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JAMA Commentary Highlights How to Improve US Healthcare

February 2009


J AMA Commentary Highlights How to Improve US Healthcare

February 20, 2009 — Medscape Medical News 2009. © 2009 Medscape
Laurie Barclay, MD
February 20, 2009 — Methods to improve and transform the way US healthcare is provided by front-line clinicians are highlighted in a commentary published in the February 18 issue of JAMA. Recommended strategies include quality measurement, health information technology (HIT), comparative effectiveness of devices and medication, quality improvement collaboratives, learning networks, and clinician training.
"We originally started to write this commentary because we felt that clinicians are increasingly disengaged from the quality enterprise and [are] often critical of quality measurement," lead author Patrick Conway, MD, MSc, assistant professor at Cincinnati Children's Hospital in Ohio, told Medscape Medical News. "However, we, as clinicians, no longer can criticize from the outside. Clinicians have to engage the quality enterprise, work collaboratively on measurement, and be willing to be transparent about results and improve those results over time — this is essential for our healthcare system to transform its level of performance."
The most important measures that should be implemented to improve US healthcare, according to Dr. Conway, are risk-adjusted outcome measures, measures that encompass episodes of care and focus on care coordination, and efficiency measures.
Complex Solutions Needed
"The causes of good or poor health are many: our healthcare nonsystem is complex, our society's health outcomes are poor, and our cost is high," Charles Homer, MD, MPH, chief executive officer of the National Initiative for Children's Healthcare Quality, told Medscape Medical News when asked for independent comment. "The solution to these problems is not unitary or simple. These are my bedrock assumptions."
Dr. Homer, who is also an associate clinical professor at Harvard Medical School and Harvard School of Public Health in Boston, Massachusetts, said that universal healthcare insurance coverage should be a core assumption underlying health system improvement and specific measures that should be implemented to improve US healthcare.
"Our nation would be well served by a primary focus on improving health and healthcare of women and children," Dr. Homer said. "This investment would be an economic and a health stimulus, amplified many times over by improving family health, economic growth, and establishing health behaviors with long-lasting implications. We need redesign in both our payment systems and our delivery systems that puts a focus on improving population health outcomes as well as improving individual clinical care (as reflected by traditional metrics of quality).
"Redesign [in payment and delivery systems] will also be enhanced through transparency about results on key measures of care; even if such metrics are rarely used by consumers to choose sites or systems of care, their presence prompts improvement and change," Dr. Homer explained. "We should substantially increase our investment in community-based prevention, such as through broad use of health impact assessments [and] incentives for greater availability of healthy foods, tobacco taxes, public transportation, and safe parks. Public health and personal health services should be more closely linked."
The authors of the commentary note that the effectiveness of pay for performance and public reporting to improve healthcare is controversial and may have adverse consequences. They add that efforts at transparency are seldom useful for patients selecting a specific clinician or treatment option. While the Agency for Healthcare Research and Quality must play an important role in developing the science of measurement, continuing research on quality improvement and disseminating information concerning how to transform healthcare, leadership, and teamwork are needed from all clinicians.
Areas for Improvement
Specific areas highlighted in the commentary are:
  • Quality measurement and payment: Quality measures should increasingly reflect patient-centered outcomes, with appropriate risk adjustment that is improved over time. A national body should develop a strategy, set goals, and address critical gaps in measurement, including efficiency, risk-adjusted outcome measures for many diseases, and measures for episodes of care.
  • HIT: Data collection at the front end of care delivery, as well as use of the electronic health record (EHR), should facilitate performance measurement, quality improvement, care coordination, patient empowerment, and communication.
  • Comparative effectiveness: Information on comparative efficacy and safety of various treatment options must be widely available, and evaluation of these parameters should continue once US Food and Drug Administration approval is obtained.
  • Quality improvement collaboratives and learning networks: Led by clinicians and other stakeholders, networks of practices and hospitals should test, implement, and disseminate interventions to improve quality and efficiency. There should be a payment system rewarding networks of providers for achieved results.
  • Clinician training: In addition to mastering detailed knowledge, clinicians should be taught how to measure outcomes, focus on improvement, and incorporate evidence into their practice.
Barriers to Implementation
"The major barrier [to implementing these measures] is data collection, especially data collection in a manner that aligns with clinician-patient workflow and can feed back information to clinicians and patients to improve care, such as real-time decision support," Dr. Conway said. "Alignment of the measurement enterprise with EHR vendors, especially given the investment in HIT in the stimulus package, could incentivize certified EHRs that collect the information needed for quality measure reporting as part of clinical care. The clinical content of EHRs also allows for more sophisticated risk adjustment, which will be needed for outcome measures."
Dr. Homer pointed out that barriers to implementing these measures are substantial, including primarily inertia and the vast scope of the US health system. However, he believes that these barriers can be overcome by political will and national leadership, as well as by a commitment to continuously improve whatever system is developed.
Dr. Conway said, "If [these] types of measures were implemented, it would enable providers to measure their results and improve care. In addition, if some of the measures were publicly reported, this would help patients make more informed decisions about where they seek care," he added. "Overall, I think the opportunity to improve performance represents greater than 100,000 American lives per year."
To improve outcomes for relatively rare conditions, such as many cancers and many conditions affecting children, Dr. Homer recommended that transparent national registry systems be developed and linked to systematic improvement programs.
"Maintaining a focus on women and children and rebalancing our health investment with proportionately greater resources in community prevention and greater emphasis on redesigned primary care should, over time, have a significant impact on the health of Americans," Dr. Homer concluded. "Engaging patients and families in the process of change is a highly effective strategy in enhancing system performance. In some areas, such as child health, extending beyond the healthcare system to include education, foster care, and other community resources is critical to improving outcomes."
A commentary coauthor is Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality, an agency of the US Department of Health and Human Services (HHS). Dr. Conway is currently on leave from Cincinnati Children's Hospital Medical Center for 1 year as chief medical officer at HHS. Dr. Homer has disclosed no relevant financial relationships.
JAMA. 2009;301:763–765.
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