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Fridays with Ambulatory Care: No Outcome, No Income!

By Mary Ann Kliethermes posted 08-02-2013 12:31


I was at a meeting several years ago that was rather small and interdisciplinary.  The group was discussing the challenges of our health care system, i.e. coordination and transitions of care, frequent health care related adverse events, etc.  At the end of the meeting one of the organizers, a physician working in public health, stated it was clear to him that in the future if there is no outcome, there will be no income.    It is one of those statements that continue to resonate with me as we move forward with pharmacy services in my clinical practice space, in our community and nationally.

It seems almost anything related to health care I pick up these days has something written on patient outcomes, quality measurement and pay for performance incentives.   I believe most health care providers are hearing this loud and clear, including pharmacists  Despite the vast amount written in the area there is no universal agreement on optimal practice measurement processes, which measures are best performers, or are our current measure sets truly yielding best outcomes and/or processes and producing the improvements we desire.    A reflection of how the science of this field is still in its infancy.   Some measures certainly are showing improvement in certain settings.

For practitioners embarking into the quality world the task is not easy.  There are nearly 8000 measures to choose from in the National Quality Measures Clearing House maintained by AHRQ.     There are numerous quality related measure organizations’ web sites to visit and documents to review.  Each of these organizations are either developing measures or measure concepts, using sets of measures for payment or accreditation or recommending or fettering the landscape for optimal measures including ASHP.  These include the following alphabet soup: NQF, NCQA, JC, PQA, PCPI, CMS, PQRS, Core measures, Star Measures, HEDIS, etc.   It begs the question: How does one choose the most appropriate measures?  

That is a tough question to answer as we need both local and global improvement.  No matter which measure or set of measures you choose, they must have three important characteristics for your practice and your organization. 

1.  Measures should be meaningful.  This means results of measurement should be telling you something important that you do not already have solid knowledge about in your practice.  You would want to measure something through observation you have identified as a trouble area that needs improvement, or at least know is problematic universally such as medication adherence or adverse drug events.  Do not loose site of the goal of measurement and that is to improve.  If you know that in your population most of your HgA1c’s are already under 8 do not measure that!

2. Measures should be feasible.  You have to ask yourself the following questions as you evaluate each measure you are thinking of using: Is the data readily available?, How disruptive will collecting the data be to your normal process of care?,  How timely will the analysis be? , What are the resources you will need, and do you have them?  Those measures that tend to yield positives answers to these questions should rise to the top.  A measure may be a great measure but if you are unable to perform what is needed to get the data, it is of no help.

3.  Measures should be actionable.  You must be able to act upon the results you get.  Make sure it is something that you can change.  If you need to go to through your reporting structure to make the change, make sure to get their buy in, so that they will facilitate and have the resources available for you to implement needed changes based on the results.

This and much more can be found in chapter 7 of our book.

Which measures you are using and why?    I am sure any sharing will help others.  I know there is much interest in CMS Star measures and the D5 measures for diabetes in many ambulatory settings.  If you have not seen a recent CMS report on quality improvement to Congress, it is worth a look as it provides some global areas in need of improvement that pharmacists certainly can impact. 

 In summary the thoughts to remember: 

“No outcome, no income”

“Measure only that which you can change and ultimately improve care of your patients”

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