On the heels of the anniversary of To Err Is Human, the NEJM published two Perspectives that call into question – rightfully so – how we measure quality in the U.S. and what to do next – The first Perspective, from Chris Cassel et al, left me wanting because of its litany of worn out platitudes about measure harmonization, the need for greater transparency, public-private sector coordination, etc…. We've heard it all before and it hasn't made much of a difference so far, perhaps because the measures that are being used and promoted today by the majority of the private and public sector have much to be desired. So much so that several recent papers have shown that very few, if any, help to differentiate provider performance. Fortunately, there seems to be a thoughtful answer, and that's what Beth McGlynn and her colleagues offer up in their Perspective. Most who read it will toss it aside as some pipe dream that is impractical and unreachable, but it is one of the first realistic answers to the dilemma that the IOM report placed in front of the entire industry…the lack of any meaningful and actionable feedback loop for most providers. Sets of disparate and disjointed (even if harmonized across payers) measures can never fit into the normal process flow of care management. What clinicians need is what Beth and her colleagues describe, an intelligent dashboard that will put the patient's problems in the context of the whole patient, and guide the clinician through the myriad and often conflicting evidence on what should be done to improve that patient's outcomes.
What this means to you – For years we've been talking (and just that) about patient-centeredness but no one has been very serious about it, certainly not in the measurement community and hardly in the payer's. The focus instead has been on specific targets which get to pieces of the problem, but never the whole patient. When we originally designed the PROMETHEUS Payment model, Beth, who was a member of the design team, kept pushing us to think about the patient as a whole, not the components of the patient. That philosophy guided us then and still does today, and it's that same philosophy that is certainly guiding her approach to reimagining quality measurement in this Perspective. The challenge with this approach that most payers and policy makers would be faced with is how to turn it into an assessment of overall quality of care. But there is an answer to that challenge as well. Consider that the purpose of the proposed clinician dashboard is to provide actionable feedback on how to reduce the number of "defects" as experienced by the patient – real negative outcomes, not simply the perceived ones. It so happens that work from Judy Hibbard and Shoshanna Sofaer has shown that consumers understand the concept of care defects quite well and would use it to gauge quality of physician care if they had it. So here you have it. Quality measurement can be designed in a way that creates very powerful and actionable feedback loops for providers and, from that, can be derived measures of defects – avoidable complications – that can be used as feedback loops for patients.