It was fascinating to read through the article published by national quality leaders yesterday (July 30) in the Health Affairs Blog entitled “High-Value Care Every Time: Recommendations From The National Quality Task Force,” written by Shantanu Agrawal, M.D, MPhil, president and CEO of the National Quality Forum; Ayesha D’Avena, vice president, strategic planning, at the NQF; and Kenneth W. Kizer, M.D., M.P.H., director of the Institute for Population Health Improvement at UC Davis Health. The Washington, D.C.-based National Quality Forum (NQF), describes itself as “a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare.” Not only did the three healthcare leaders lay out a vision of what quality means in healthcare going forward; they spent a considerable amount of virtual ink on issues around data optimization and achieving interoperability. It was exactly the kind of perspective article that healthcare IT leaders and healthcare leaders in general needed to read right now, as we struggle through the COVID-19 pandemic and attempt to craft a vision of the U.S. healthcare delivery system in the next few years.
“Despite significant policy efforts and investments in the past two decades, notable shortcomings in the health care system persist,” the authors wrote. “Health equity concerns continue to grow, and care is increasingly fragmented and insufficiently person-centered. Although notable progress has been made towards ensuring patients receive high-quality, cost-effective care, this goal remains illusory for too many, and the most feasible strategy to achieve it remains unclear.”
In that regard, they wrote, “To address these concerns, the National Quality Forum (NQF) launched the National Quality Task Force (the ‘Task Force’) in 2019. The Task Force sought to address systemic limitations and define actionable opportunities to improve delivery system alignment, so that every person in every community consistently receives high-value care by 2030. Through a process that engaged diverse leaders, subject matter experts, innovators, consumers, and patients, the Task Force reflected on challenges that have emerged since the Institute of Medicine (IOM) published its landmark report Crossing the Quality Chasm in 2001. The Task Force’s report, The Care We Need: Driving Better Health Outcomes for People and Communities, affirmed two key points.”
The authors framed two core issues: first, healthcare system leaders continue to struggle with the same fundamental landscape that existed with Crossing the Quality Chasm was published in 1998—well over two decades ago now. And second they emphasized that healthcare leaders need to more actively work to learn from the leaders of other industries, who have made use of formal quality improvement methodologies including the Toyota Production System, Lean, and High Reliability, to reshape U.S. healthcare delivery.
Importantly, the authors focused on a list of “accelerators” that could help the industry move forward, including “ensur[ing] advanced technologies improve safe and appropriate outcomes through the use of technology evaluation framework; expand[ing] use of high-value care settings by integrating virtual and innovative care modalities throughout the delivery system; improv[ing] access to optimal care anywhere by creating pathways to recognize clinical licenses across the country; accelerat[ing] adoption of leading practices by highlighting exemplar performers; [and] cultivat[ing] a culturally aligned, value-driven workforce by fostering competencies in safe, appropriate, person-centered care.”
There is so much around healthcare data and information technology implicated in those “accelerators,” but the authors went far further, noting that one of the core differences between healthcare and other mature industries is the lack of standardized reporting of financial and clinical data in healthcare, in contrast to in other industries.
Terminology is at the core of this issue. “By comparison,” they note, “in the health care sector, multiple definitions may exist for critical terms and measures, undermining peer-comparisons and data analyses. Furthermore, the relevant data may not be readily available. An organization’s accounting system is the hub of financial data, but a unified repository with complete patient data does not exist for health care; data is typically captured in discrete environments with limited interoperability. Electronic Health Records (EHR) are increasingly viewed as the hub of health care data; however, they face challenges in unifying patient data across an increasing number of sources. The lack of standardized data in health care undermines the free flow of data into, out of, and among silos,” the authors emphasize. “This challenge becomes more acute as the number of relevant data sources grows (e.g., condition-specific registries) and as new partners enter the ecosystem (e.g. Community Benefit Organizations that are capturing critical information related to social determinants of health).”
The need for “standardized, reliable, valid data to address challenges and capitalize on opportunities,” is at the core of our challenges when it comes to leveraging data to transform healthcare, these quality leaders have concluded. What’s fascinating is how far we’ve come, and yet how far we lag behind where we need to go, when it comes to these data-related challenges.
On the one hand, Crossing the Quality Chasm: A New Health System for the 21st Century, published in July 2001 and authored by the Committee on Quality of Health Care in America at the Institute of Medicine, did include one chapter, “Using Information Technology,” as the seventh of its nine chapters. And the authors of Crossing included a section of that chapter entitled, “Need for a National Health Information Infrastructure.” But, given that the book was written during 2000, they noted that, “Nonetheless, IT has barely touched patient care. The vast majority of clinical information is still stored in paper form. Only a fraction of clinicians offer e-mail as a communication option to patients.” And, as we all know, in 2000, only a tiny percentage of hospitals and medical groups had fully operating electronic health records (EHRs); that revolution came only with the passage of the HITECH Act (Health Information Technology for Economic and Clinical Health Act) as part of the ARRA (American Recovery and Reinvestment Act of 2009). The meaningful use process that evolved forward out of the HITECH Act put in place the clinical information infrastructure that makes 2020 totally different from 2001.
On the other hand, even with the universalization of EHRs in patient care settings, the strategic organization of data remains lacking on the delivery side in healthcare, and lags far behind the level of data organization among health plans. As the quality leaders note in their Health Affairs Blog article, “[S]olving interoperability problems has been slow. Similar to accounting systems, EHRs may not be suitable for maintaining all data necessary to support both internally focused quality improvement priorities and externally focused, consumer-driven quality analysis.”
So, on a very fundamental level, we in healthcare have reached another moment of truth and reckoning, this time, around the need to turbocharge efforts to truly empower quality and clinical transformation in healthcare through the strategic use of data. This time, the challenges are more nuanced and complex than they were two decades ago when the core EHR infrastructure had not even been developed. The “target” this time around is far more complex and multi-layered; it involves the marshaling of “troops”—human and information system—to systematize the masses of data that are everywhere in U.S. healthcare. Not only is the data not in standardized form, as they quality leaders note; there is another whole layer involving what people are doing with the data. Is it sitting quietly in databases, unused? Is it being used, but only haphazardly? Or is it being used across entire individual health systems, and beyond?
In addition to the universal existence and deployment of EHRs, today’s healthcare leaders have one additional advantage compared to 2001, and it is strategic rather than technological: the policy and payment direction of U.S. healthcare is absolutely clear now, in a way that it wasn’t, two decades ago. With the Medicare actuaries warning that in the next several years, total annual U.S. healthcare expenditures will soar to around $6 trillion, and at least 20 percent gross domestic product (GDP), the burning platform for change on the policy level is leading to an all-out push for healthcare delivery transformation on the clinical and operational levels.
All of what is happening now is part of a larger landscape that involves the discourse around what “quality” and “value” mean. As the classic saying about art—which applies equally well to value—goes, “I’ll know it when I see it.” Well, the purchasers and payers of healthcare are sharpening their vision of what value means; and a core component will be their perceptions of what quality means.
One can only hope that these National Quality Forum/National Quality Task Force leaders and their colleagues in the leadership of the quality movement in healthcare, will be widely listened to by individual patient care organization leaders, as those leaders move to reshape their patient care organizations to deliver on the quality/value promise in the coming months and years. The COVID-19 pandemic has actually opened up a very interesting and worthwhile dialogue on what kinds of care should be delivered, and when and how. And this new report will provide yet another touchstone for patient care organization leaders going forward. Good thing, too, as clarity on this journey will be of absolute importance in the future.
