Question

Discuss how meaningful use criteria tie back to goals for the healthcare system, giving specific examples.

Answer 1

The healthcare industry is riddled with administrative and regulatory complexities that make it difficult for health systems to achieve the Triple–or better yet, the Quadruple–Aim of healthcare. The complexities found in outcomes improvement are particularly challenging, as health systems measure and report on hundreds of these outcomes annually. Health systems can manage these complexities by taking a closer look at outcome measures—understanding their definitions and nuances, reviewing real-world examples, and integrating three essentials for successful outcomes measurement.

Given the complicated nature of quality improvement and the numerous requirements for building and maintaining an effective, continuous quality improvement program with sustained outcomes, it’s no surprise health systems feel overwhelmed. Successfully sustaining quality improvement in healthcare is a tall order to fill—consider this partial list of success factors and requirements for effective quality improvement programs (explained later in this executive report):

• Adaptive leadership, culture, and governance
• Evidence- and consensus-based best practices
• Healthcare analytics
• Adoption
• Financial alignment
• Value-based systems of care
• Clearly defined goal and aims
• Defined measures and validated baselines
• Quality improvement teams, tools, and methodologies

The goal of measuring, reporting, and comparing healthcare outcomes is to achieve the Quadruple Aim of healthcare:

•     Improve the patient experience of care.
•     Improve the health of populations.
•     Reduce the per capita cost of healthcare.
•     Reduce clinician and staff burnout.

The organization behind the Triple Aim—the Institute for Healthcare Improvement (IHI)—is dedicated to outcomes improvement. IHI describes measurement as “a critical part of testing and implementing changes. Measures tell a team whether the changes they are making actually lead to improvement.” The fourth aim may vary depending on the organization.

Healthcare organizations–motivated by the Quadruple Aim–measure outcomes for several reasons:

•     Reveal areas in which interventions could improve care.
•     Identify variations of care.
•     Provide evidence about interventions that work best for certain types of patients under certain circumstances.
•     Compare the effectiveness of various treatments and procedures.

Fortunately, as healthcare organizations strive to improve care quality and affordability, they’re beginning to understand the quality improvement essentials—critical elements successful quality improvement programs have in common. This executive report defines quality improvement in healthcare, describes critical quality improvement considerations, components, and tools, and identifies the top five quality improvement essentials:

1. Adaptive leadership, culture, and governance
2. Analytics
3. Evidence- and consensus-based best practices
4. Adoption
5. Financial alignment

CDC’s definition focuses on activities that improve populationhealth, ensure healthcare’s affordability, and deliver the best patient experience. These three dimensions mirror The Institute for Healthcare Improvement (IHI) Triple Aim; the framework all quality improvement in healthcare ties back to:

1. Improve the health of populations.
2. Reduce the per capita cost of healthcare.
3. Improve the patient experience.

The Triple Aim is a framework for optimizing health system performance. And the primary goal of quality improvement is to improve outcomes. CDC also describes quality improvement as one component of the performance management system, which has three defining characteristics: It uses data for decisions to improve policies, programs, and outcomes. It manages change. And it creates a learning organization.

Healthcare professionals go into healthcare because we care about people; we truly want to improve patient health and experiences, and help make care affordable. So we need to constantly keep the end goal in mind: the Triple Aim. We need to make sure every quality improvement goal ties back to improving the health of populations, reducing the per capita cost of healthcare, and improving the patient experience. By focusing on collaboration, sustainability, and the Triple Aim, health systems will do more than provide better care—they will transform the industry into one unequivocally dedicated to quality.

Outcomes measurement should always tie back to the Quadruple Aim, so healthcare organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality and improving the care experience at the most efficient cost.

Health systems measure outcomes to ensure they are delivering the best care for patients and providing a transparent, efficient, and accessible environment for all healthcare providers. That is outcomes nirvana.

An overview of the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA, also known as the “economic stimulus bill”). The centerpiece of HITECH is a plan to vastly expand the adoption and “meaningful use” of electronic health records (EHRs), based on a growing body of research demonstrating that EHRs, especially when combined with clinical decision support (CDS), can improve the quality, safety, and coordination of healthcare. Similar to other areas related to technology and/or healthcare, the US has become a laggard in the adoption of EHRs, falling behind most other developed countries.

HITECH provides up to $27 billion for eligible professionals and hospitals to receive incentives for achieving the meaningful use of EHRs. Meaningful use is a critical concept. The goal of HITECH is not just to put computers into physician offices and on hospital wards, but rather to use them toward five goals for the US healthcare system: improve quality, safety and efficiency; engage patients in their care; increase coordination of care; improve the health status of the population; and ensure privacy and security. As such, every criterion in meaningful use (e.g., drug-drug interaction checking) must tie back to a healthcare goal (e.g., improve quality, safety and efficiency).

Government funds for HITECH incentives will be distributed through the public Medicare and Medicaid reimbursement systems. Depending on choice of funding through Medicare or Medicaid, eligible professionals can receive $44,000-$63,000, while eligible hospitals can receive $2-9 million between 2011 and 2018. The main purpose of these incentive funds is to cover the costs of investment in EHR systems. It is anticipated that further costs will become part of the "costs of doing business" for healthcare.

The HITECH legislation recognizes that incentives alone will not be enough to achieve all the goals of meaningful use. As such, HITECH allocates an additional $2 billion for various human and organizational infrastructure elements to attain its mandates. A critical portion of this infrastructure is the ability to achieve health information exchange (HIE), which is the secure flow of data to wherever it is needed for patient care, including across traditional business and other boundaries in the healthcare system. About $547 million is allocated to states for HIE development.

Another critical piece of the infrastructure is the provision of technical support to achieve meaningful use. This is done with the allocation of about $677 million to 62 regional extension centers that are providing a variety of forms of assistance, mainly to small primary care practices.

An additional portion of the required infrastructure is a competent professional workforce to develop, implement, and train users of EHR and related systems. It has been estimated that the HITECH agenda will require an additional 50,000 professionals trained in fields such as biomedical informatics and health information management. About $118 million has been allocated for both short-term training programs in community colleges as well as longer programs mostly at the graduate level in universities. My institution, Oregon Health & Science Univeristy, is playing a major role in this program.

The HITECH legislation also recognizes that additional research and development is required. As such, $60 million has been allocated to establish four collaborative research centers focusing on the topics of security and health information technology, patient-centered cognitive support, health care application and network design, and secondary use of EHR information. A related funding initiative is the Beacon Communities Program, which has funded about $250 million for 17 advanced demonstration projects “shine the light” forward.

Just as meaningful use connotes that EHR adoption is not just about installing computer technology in clinical settings, there are related initiatives in the United States that will synergize with the substantial HITECH investment. One initiative from the Institute of Medicine aims to develop the “learning health care system” that learns from the growing volume of captured data what does and does not work in healthcare. This is closely related to the growing push for “comparative effectiveness research” that aims to compare tests, treatments, and other medical activities in head-to-head studies carried out in real-world settings. This infrastructure will also likely contribute to the growing push for translational research, as exemplified by funding for the Clinical & Translational Science Award (CTSA) program of the National Institutes of Health.

Taken collectively, all these programs from HITECH to ACA, the learning healthcare system, and CTSA provide a vision of a new healthcare system that learns from its successes and changes based on its mistakes. This vision uses data as the critical enabler of coordinating, measuring, and researching care. HITECH is indeed a grand experiment, and it is likely be that some elements of this experiment will succeed whereas others fail. But in the end, the healthcare system should benefit this unprecedented investment in information systems, human capital, and goals for improving health.