge practical value for our practice to be able to understand, at the population level, where we had missed people getting the care they needed, but those early metrics somehow got standardized and nationalized and became the goal just to get stuff done, as opposed to actually evolve into being able to look at outcomes.

Graham Brown:

Mm-hmm (affirmative). It's interesting because, Marty, I know after you left your direct practice, you took on a role as a chief medical officer with a large medical group, but also later, with a large managed care company. And managed care companies have developed a lot of their own local measures in addition to those established by specialty bodies and CMS and other entities. To what end do you think the managed care payer group of measures have been effective or, to Betty's point, maybe have just added to the confusion of activities that practices need to undertake to be compliant?

Dr. Martin Lustick:

I think it's been a vicious cycle of adding to activities. I think the early measures were what people were able to measure. Oftentimes, it was based on claims data, which was available electronically earlier than clinical data. And then companies like NCQA and Jaco and these oversight national organizations codified those measures because that's what we had and then created standards and benchmarking of those measures. And before we knew it, they were totally institutionalized and dollars started to get attached to them. And everyone now is stuck in that place of meeting the measures to get the revenue that they need.

Graham Brown:

Thanks, Marty. That's really interesting. Betty, you left clinical practice to establish a population health software company that's used by providers across the country. Electronic health records also have been built on many different platforms and have different ways that things are tracked and measured depending on what software you're using. So as someone that's led a software company, how has your solution had to evolve over the years to keep pace with quality measurement and reporting requirements?

Dr. Betty Rabinowitz:

It's a great question, Graham, because that has been one of the foundational challenges. We've experienced it clearly. We've created a very disparate data model across multiple EHRs, which further compounds physicians' challenges around reporting on their activities. So many times, physicians have performed an activity or done an action that is necessary for a patient, but the way that action is recorded or documented in a specific EHR is different than in other data models. And that creates barriers for reporting accurately, which frustrate physicians to no end. We continuously hear from physicians "But I did that colonoscopy. The patient had the colonoscopy. How come you're not giving me credit for it?" We have, in many ways, become completely bogged down in the mechanics of measurement, in the complexity of it, and have done so little to truly change staffing models, workflows, physicians' commitment to actually enhancing quality while we have kicked up tons of dust around this measurement. So as you can tell, I am not a fan of formalized, pair, CMS quality measures.

Graham Brown:

So electronic health record companies have had to comply with all of these different requirements that CMS and payers have put in place. And, in fact, they've probably tried to be flexible to incorporate those institutionalized measurement approaches. Do you think EHRs and other practice technologies have made it easier or harder to report on this? Marty?

Dr. Martin Lustick:

I would say that EHRs themselves, unfortunately, have made it harder because of the paucity and variability of the way information that comes into the EMR is ultimately stored and made available. The work that Betty has done to create population health is essentially filling a gap that EMRs did not supply when they were put in place. And what I'd love to see is that the type of information that we're able to glean from a population health capability could ultimately drive the decisions about what is useful to measure and how we can use those measurements to continually improve care instead of the claims-based metrics or process-based metrics that we're stuck on.

Dr. Betty Rabinowitz:

I'd like to, in continuation of what Marty said, give example of an issue that EHRs didn't even begin to grapple with, which is currently so central to quality measurement, and that's patient attribution. So, in the world EHRs' attribution, in the early days was as simple as if I registered you into my EHR, that's the only type of connection and relationship that EHRs were designed to support. And we know that the complexity of the landscape in healthcare systems among ACOs, physician groups, PHOs, reporting entities, cohorts that have specific attribution needs, was completely neglected in EHRs that still have continued to maintain a very linear, two-dimensional attribution logic that now needs to be supplemented, enriched, and provided by population health platforms that sit on top of EHRs. So even in that seemingly basic foundational way, EHRs are not particularly helpful to this task.

Graham Brown:

So we've got a complex reality for practices to navigate multiple different types of measures to different entities. So, I guess, the final question to each of you then is, if we've got this massive different tools and systems now that may not ultimately have a lot of correlation to outcomes, what do each of you think we should be measuring? Betty, could we start with you?

Dr. Betty Rabinowitz:

It's a tough question, but clearly, we have an opportunity to define, as an industry, patient outcomes and how we define positive outcomes across chronic conditions, interventional specialties. There are some tools that have gained some interest around patient-derived outcomes, what patients perceptions are of their wellbeing and health after healthcare interventions. Promise is one of those that is very broadly and widely used. There's a lot of experience with it already in many healthcare systems, which is a useful, now highly-validated tool to assess outcomes. There are other measures of quality that pertain to measuring practice pattern variation and reduction of unwarranted practice pattern variation that would do a lot to ensuring that we were not only measuring quality but that we were measuring value, which incorporates cost and quality at the same time. Those are a couple of examples. Obviously, in another podcast, we can talk a little bit more about both, but I'd love to hear Marty's thoughts on this.

Dr. Martin Lustick:

Well, I'd actually like to talk a little bit about each of those, because I do think they're at the core of the direction that we should be going. From the patient's perspective, from the community's perspective, patient-reported outcomes are probably the most useful information they could have. Imagine a patient who needs hip replacement surgery, who could go to a website, where they could see what the last 100 patients who had surgery with each of the surgeons and their region, at each of the facilities in their region could see who got the best outcomes. From a patient point of view, patient-reported outcomes would be hugely valuable. From a physician perspective, practice pattern variation is at the core in the foundation of improving care over time. If you can have a deep view of exactly how your care for something as basic as sinusitis might vary among the physicians in your practice or among the physicians in your community, you can start to understand who's getting the best outcomes, who's wasting resources, what's the best way for us to manage people with any given diagnosis, and we can all learn from that as clinicians. So I think those two areas are where we need to move and to get away from these very granular measures of things that just are easy to capture.

Graham Brown:

Mm-hmm (affirmative). It's an interesting topic. And thank you, listeners, for joining us. I'd also like to thank Dr. Betty Rabinowitz and Marty Lustick for sharing their insight and perspective on the state of quality measurement. If you've enjoyed today's topic, consider subscribing to our podcast. This is Graham Brown with NextGen Healthcare. Have a great day.