September 15, 2015

Measuring what matters: U.S. health care's vital signs



Blood pressure, pulse, and temperature measure a body's functions. Dr. Eric Larson writes about how to measure the functions of the U.S. health care system.

by Eric B. Larson, MD, MPH

Vital signs like heart and respiratory rate are standard measures of a patient's general status. We have ways to monitor the overall status of health care, too, like counting how many people have a disease or how much the average person spends on care. Unfortunately, though, many of these measures are not nationally standardized so they are inconsistent and difficult to compare. They are also becoming so numerous that they burden the health care systems that must report them. The problem and the beginning of a solution are described in a recent commentary by Drs. David Blumenthal and J. Michael McGinnis, in JAMA.

The reason behind the proliferation of health performance metrics is understandable, Drs. Blumenthal and McGinnis explain: As we work to improve U.S. health care, we need to objectively measure which efforts yield the greatest payoff. Since we don't have nationally agreed-upon health care metrics, though, improvement initiatives generate their own measures, leading to duplications and other inefficiencies. This problem could get worse, with the recent passage of a new law (HR 2: Medicare Access and CHIP Reauthorization ACT of 2015) with a good intention: to pay clinicians and other providers of care based on the value rather than the volume of services provided. But the absolute number of services like x-rays, lab tests, and surgeries is easy to count. Measuring value is harder. That’s why the law, known as Doc Fix, might add to the many measures that physicians and health care systems already track.

The system fix: health care vital signs

In a timely move, the Institute of Medicine (IOM) just released a long-awaited reportVital Signs: Core Metrics for Health and Health Care Progress. The report says that, with our fragmented care system, we don't even know how many measures are being used to monitor community and personal health, assess care quality and patient experience, and report health care benchmarks. The report cites numbers like nearly 1,700 measures used by Medicare and Medicaid programs, a National Quality Forum database of 630 measures, and the 81 HEDIS (Healthcare Effectiveness Data and Information Set) measures used by more than 90 percent of health plans.

The IOM report proposes a core set of 15 health metric areas, or "vital signs" of our health and health care: Life expectancy, well-being, overweight and obesity, addictive behavior, unintended pregnancy, healthy communities, preventive services, care access, patient safety, evidence-based care, care match with patient goals, personal spending burden, population spending burden, individual engagement, and community engagement. Within these 15 core areas, the IOM report names more specific, representative “related priority measures," such as shared decision making as a measure of care matched with patient goals.

Drs. Blumenthal and McGinnis write that our nation is at a turning point, with increasing agreement that ever more resources cannot be committed to health care. Valid, widely accepted measures for improvement will be at the heart of using health resources more efficiently and effectively. The proposed IOM measures reflect our shared goals and are an excellent start, although it remains to be seen if they become our country’s standard and are used in many diverse settings.

I agree with Drs. Blumenthal and McGinnis when they conclude that “Vital Signs has the potential to turn the aspiration for better health and health care into reality.” The ideal situation would be a core set of common health metrics supplemented by local measures reflecting the unique needs of communities and individual organizations. To achieve this goal, we need consensus-based, national health care metrics like the set proposed by the IOM, plus the local engagement that comes when people at the sharp edge of health care determine what matters to their community and understand the need to measure what matters.