Developing Quality Measures for Longitudinal Care

By Terrence A. O’Malley, MD, and John F. Derr, R.Ph

Editor’s note: This is the first in a series of three articles reviewing the current and desired state of longitudinal care, as well as the steps healthcare stakeholders need to take to embrace this emerging quality measurement process.

The confluence of social media, electronic health information exchange, and growing awareness of the importance of coordinated longitudinal care has brought together the essential components for creating a new patient-centric quality measurement process.

This article series will review where the healthcare industry is now, where it needs to go, and the first steps to get quality measures for longitudinal care embedded in electronic health information exchange.

As the first installment of the series, this article discusses current “site-specific” quality measures, which provide detailed snapshots of care within a provider entity. Providers should re-aggregate this quality measure data to measure the care that each patient receives. Doing so would help answer a patient’s most important question, “Did I receive everything I needed to achieve the best outcome possible?”

Newer care models and changing reimbursement incentives highlight the importance of managing the care of individuals with complex health issues across multiple sites and across entire episodes of care. This type of patient management is called longitudinal care because it extends across multiple sites and for the entire duration of an episode of care, in contrast to management within one site of care.

As the healthcare industry moves toward an integrated, dynamic, electronic, person-centric health record, healthcare quality measures and processes will evolve to better leverage electronic health information exchange (HIE) and reflect the new requirements of longitudinally integrated care across multiple sites and providers.

The following discusses a model for quality measurement that supports these new care paradigms and that focuses on the experience of the individual patient, rather than the experience of a population of patients.

Today’s Quality Measurement Details

Many of the current quality measures focus on attributes of the intervention (effectiveness) and attributes of the system of care, such as the ability to identity individuals for whom the intervention is appropriate (appropriateness), how reliably the intervention is applied (reliability), and how consistently the intervention is provided (consistency). These are all critical components of quality measurement. Ideally, only effective interventions are proposed, all appropriate patients are identified, and the interventions are provided reliably in a manner that is consistent with the standard of care.

Typically, these quality metrics are reported as a percentage of patients who receive an intervention and for whom the intervention is appropriate (i.e., patients with atrial fibrillation on anticoagulation), who receive the intervention according to the standard of care (i.e., warfarin managed per protocols), or who achieve a desired outcome (i.e., percentage of patients on warfarin with INR time in therapeutic range >70 percent). Variations on these measurements are important and have led to significant improvements in quality and safety.

These measures are highly effective as part of site-specific quality programs. The measure denominator includes all patients for whom the intervention is appropriate. The measure numerator consists of those patients who received the intervention completely, in a timely manner, and without complications.

This approach has enabled entities to focus on internal process improvement that has led to higher percentages of patients receiving appropriate interventions more reliably and consistently. Performance is reported through the trending of result percentages over time.

Most of these measures were developed for, and apply to, short-term acute care hospitals, ambulatory care practices, and a smaller number of long-term acute care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities.

Limitations of Today’s Metrics

In today’s view, the responsibility for quality care rests with the individual and the entity that is currently providing that care. This view applies across different disciplines and within different sites and helps ensure each individual provider and entity correctly delivers care.

Currently available quality metrics are largely focused on clinical appropriateness within entities such as short-term acute care hospitals, skilled nursing facilities, home health agencies, and patient-centered medical homes. Each has its own set of quality metrics, with many dictated by the Centers for Medicare and Medicaid Services.

This “entity-specific” approach has resulted in significant improvements in quality and safety within facilities. One limitation of these metrics is that they are site specific and do not apply to some high volume sites of care-notably, assisted living facilities.

Because the focus of these quality measurements has been so site-specific, there has been limited interest in developing common metrics that can be shared across different sites of care, even when those sites treat patients with similar conditions. As a result, healthcare providers are unable to compare outcomes across different sites of care-a significant impediment to comparative outcomes research, as well as longitudinal management of care.

Despite these limitations, this focused approach will continue as an essential part of quality measurement. In addressing effectiveness, appropriateness, reliability, and consistency, site-specific quality measures provide a sharp picture of each encounter. The most significant limitation of this approach, however, is that it is too restricted and unable to address what patients want. This is a gap that longitudinal measures can help fill.

Building Tomorrow’s Quality Framework

Patients look at care differently than providers. Patients see in terms of “my total care” rather than as a series of separate encounters. Care is organized around one or more health concerns that lead to physician interventions. The point of treatment is to meet specific goals of care. The episode may extend across multiple sites with multiple providers, but for patients it has a start, middle, and end and is directed towards specific goals.

For example, joint replacement is a single episode that might start with a patient getting treatment at an ambulatory care practice, then moving to a hospital for surgery, then moving to a long-term post-acute care facility for rehabilitation before finally moving home.

Total care can be as short as a visit to the doctor’s office or can unfold over years of preventive care treatment, wellness interventions, and chronic disease management. This longitudinal outlook needs to be adapted by providers so that the patient’s care is viewed as a whole rather than as a series of symptoms or one-off issues.

There are two outcomes that the patient wants to measure that are not addressed within our current quality measurement processes. The first is whether his or her goals have been met. The second is whether all components of care that were essential to achieve an optimum outcome were delivered. The combination of site-specific measurements with patient-centric outcomes provides a platform for longitudinal care quality measurement.

If an episode of care is made up of a series of sequential steps contributed by different providers, then as a whole the involved providers must give a patient all essential elements of care, with each individual provider reliably and completely delivering his or her contribution to the overall care of the patient. Our current quality metrics measure the quality at each point in this series of steps and not across the total episode.

To assess quality longitudinally across the entire episode of care requires four other components that are not currently part of quality measurement:

• A checklist or “bundle” containing the elements that are essential for an optimum episode of care outcome
• Metrics for safe and efficient transitions of care between provider sites
• Presence of an exchangeable plan of care that is consistent with the individual’s goals and wishes
• Acknowledgement by the individual that the essential elements were provided in an appropriate manner

The second installment in this article series will provide examples from the long-term and post-acute care industry to describe a process for measuring longitudinal care quality across a well-defined, multi-provider network. The third and final installment will discuss the next steps for achieving the vision of patient-centric longitudinal care quality measurements.

Acknowledgement

The authors wish to acknowledge the contributions of the Longitudinal Coordination of Care Work Group, Transitions of Care, ONC Standards and Interoperability Framework, whose work is reflected in this article series.

Learn more on the S&I Framework Longitudinal Coordination of Care Web page, http://wiki.siframework.org/Longitudinal+Coordination+of+Care+WG. The web site features information on the group’s processes and guidelines, an FAQ list, and information on how to volunteer.

John F. Derr (john.derr@goldenliving.com) is a strategic clinical technology consultant with Golden Living, LLC. Terrence A. O’Malley (tomalley@partners.org) is medical director, non-acute care services at Partners HealthCare System, based in Boston, MA.