60 percent of the physician measures used in Medicare’s PQRS program came from PCPI recommendations. While PCPI generally leads the development of physician quality reporting measures, in- dividual medical specialty societies, the National Committee for Quality Assur- ance, and state-based quality improve- ment organizations also contribute. Once at NQF, the Measures Applica-
tion Partnership (MAP), where Dr. Wal- ters serves, again sifts through the data and “spends a great deal of time look- ing at measures to see if they are doing what they are supposed to do. We have to make sure the measures are in accor- dance with the priorities in the National Quality Strategy. Are they relevant? And how are we going to know we are get- ting better?”
The National Quality Strategy in- cludes six priority areas for measure- ment and improvement: patient safety, patient engagement, effective communi- cation and care coordination, prevention and treatment practices for the leading causes of mortality, community involve- ment, and care affordability. Read more at
www.qualityforum.org/Setting_Pri orities/NPP/Input_into_the_National_
Quality_Strategy.aspx. The rigorous process does not stop
there. Even after endorsement, MAP continues to evaluate whether physi- cians use a measure, if it provides value, and if it needs revision. Last December, the committee revised 550 measures. Dr. Morrow acknowledges criticisms that most quality measures so far tend
to focus on care processes rather than care outcomes, for example, whether a physician gave a beta blocker to a pa- tient with heart disease or whether the doctor counseled a patient who smokes on cessation versus whether their condi- tion improved.
While the next generation of quality
measures moves in the direction of out- comes tracking, they always will reflect a combination of both elements, he says. That’s because outcomes are difficult to measure, often because of the time it takes to reach that point and the lack of data due to that lag. Process measures, on the other hand, are more attributable to certain parts of the care cycle, and data systems are better equipped to cap- ture that information. At the same time, the outcome does not always reflect the quality of the ac- tual care, Dr. Morrow added. “You’ve no doubt heard the phrase: ‘The opera- tion was a success but the patient died.’ Sometimes people get very good care and have what we all agree is a poor outcome. By the same token, you can have poor care, but a good outcome. We are people, after all.”
The next frontier For those reasons, NQF aims for some flexibility, Dr. Walters says. For example, the forum may offer measures for a particular part of care delivery — like a bundle of surgical care improvement measures — and physicians or other health care entities can adopt different combinations to fit their needs.
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“Just because we can’t measure long- term outcomes doesn’t mean we should give up on measuring short-term pro- cess measures because some of those we know are correlated with long-term out- comes,” he said.
A patient with chest pain is more
likely to die if he or she does not get as- pirin within an hour. If a surgeon does not clean the surgical area, the patient is more likely to get an infection and stay in the hospital longer. “Obviously if you don’t do something that leads to higher mortality, then the long-term outcome is going to be bad. So what we try to do in the measure world is find examples like that where the train and the linkage of the process- es to outcomes is pretty nondebatable,” Dr. Walters said.
Other goals for quality measure de- velopment include efforts to link them across the continuum of care and allow for patient satisfaction input. So-called “efficiency” measures are also on the horizon, Dr. Salman says. Translation: costs in relation to quality — measures the federal health reform legislation specifically calls for. While not the most important out- come, cost is a factor in delivering the best care possible, Dr. Salman says. It’s also a big reason why everyone,
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from physicians to hospitals to payers, has taken a bigger interest in incorpo- rating quality measurement into a vari- ety of payment- and performance-based programs. Dr. Salman’s practice alone is en- gaged in half-a-dozen quality incentive initiatives: PQRS, meaningful use of electronic health records, internal clini- cal quality programs, a disease manage- ment registry, and a health plan-spon- sored Bridges to Excellence program. A majority of the measures used in
those programs track NQF standards and overlap across initiatives. Ideally, all players would follow NQF
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standards, Dr. Salman says. “That would be in the best interest of patients, if they were to ask, and it makes us [physicians] more efficient, which is the goal.” The reality is that’s not always the
case. While NQF directly forms CMS mea- 62 TEXAS MEDICINE April 2013
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