SIR FOUNDATION RESEARCH FORUM by Jeremy Collins, MD


federal “meaningful use” requirements, meaning that our electronic medical records can produce quality measures.


Beginning next year, the Centers for Medicare and Medicaid Services (CMS) will require reporting on electronic clinical quality measures (ECQMs) that are similarly derived from the electronic medical record. Under this program, providers must be able to show they can both produce the measure and achieve a degree of performance. Although private payers have developed their own versions of metrics, the domains are similar—both CMS and private payers are thinking about readmissions, length of stay, infections and mortality. I would anticipate in the years to come as the industry gets a little bit further advanced in measurement and as these ECQMs emerge they will probably cohere around a library of common measures.


COLLINS: What is the biggest barrier to improving health care quality? BARNARD: I would say accurate measurement is the first barrier. However, even when we can pinpoint a deficiency, aligning stakeholders and driving change using our rather rudimentary medical record systems and limited experience in process engineering are bigger barriers. Joint Commission President Mark Chassin has said that the single biggest problem in American health care is the lack of robust process improvement expertise. I think there’s great truth to that, although the lack of data really needs to be up there at the same level.


COLLINS: Is there a difference between quality and patient safety? BARNARD: They are certainly aligned and both are produced as the result of robust and reliable systems executed by competent people with adequate resources in a fair and just work


environment or culture. Quality means you deliver the right care every time and safety means freedom from accidental injury in the process of receiving care. However, there is a blurred boundary between them—for instance, if you don’t deliver the correct diagnosis, you are heading into a patient safety problem.


COLLINS: How can health care providers, payers, health care systems and hospitals best work together to improve health care quality? BARNARD: The ideal scenario would involve the development of grand common measures aimed at incentivizing the right behaviors without contributing to unintended consequences.


A good example of a measure leading to unintended consequences comes from an experiment almost 30 years ago in Rochester, New York, where a payer published cardiac surgery mortality and complication rates. The immediate fallout from that was that some cardiac surgeons refused to operate on high-risk patients— that’s an unintended consequence.


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transparency and accountability need to be properly risk-adjusted.


If we all could agree on well-designed measures that truly matter, then we could partner with our payers to roll them out across electronic health record vendors and regions. Some of this work is advancing thanks to a provision of the Affordable Care Act that requiring payers to devote at least 85 percent of their premium dollars on the delivery and improvement of health care. As a result, some payers began putting money aside to fund innovative work in health care improvement.


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COLLINS: Measurement is a necessary process in a quality program and payers are working to define the structure of value-based payment


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systems. However, physician compensation in the present environment is often more driven by measures of productivity rather than quality. Do you have any insight into how value-based compensation systems could best be structured to better align productivity with quality? BARNARD: I think that we need to focus more on the process: did the doctor do everything humanly possible and do it in a way that was, as objectively as we can measure, competent? If so, then we accept the fact that the patient may or may not comply and that such noncompliance could adversely impact metrics that are out of the practitioner’s control.


However, the current payment models that are value-based tend to reflect compensation for RVUs and quality. Typically, the argument you hear is, yeah, we know these aren’t very good measures, we know there could be a selection bias, we know we’re going to run the risk of possibly making a doctor


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