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When's "Good" Quality, Good Enough?

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"The current system is a mess because payment in the private sector is related to competition, contracts, etc. One gets paid a different amount by each. A single payer would have lower per episode payment, but would cover all and make billing simpler and more reliable."

Leemore Dafny, PhD Harvard Business School Namita S. Mohta, MD NEJM Catalyst;  "New Marketplace Survey; What's Next for Payment Reform?"  Insights Report · September 2017 

A payer judges a physician or a practice organization by the proportion of patients for which the physician adhered to one or more abstract practice measures. Those in quality measurement seem to be attempting to align the clinical quality measures that are relevant to Electronic (EHR) Incentive Programs.  Isn't that artificial and once removed from the patient's care?  Furthermore, even with the recommendations of the the Department of Health and Human Services, ​the Health Information Technology Policy Committee​, and the National Quality Strategy's (NQS's) six priorities or "domains," is this way of looking at things, 'good enough?

(Note that each measure falls into one of the following domain buckets:)

  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination
  • Population/Public Health
  • Efficient Use of Healthcare Resources Clinical Process/Effectiveness
  • Clinical Process/Effectiveness

​For a full list of the approved Clinical Quality Measures (CQM) visit the Centers for Medicare and Medicaid Services (CMS) website.  Go there to learn more about the specific requirements to qualify for the government incentive payments. Depending on a medical facility’s mix of health plans, other mechanisms of reporting like HEDIS-related analysis of claims data and chart reviews may also come to bear as will other quality improvement initiatives, patient surveys, and so forth.

The evidence base for CQMs is constantly evolving, so carefully select the most appropriate CQMs for your setting, while being vigilant of the  risks and limitations inherent within this industry's evolution. For More Information,[] target="_blank">

"Acceleration of outcomes measurement can unlock the potential of value-based health care for driving improvement. It requires a commitment to measuring a minimum sufficient set of outcomes for every major medical condition."

"The International Consortium for Health Outcomes Measurement (ICHOM) has convened [various] experts on specific conditions, together with patient representatives, to outline minimum standard outcome sets and risk factors using a structured process.....ICHOM working groups understand that their role is not to devise new outcomes measures but to agree on which well-validated ones, including patient-reported measures, everyone should use. These standards are putting providers, payers, patients, and information technology vendors on a common path for tracking what needs to be tracked, making implementation of outcomes measurement easier and more efficient. Organizations may collect additional measures, but everyone is encouraged to deploy the minimum set.....We predict that a time will soon come when it will be hard to believe that measurement of outcomes that mattered to patients was rare in 2016 — and organizations that measured them each did it in their own way. Universal measurement and reporting of outcomes won’t happen overnight. But we believe that agreeing on and implementing respected standard sets of outcomes for each medical condition is a practical and decisive step in accelerating value improvement in health care. This is an agenda whose time has come.

Porter ME,  Larsson S, and Lee TH. "Standardizing Patient Outcomes Measurement."  {Free] N Engl J Med 2/11/2016; 374:504-506.


"Providing information on quality and costs of care to physicians helps to visualize value improvement opportunities, areas of significant variations of care delivery, and care redesign ideas."

Lessons Learned –
"While we are still in the middle of the value Journey, we have learned several lessons through the deployment of Value-Driven Outcomes (VDO) Scorecards for Top 50 Medical Conditions (MC) in the past few years."

  1. "Data analytics requires iterative refinement
  2. Accuracy of data depends on accuracy of EHR documentation
  3. Population definitions require broader perspectives with subgroup analysis
  4. Severity adjustment must be considered : compare apple and apple
  5. Clarify attribution – who is responsible for care for the entire admission?
  6. Physician engagement is critical
  7. Quality improvement should be recognized as a career pathway
  8. Alignment with Department Chairs and School of Medicine is critical"

​Quality of Care--How Good Is Good Enough?

"According to current practice, a payer judges a physician or a practice organization by the proportion of patients for which the physician adhered to the practice measure. 'Good enough' therefore is an adherence rate that exceeds a threshold, which is typically expressed as a percentile of the distribution of adherence rates in a population of clinical practices. For example, in its recognition program, the National Committee for Quality Assurance sets the threshold for passing a measure according to the population-derived adherence rate for the corresponding Healthcare Effectiveness Data and Information Set (HEDIS) Health Plan measure (usually at the 70th percentile) (Gregory Pawlson, MD, National Committee for Quality Assurance, e-mail communication, April 2010).

[However,] shortcomings in measuring case-mix determinants, judging all practices by whether they exceed the same threshold level of quality is not equitable. Set the threshold too low, and a practice in an upper-middle-class suburb has no incentive to improve. Set the threshold too high, and an inner-city safety net practice may take years (if ever) to meet it.

Setting a threshold level of adherence to practice measures is not a good way to decide when care is good enough to be acceptable. A better way is to reframe the problem in clinical terms, as an individualized decision between adhering to the guideline or deviating from it. The outcomes of choosing either action are not knowable in advance. According to a basic principle of decision analysis, when making a decision under uncertainty for a single patient, the physician should choose the action that would give the best average outcome after making the same decision for many similar patients. To forecast these expected (or average) outcomes, the physician must estimate the probabilities of the outcomes and assess the effect of each outcome on the patient. The probabilities should be specific to the patient's clinical findings, and the preferences, perceptions, and values about the outcomes should be the patient’s. These individualized data are the key to good decision making, whether by conducting a formal decision analysis or simply talking with the patient about the factors affecting the decision.

In this decision process, the patient should be an informed full participant. The patient should know the likelihoods of outcomes, and the physician should know how the patient perceives, prefers, and values those outcomes. Decision aids describe the outcomes and their likelihoods and can help patients identify their preferences. The aids include "fact boxes,"1 electronic media for patients to view and discuss2 and a decision analysis that calculates patient-specific expected outcomes of the decision alternatives.

For several reasons, a decision-making process* that fully informs the patient may be the best way to judge if care is good enough. When a fully informed patient makes a decision, his or her choice is as likely to maximize future welfare as can be reasonably expected. Of course, some patients may misunderstand the information provided, process it irrationally, or decide idiosyncratically. Still, an informed choice under uncertainty is an ideal to strive for, especially because it enhances the exercise of the patient's right of self-determination, which is a cornerstone of medical ethics.3  A well-informed decision also incorporates the difficult-to-measure variables—an individual's probabilities and preferences—that cause practice populations to differ from one another. In this way, it avoids the need to adjust case-mix differences that confound efforts to compare the quality of care in different practices. Finally, informed decisions have another attractive feature: the best way to maximize patient welfare, as they advance the principal goal of health care."

Harold C. Sox; Sheldon Greenfield JAMA. 2010;303(23):2403-2404: (doi:10.1001/jama.2010.810 [Extract]:

* "Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.... In addition, the improved quality of care and savings gained [can be enhanced] by integrating this approach into other [Affordable Care Act] ACA initiatives. For example, the documented use of patient decision aids could be used as a quality metric in patient-centered medical homes, accountable care organizations, and systems caring for patients eligible for both Medicare and Medicaid. Eligibility criteria for incentives to adopt electronic health record technology might [include this]. Moreover, information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches."

"Shared Decision Making to Improve Care and Reduce Costs" by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.  N Engl J Med 1/3/13; 368:6-8.

  • Crossing the Quality Chasm called for a “system that provides provides care that is respectful respectful to individual individual patient patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions”
  • The Affordable Care Act Calls for new Shared Decision‐Making Resource Centers (Section 3506) to help integrate shared decision making into practice.  Section Section 3021 (Center (Center for Medicare Medicare and Medicaid Medicaid Innovation Innovation [CMMI]) [CMMI]) to examine how support tools can be used to improve patients understanding of their treatment options
  • Formation of Patient Centered Outcomes Research Institute (PCORI)
  • Comparative Effectiveness Research (CER) provides pertinent "information to assist patients, clinicians, purchasers, and policy makers in making informed health decisions." Caveat -  there may be a gap in translation or even obfuscation from misalignment of financial incentives, complexity of research,  biases in the interpretation of results, applicability of the evidence or limitations in the use of decision support.
  • The SHARE Approach is a five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.

Seek your patient's participation.

Help your patient explore and compare treatment options.

Assess your patient's values and preferences.

Reach a decision with your patient.

Evaluate your patient's decision.

The “AHRQ Webinar on Patient-Centered Outcomes Research (PCOR) and the Use of Decision Aids to Facilitate Shared Decision Making.[March 18th 2015, but to be posted as a Toolkit website,]. [Re-pub. here with permission from Deidrè M. Young, CMP, CGMP  |  Senior Conference Manager |  AFYA, Inc. ; March 19 5:51 PM]

"Quality measurement for doctors' offices needs improvement" Source

The Institute of Medicine's 2001 report, "Crossing the Quality Chasm," outlined six domains of quality in medical care: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. Dr. Tara Bishop, however, stated online March 21, 2013 in the Journal of the American Medical Association (JAMA) that "current quality measures for the outpatient setting do not include all of these domains. [Moreover,] The majority of outpatient quality measures focus on preventive care, chronic disease care, and, to some extent, timeliness of care and patient centeredness . [Worse,] Safety, high-level effectiveness, coordination and efficiency are not captured in the current measures of outpatient quality."

Bishop adds "that problems can arise when quality measurement centers on a small aspect of care and neglects others. These problems include the potential for unmeasured quality to be reduced and conclusions about overall quality to be drawn from a small segment of measured quality. For example, clinicians who are evaluated only for providing preventive care and chronic disease management might focus less on equally (if not more) important aspects of care such as diagnostic accuracy and appropriateness of testing."

Understanding Health Status and How That Factors In Incentive Programs

Richard Fuller, MS [health care economist] and Dr. Norbert Goldfield of 3M discuss using state-of-the art, patient-centered health status*-outcome measures that actually have been used to improve patients' functionality and/or quality of life.

  • Additional qualifications pertaining to0 the quality of life measure: "Functional limitations, limitations in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), are measured (either by the patient or the health professional) by a variety of tools utilizing a variety of scales."

  • Better outcome information and more equitable payment for care delivered:  Functional health measures are incorporated into 3M's Clinical Risk Groups, Patient-Focused Episode classification methodologies and/or bundled payments, which certainly helps explain cost variances "associated with a snapshot of functional limitations and target payment." [In addition, the authors note] "that changes in health status are an important dimension to track, both for those interested in linking outcomes quality to payment and those that are trying to understand how differences in approach can lead to better long-term outcomes"[4] 

"Measuring the quality of life component in patient-centric care." Posted 12/21/2015 by  [rearranged for presentation here by jgk] * Note: "Health status" df.: “the range of manifestation of disease in a given patient including symptoms, functional limitation, and quality of life, in which quality of life is the discrepancy between actual and desired function.” [1]

See also, Norbert Goldfield, MD, Richard Fuller, MS "Pay for better risk-adjusted outcomes and let’s cut down on waste." in 3M's Inside Angle blog, posted  April 19, 2017, referring to potentially preventable events (collectively, PPEs).

"Seven 21st-Century Skills Doctors Wish They'd Learned in Medical School" by Christina Farr on, Posted Sept. 24, 2015

  1. Data Science and Statistics
  2. Nutrition and Disease Prevention
  3. Ultrasound Training
  4. Information Technology 101
  5. Communications and Empathy (Emotional Intelligence)
  6. Personal Finance
  7. Management and Leadership

A Transitions of Care Toolkit, designed to assist physicians in transitioning patients from pediatric care to an adult primary or specialty setting of care is available.

Developed by the American College of Physicians (ACP) Council of Subspecialty Societies, with participation from the American Academy of Pediatrics (AAP), multiple medical specialty groups and patient advocacy organizations, the toolkit contains disease/condition-specific tools developed to assist physicians in transitioning young adults with chronic diseases/conditions into adult care settings. Based on the clinical report, “Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home,” from the AAP, ACP, and American Academy of Family Physicians, the National Health Care Transition Center/Got Transition developed an evidence-informed model, the Six Core Elements of Health Care Transition, which includes free sample tools clinicians can download and implement in their offices. These core elements were used as a basis for the development of the Transitions of Care Toolkit.

Click here for more information and to access the Transitions of Care Toolkit

Jackie Burke, AAP Sections Manager (800) 433-9016 ext 4759

Actionable Analytics

An excellent (videopresentation on this subject is: "Why Reports Aren’t Enough: Turning Population Health Data Into Actionable Insights," posted April 2, 2015 by,

Currently, electronic health records (EHRs) are not built to make procedural, prescriptive orders, process, outpatient, referral, complementary or outcome data very actionable.  If, for example, there's a patient registry, that data may not be interoperable enough to generate a working list of patients who need specific services and meld that to a semi-automated messaging system or send messages to an outside party registry.  Instead, the medical practice may export the registry report data to a spreadsheet that includes "patient demographic information, including addresses and phone numbers. Since regular mail hasn’t proved to be effective, the staff either calls patients or contacts them via the patient portal, 'but it’s not an automated process.'”  

Terry, Ken. " [See" target="_blank">EHRs: 5 ways to put data into action; Physicians share strategies to improve quality metrics, chronic care." June 10, 2014  Medical Economics

Clinical Quality Measurement in a Fast-Moving, Complex Environment

It must be understood that data ain't information.  Nevertheless, the translation of data into information is paramount.  Consider, for example, how health plans and individual medical practice offices must now be able to prove they are the 'Right Stuff' when it comes to 'Meaningful Use" activities such as communication as patients transition their care or in outcome measurement and management. While, the current demands for CQM are "fresh," they hardly are new–consider Total Quality Management (TQM) or Continuous Quality Improvement (CQI) of years past.

"Patients and their caregivers believe that performance reporting misses what matters most to them and fails to deliver the information they need to make good decisions. In an attempt to overcome these troubles, measure developers are creating ever more measures, and payers are requiring their use in more settings and tying larger financial rewards or penalties to performance. [A better approach] would be guided by three principles: quality measurement should be integrated with care delivery rather than existing as a parallel, separate enterprise; it should acknowledge and address the challenges that confront doctors every day — common and uncommon diseases, patients with multiple coexisting illnesses, and efficient management of symptoms even when diagnosis is uncertain; and it should reflect individual patients' preferences and goals for treatment and health outcomes and enable ongoing development of evidence on treatment heterogeneity.1"

McGlynn EA, Schneider EC, Kerr EA. "Reimagining Quality Measurement." N Engl J Med 12/4/2014; 371:2150-2153

Spencer Hamons writes: "Healthcare organizations suffer from what I refer to as 'DRIP,' which means they are "Data Rich and Information Poor." Healthcare systems have been collecting data for a couple of decades now, but most of that data is not necessarily clinical data. In the past seven to 10 years, there has been an uptick in the collection of discrete clinical data, and that has ramped even more in the last five years."

"HIMSS 2015: Is Your Healthcare Organization Data Rich, but Information Poor?" [Pub. online April 13, 2015, however,that link fails 11/11/15 due to an internal server error.] 

As stated by Amy Sheide, a clinical analyst at 3M Health Information Systems (HIS), Inc. who serves as a part of the Healthcare Data Dictionary (HDD) team in an article, "Keeping Up With HIT Regulations," pub. May 2, 2014 by : "Meta-data management and expertise will be a key differentiator as organizations attempt to meet evolving regulatory requirements and internal quality initiatives." .... "One area where this is incredibly relevant and challenging is with electronic Clinical Quality Measures (CQMs):

Clinical Quality Measures, or CQMs, are tools that help us measure and track the quality of healthcare services provided by physicians, nurses, hospitals and others in our health care system. These measures use a wide variety of data that are associated with a provider’s ability to deliver high-quality care or relate to long term goals for health care quality. CQMs measure many aspects of patient care including: health outcomes, clinical processes, patient safety, efficient use of healthcare resources, care coordination, patient engagements, population and public health, and clinical guidelines.“

The Centers for Medicare and Medicaid Services

Artificial Intelligence and Patient Engagement

"A recent article in The Commonwealth Fund blog, 'Envisioning a Digital Health Advisor,' raises the question of being able to use smartphone apps to get real-time, accurate and personalized guidance for health concerns. While one can envision the convenience, affordability and peace of mind that would result from their use, such services face a number of hurdles before they become reality. As a result, the 'digital revolution' has not yet greatly affected most people’s interactions with the health care system.

These challenges fall into two main categories: fiscal/policy and technology....

"A new generation of apps can be built to make these AI-derived recommendations useful. They need to be easy-to-use, consumer-grade apps that can connect to the aggregated data store and the AI analytics engines that sit on top of that. They can empower consumers / patients, and reduce the demand burden on clinicians. Will they replace clinicians? No, of course not. But they will help filter the demand to those who truly need to be seen, while empowering patients with real-time, believable and personalized guidance for the more common things in day-to-day life."

Rowley R. "How can Artificial Intelligence in healthcare help patient engagement?" June 22, 2016

Clearly, the buzz words in these attempts to 'translate, and communicate' are interoperability, transparency and monitoring care over time.

To put this 'SHARED DECISION MAKING' information into perspective, see the Agency for Healthcare Research and Quality (AHRQ)'s "Patient-Centered Outcomes Research and the Use of Decision Aids to Facilitate Shared Decision Making" and "Empathy: The Human Connection to Patient Care." [pdf]



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