By Margaret E. O'Kane, MHA

The premise of a value-based healthcare system is simple: Get people healthy and keep them that way. Unfortunately, ample documentation of the shortcomings in healthcare quality in this regard exists.

An oft-cited RAND Corporation study estimates that Americans receive evidence-based care only about half the time. The National Committee for Quality Assurance (NCQA) estimates that between 40,000 and 80,000 Americans die every year due to "quality gaps" in the system. According to the Institute of Medicine, 98,000 Americans die every year owing solely to medical errors, and the CDC estimates that more than 2 million avoidable infections are acquired in hospitals each year.

These gaps in care are set against a backdrop of double-digit premium increases over the past four years, placing pressure on purchasers to defend their balance sheets by selecting plans strictly on the basis of cost, rather than purchasing for value by weighing both cost and quality when making a purchasing decision.

Although pressure from employers to improve quality may have abated slightly in recent years in favor of cost concerns, the healthcare system must be held to a higher standard of accountability. Americans demand accountability from car manufacturers for safety and efficiency and from schools for their children's education. And since healthcare is the most personal of all products put forth in the American marketplace, it makes sense that the public raise the bar for healthcare accountability, too.

NCQA's work to bring accountability to health plans has resulted in improvements at several levels of the health system. Its public reporting of HEDIS results has led to consistent gains in clinical quality among those plans that publicly report their results. Voluntary physician recognition programs have made significant inroads toward measuring quality at the physician and practice levels. Quality gains among accountable plans, as detailed in NCQA's State of Health Care Quality report, as well as the improvements in diabetes and heart/stroke care documented by recognized physicians, represent thousands of lives saved.

NCQA has also helped drive the development of disease management programs and led to greater interest in health outcomes at the population level. The public reporting of HEDIS results has also led to health plans developing systematic approaches to quality reporting and improvement among their participating physicians.

Yet a clear need remains for a more fully fleshed-out accountability framework at all levels of the healthcare system:

• Health plans should more fully commit to measuring and reporting on quality at the plan level.
  
  
• Physicians should actively engage in the process of quality measurement and support systematic delivery of care through use of electronic systems.
  
  
• Patients should be realistic about their role in maintaining their own health, as well as informed about the capabilities and limitations of the system.
  
  
• Payers should increase their support for quality improvement efforts at all levels of the system — especially adoption of IT at the physician or practice level.

The Importance of Information Technology (IT)
The widespread adoption of healthcare information technology is a key component of quality improvement. Hence, it is imperative that that stakeholders across the healthcare system create an environment that fosters and rewards investment in information technology — through creating broad-based support for evidence-based medicine, facilitation of greater IT adoption, and alignment of payment incentives with quality improvement and IT adoption goals.

Consider the following:

• 85% of physicians can't generate registry lists by test results or current medications.
  
  
• 33% of physicians repeat tests because results are unavailable.
  
  
• 15% of observed abnormal test results receive no follow-up.
  
  
• Only 18% of physicians have data on patients' outcomes.

The above demonstrated the need for better-organized health information — information that has the potential to profoundly impact the doctor-patient relationship. Better access to information allows physicians to take a more holistic view of the patient, gives patients the opportunity to take a more active role in their own care by providing ready access to information about their own health, and — above all — helps facilitate an ongoing healing relationship between a doctor and her patient rather than an episodic visit-based model. Ongoing relationships help close gaps in care and lead to better outcomes.

A systematic approach to patient care can also reduce errors in care. Automated reminders to physicians can reduce prescribing errors by flagging contraindications; patient self-management support leads to better outcomes for those with chronic conditions; systematic measurement and feedback to physicians improves the quality of care across a variety of conditions.

Promoting Systematic Care: Physician Practice Connections
NCQA's Physician Practice Connections (PPC) is a program that spotlights those physician practices that use systematic processes and adopt information technology to enhance patient care. The program measures such functions as whether physicians track and manage test results, whether they use electronic systems to enter pharmacy and lab orders, the extent to which they measure their results across their entire practice and whether they use the results as a tool for quality improvement, and the extent to which they provide their patients self-management support tools.

PPC's program standards allow for a phased approach to information technology adoption:

• Basic standards address the use of evidence-based standards of care, maintenance of patient registries, and provision of educational resources to patients.
  
  
• Intermediate standards assess the use of electronic systems to maintain patient records, provide decision support, enter orders for prescriptions and tests, and patient reminders.
  
  
• Advanced standards ask whether practices have implemented electronic systems that interconnect and are "interoperable."

Over the past year, PPC-Recognized practices have sounded a common refrain in their assessment of the program: measurement provides physicians with a new perspective on their practice. Further, the process of measurement provides practices with the roadmap — and the incentive — to change their processes of care in order to meet the standards. And, interestingly, small practices perform as well as large practices against the PPC standards: the typical PPC-Recognized practice has four doctors.

Looking to the Future
A healthcare information technology strategy is central to the next leap forward in quality improvement. Experience has shown that measurement is key to such improvements — and that any future accountability model must strongly emphasize quality and efficiency.

While advances in health information technology — such as electronic health records and computerized physician order entry — hold great promise to bring greater consistency to health documentation, only by treating advances in IT as opportunities for quality improvement — as do the Physician Practice Connections standards — will the vast promise of technological advances be tapped.