In times of rapid change and constrained resources, progress depends on theability to focus attention on the outcomes that matter most. Progress in anyendeavor is a product of an understanding of the current state, the toolsavailable for addressing challenges, and the resolve to take the actionsrequired. Basic to each is the choice of measures—measures that give thebest sense of progress, measures that guide actions, and measures that can beused to gauge impact.
For Americans today, health care costs and expenditures are the highest in theworld, yet health outcomes and care quality are below average by many measures(OECD, 2013). If healthexpenditures are to be brought into alignment on behalf of better health andlower costs, keen attention and decisive actions will be required of allstakeholders—health professionals; payers; policy makers; and allindividuals as patients, family members, and citizens—on what mattersmost. That is the focus of this report. What matters most for health and healthcare? What are the vital signs for the course of health and well-being inAmerica?
Accurate information about health and health care enables success to beaccurately defined, and it draws attention to gaps and shortfalls in need ofattention. But the existence of too many measures can limit effectiveness. Nosingle, objective measure set exists for the state or the priorities of thenation's health and health care system. Rather, thousands of differentmeasures are used to assess intermediate aspects or qualities of the four keydomains of influence on health and well-being that helped frame thisstudy—healthy people, care quality, care costs, and people'sengagement in health and health care—from emergency room wait times, toblood pressure, to out-of-pocket costs, to life expectancy. Because standardizedaction-anchoring measures are relatively rare, the numerous measurements takenoften are overlapping or redundant. One result is a diffusion of focus.Moreover, as the number of available measures continues to grow withoutconcomitant gains in health outcomes, responsibilities for assessing, measuring,and reporting can become a burden in terms of cost, time, and efficiency, withmarginal benefit (Meltzer and Chung,2014). Identifying and prioritizing the most powerful of these myriadmeasures at each level of activity—establishing core measures—canenable the health system to work in a coordinated fashion toward a shared visionof America's health future. Box1-1 previews and summarizes some of the compelling issues that theInstitute of Medicine (IOM) Committee responsible for this report identified andsought to address in the course of its work.
BOX 1-1
Committee Framing Perspectives. Measurement aims. Measurement aims to convey opportunity andpriority, focus attention and activity, improve targeting and effectiveness,introduce accountability, identify what works, and help celebrate progressand motivate (more...)
The implementation of core measures will depend on a culture of sharedaccountability for health. Responsibility for improving the nation'shealth outcomes must be assumed by all members of the multisectoral healthsystem, defined broadly to include the full array of sectors andentities—from clinicians and hospitals to schools andfamilies—that influence the health of the population through theiractivities (IOM, 2012b). Bygarnering the attention of all stakeholders involved in the health system,measurement activities can be coordinated and redirected toward those outcomesthat are most meaningful to all.
MEASUREMENT IN HEALTH AND HEALTH CARE
The health and health care landscape in the United States is changingmarkedly for reasons that extend far beyond recent health care reformlegislation, including an aging population, new science and technology,personalized medicine, shifts in the roles and perspectives of patients andclinicians, new payment models, and unsustainable costs. As a result,initiatives are under way throughout the country to promote the health ofthe population, improve health care quality, reduce health care costs, andengage people and communities in their health and health care. Finding thebest ways to assess the results of these initiatives has become a majorfocus of tracking and improvement efforts, with payers collecting andanalyzing claims data, hospitals tracking care quality, patients monitoringtheir own health through mobile apps, and public health agencies recordingpopulation-wide trends.
The need for change is further motivated by inconsistencies in overall healthsystem performance. Multiple technological advances, including innovativeimaging and diagnostic tools, new interventions for chronic disease, and newpersonalized treatment plans, have emerged in the health system. Yet thesystem is also characterized by shortfalls with respect to what is possible.Americans' life expectancy and overall health tend to be poorer thanin peer countries; the quality and safety of health care vary significantlyacross communities, regions, and states; health care is guidedinsufficiently by available evidence; and increases in health care costsgenerally have outpaced the nation's economy (IOM, 2012a; McGlynn et al., 2003; NRC and IOM, 2013; OECD, 2013). The combination of these majorchallenges necessitates a new approach to monitoring progress andunderstanding whether reforms are leading to their expected results at thenational, state, regional, community, and organizational levels.
A dominant feature of the health system is its fragmentation, and thatfragmentation is reflected in the measures currently in use. Because of thegreat number and variety of organizations requiring information for claims,program performance, safety, and quality assurance purposes, the totalnumber of health and health care measures in use today is unknown.Nonetheless, reference points such as the Centers for Medicare &Medicaid Services (CMS) Measure Inventory, which catalogs the nearly 1,700measures in use by the U.S. Department of Health and Human Services (HHS),indicate that they number in the thousands (CMS, 2014). The National Quality Forum's(NQF's) measure database includes 620 measures with current NQFendorsem*nt. The National Committee for Quality Assurance's(NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS),used by more than 90 percent of health plans, comprises 81 differentmeasures. And in 2010, the Joint Commission required hospitals to providedata for measures selected from a set of 57 different inpatient measures, 31of which were publicly reported at the time (Chassin et al., 2010). The measurementinitiatives and reporting requirements included in Appendixes A and B, respectively, provide a sense of the range and diversity ofmeasures in use today.
While many of these measures are of high quality and provide valid and usefulinformation about health and health care, many examine only slightvariations of the same focus. Furthermore, although many of the measures inuse today are similar enough to serve the same purpose, they also differenough to prevent direct comparison among the various states, institutions,or individuals interested in the same focus. The causes and consequences ofthis variability are explored in Chapter 2.
Data Gathering Efforts
The current measurement enterprise is characterized by multipleinitiatives across the many dimensions of the health system, with littlealignment of measures or goals. Given the proliferation of measures inplay, a key challenge is harmonizing and aligning measurement programsto minimize redundancies and unnecessary customization (Hussey et al., 2009; IOM, 2006; NQF, 2013; Wold, 2008). The collectionand analysis of measures require significant effort, time, andresources; therefore, it is important to ensure that measurementproduces the maximum amount of information for the least amount ofinvestment in resources. Similarly, significant opportunity costs areentailed in devoting resources to inefficient, redundant, or poorlyspecified measurement activities, which can displace other valuableopportunities to improve health and health care. The appendixes of thisreport provide widely ranging examples of measurement activities,reporting requirements, and data sources that support measurement ofdifferent aspects of the health system. Yet while more than 27organizations, 36 programs, and 1,235 individual measures areidentified, they represent only a portion of the measurement activitiesunder way.
In addition to the sheer number of measures, another challenge lies intheir focus. Many measurement programs limit their focus to narrow ortechnical components of health care processes instead of targetingoutcomes. Health care measures also often fail to capture the multiplefactors that lie outside the domain of the traditional health caresystem but represent the most important influences on health (IOM, 2011b, 2013b; Kindig and Stoddart, 2003; McGinnis and Foege, 1993;McGinnis et al.,2002). Without understanding these factors, it will be difficultto make sustainable progress toward improving the health of thenation.
Measurement Requirements
An increasing number of organizations require health care providers andothers to report data on a variety of measures. These contractualrequirements range from long-standing government programs, such as thereporting of vital statistics, to requirements related to specificprograms, such as the Medicare Shared Savings Program for accountablecare organizations (ACOs) or incentive payments for the PhysicianQuality Reporting System (PQRS). Reporting requirements often are aimedat assessing similar features and targets, such as readmission rates orcosts of care, but with differently structured and implemented measures.As a result, hospitals and other health care organizations often arerequired to report redundant and overlapping measures, which imposes anadditional time and resource burden. A detailed overview of majorreporting requirements and their similarities and differences isprovided in Appendix B.
Despite the call by organizations such as NQF and HHS for greateralignment and harmonization in health system measurement, the variousmeasurement efforts remain broadly uncoordinated both horizontally, oracross various activities, and vertically, in terms of consistent andcomparable measurements at the national, state, local, and institutionallevels. The Committee believes that renewed attempts to align andharmonize measures to reduce redundancies and inefficiencies may nowsucceed because of the significant changes that have occurred in theenvironment for measurement. Notably, data capture capabilities havegrown rapidly, with electronic health records and other digital toolsseeing increasingly widespread use (IOM, 2011a). The emerging health informationtechnology infrastructure could support a real-time measurement systemfor the routine collection of information about care processes, patientneeds, progress toward health goals, and individual and community healthoutcomes. The transformation of technology and capacity provides anopportunity to measure what matters most, enabling goals to drivemeasures rather than measures driving goals.
BETTER HEALTH AT LOWER COST: DOMAINS OF INFLUENCE
At the most basic level, the targets and outcomes of interest for measurementare those that reflect the greatest potential for the health and well-beingof the population and each individual within it, now and in the years tocome. This potential is shaped by the four key domains of influence notedabove: healthy people, care quality, care costs, and people'sengagement in health and health care.
Healthy People
The foundational motivation of this report, and of the health system atlarge, is improving the health of individuals, communities, and thenation. From a population health perspective, the United States facessignificant challenges, with chronic disease afflicting nearly half ofall adults, violence and injury being the leading cause of death forpeople aged 1 to 44, and childhood obesity—a harbinger of poorhealth in adulthood—affecting 17 percent of America'schildren (CDC, 2012; Ogden et al., 2014; Ward and Schiller, 2013).From an international perspective, the United States is below average ona range of health measures. The nation spends nearly twice the OECDaverage on health, yet Americans have a life expectancy of 78.7 years,below the OECD average of 80.2 years (OECD, 2013). The National Research Council(NRC)/IOM report U.S. Health in International Perspective:Shorter Lives, Poorer Health provides a broad look at thestate of the nation's health in comparison with other nations(NRC and IOM, 2013). Akey finding in that report is that Americans fare worse than otherdeveloped nations in at least nine health areas: infant mortality andlow birth weight, injuries and homicides, adolescent pregnancy andsexually transmitted infections, HIV and AIDS, drug-related deaths,obesity and diabetes, heart disease, chronic lung disease, anddisability. Among the contributors to this American disadvantage arelimitations in access to care, disparate quality of care delivered bythe nation's health systems, risky health behavior profiles, andsocioeconomic disparities (NRCand IOM, 2013).
The U.S. health system is marked by significant challenges beyond thedelivery of care in hospitals or provider offices. Such factors associoeconomic status, behavior, environment, and health literacy haveimportant implications for the health of individuals and communities. Itis estimated that in the United States, 10 to 15 percent of preventablemortality is amenable to health care interventions, while approximately40 percent of preventable deaths are attributable to behavior patternsthat could potentially be modified (McGinnis et al., 2002). Paradoxically, it isestimated that 95 percent of U.S. spending on health goes to directprovision of health services, with the remaining 5 percent being spenton public health (McGinnis etal., 2002). While spending on health care is significantlyhigher in the United States than in other developed countries, thenation spends less, as a proportion of total spending, on public healthand social programs that address those aspects of health outside ofclinical care (Bradley et al.,2011). The IOM report For the Public's Health:Investing in a Healthier Future explores in detail thestate of America's public health system and financing, andpresents a case for reformulating the nation's portfolio ofhealth investments to focus more resources on public health andprevention as a step toward improving health and reducing health carecosts in the United States (IOM,2012b).
Care Quality
A major impetus for transforming the measurement enterprise is the unevenperformance of the health system, which is characterized by islands ofexcellence existing alongside areas in need of improvement. On the onehand, significant advances have been made in improving the publichealth. During the 20th century, life expectancy increased by nearly 60percent (Guyer et al.,2000), while the mortality rate has declined by more than 60percent over the past 75 years (Hoyert, 2012). Clinical care also has seen marked progress,including vaccines that have virtually eliminated many childhoodinfectious diseases; antibiotic therapies for infectious diseases;multiple interventions for cardiovascular disease, from beta blockers topercutaneous coronary intervention (PCI) and coronary artery bypassgrafting; and co*cktails of pharmaceutical agents tailored to thespecific genetic characteristics of HIV, a microbe identified just 30years ago (Fauci, 2003;FDA, 2011; Fischl et al., 1987; IOM, 2012a; Nabel and Braunwald, 2012;Simon et al.,2006).
At the same time, the system has compelling needs for improvement. Adecade ago, in the report To Err Is Human: Building a SaferHealth System, the IOM estimated that 44,000 to 98,000people died in hospitals every year as a result of preventable medicalerrors (IOM, 1999).Medical errors remain common, occurring in almost one-third ofhospitalized patients (Classen etal., 2011; Landriganet al., 2010; Levinson, 2010, 2012). One recent analysis suggests that preventable harmmay lead to more than 200,000 deaths per year (James, 2013). In addition, applicableresearch and evidence are not integrated routinely into direct patientcare, with Americans receiving only about half of the care recommendedby current evidence (McGlynn etal., 2003) and with a lag of years or even decades in theapplication of new evidence to current health practice (IOM, 2012a).
The care system also faces significant challenges in terms of access tocare, with many Americans encountering limitations due to cost,transportation, wait times, and other factors that can impede theirability to receive the care they need at the right time and place.Relatedly, the care received often is limited in the extent to which itmeets and accounts for the needs, priorities, and perspectives ofpatients.
Health care also has become increasingly complex, resulting in shortcutsin decision making and clinical processes, fragmentation of care,preventable errors, and a lack of accountability. Moreover, the healthcare system is characterized by inefficiencies in spending and resourceuse, such that an estimated 30 percent of health care spending iswasted. The 2012 IOM report Best Care at Lower Costexplores the causes and consequences of shortfalls in health carequality and outlines approaches for addressing them (IOM, 2012a).
Care Costs
The relative underperformance of the health system with respect topopulation health and health care quality has coincided with growth inhealth care costs that has vastly outpaced the rest of the economy,highlighting the lower levels of productivity being achieved by thehealth system (IOM, 2010,2012a). Health carecosts now constitute almost a fifth of the nation's economy(Hartman et al., 2013)and pose a challenge for the budgets of the federal and stategovernments, businesses, and families. Costs vary significantly and withlittle correlation with quality among different regions of the country,states, localities, and even clinicians operating in the same practice(IOM, 2013c). Healthcare expenditures sometimes are only coincidentally related to careoutcomes.
The costs of health care in the United States for individuals, states,and the nation pose significant challenges for the accessibility andaffordability of care and raise questions as to whether the care beingpurchased is worth the investment. Growth in aggregate health care costschallenges the competiveness of U.S. companies and reduces take-home payfor working Americans. High out-of-pocket costs place financial pressureon individuals and families, potentially leading people to avoid ordelay care or to ration personal care resources by, for example, takingmedications less frequently than prescribed (Goldman et al., 2004). Health care also is asignificant source of debt for many Americans (Doty et al., 2005), while health care costsare the major contributor to growth in the national debt. And demandsplaced on state and national budgets by health care costs may drive downinvestment in other critical areas impacting health, including educationand the environment (McCulloughet al., 2012). Although some recent trends in health carecosts have been encouraging, with the pace of increases remaining lowerthan expected, the precise cause of this effect and whether it willcontinue over time are unclear (Blumenthal et al., 2013; Cutler and Sahni, 2013; Ryu et al., 2013).
Moving forward, how will the nation know whether its investments in thehealth care system are improving health and yielding a higher quality oflife for its citizens? While the current measurement system evaluatesmany aspects of health care delivery, little attention is paid tomeasurement of the “value” of health care—betterhealth outcomes per unit cost. No single measure of value exists, andimprovements in quality or outcomes and in cost often are measured usingdifferent scales. In the absence of quality information, people tend toequate higher cost with higher quality. Moreover, different people mayassign different weight to various aspects of quality—forexample, expected mobility versus length of recovery time or anticipatedrisk. Information should enable care choices and treatment that bestmatch individual priorities. From a consumer perspective, therefore,price is a poor indicator of quality and, by extension, not a usefuldata point for choosing among services or providers. Unlocking the powerof the demand side—people, patients, employers, families, andgovernment programs—to drive progress in the health system willdepend on the provision of meaningful, accurate, and comparableinformation about value.
People's Engagement in Health and Health Care
In the context of legislative and payment reforms, changes in technologyand access to information, new models of care delivery, and linksbetween progress in chronic disease and patient initiative, patients,consumers, and the broader public are playing an increasing role inhealth and health care. Evidence suggests that people who are moreactively involved with their health and health care may have improvedoutcomes. Research has found that people who use health-related socialnetworking sites, such as PatientsLikeMe, TuDiabetes, and TheBody, haveimproved treatment adherence and a better understanding of their medicalcondition and feel more in control of their disease management (Grajales et al., 2014). Onesurvey conducted in partnership with Consumer Reportsfound that American social media users have a high level of interest insharing their personal data to improve the evidence base, assumingadequate privacy protections are in place. Fully 94 percent of peopleparticipating in the survey reported being willing to share their healthdata to help doctors improve care (Grajales et al., 2014).
Importantly, the concept of engagement pertains both to individuals andto the community. Individuals and communities share responsibility formaintaining and promoting the health of individuals and populations.Effective engagement is built on public understanding of thedeterminants of health. Similarly important is that determinants ofhealth be reflected in public agendas for health improvement, whichdemonstrate the extent of a community's commitment to addressingthe population-wide factors in the community that shape people'shealth, health care, and health prospects. While the evidence base isstill evolving in this domain as it is in the domains of healthy people,care quality, and care costs, an effective strategy for marshalinggreater individual and public engagement in health and health care isneeded.
CHALLENGES TO MEANINGFUL MEASUREMENT
Ironically, the rapid proliferation of interest, support, and capacity fornew measurement efforts for a variety of purposes—includingperformance assessment and improvement, public and funder reporting, andinternal improvement initiatives—has blunted the effectiveness ofthose efforts. This situation reflects in part the fragmentation of thehealth care sector, as well as the range of legislatively mandatedactivities that involve measurement of health and health care. Absent ashared strategy, the variation inherent in thousands of disconnectedmeasurement and accountability systems frustrates understanding of healthsystem performance and the accomplishment of shared goals.
The Changing Measurement Landscape
Rapid change in the organizational and payment landscapes for health carehas introduced new measurement responsibilities. Moreover, theintroduction of multiple new models for delivering, paying for, andorganizing health care has coincided with new initiatives to improvepersonal and population health. Developments range from ACOs, insurancemarketplaces, and value-based payment programs to regional and communityhealth improvement collaboratives. These new models and initiatives arenot adequately supported by current assessment capabilities; bettermeasurement tools are needed to support their operations and capturetheir successes (Schneider etal., 2011). Furthermore, the lack of alignment andcomparability in the current measurement landscape limits the capacityto make meaningful comparisons among approaches or solutions and, byextension, may limit the spread of best practices and solutions forwidely shared health system challenges.
Increasingly Burdensome Measurement Requirements
Tremendous growth in the development and use of measurement in the healthsystem has led to a large number and variety of measures that, althoughin many cases of high quality, may create significant areas of overlapor redundancy. Health care organizations report rapidly growingrequirements for the devotion of staff time andmoney—particularly clinician time—for measurementrequirements of marginal utility in improving care and outcomes (Meyer et al., 2012). Theburden of so many measurement activities and requirements can havenegative consequences in terms of both the real cost of inefficiency indata collection and reporting and the opportunity costs associated withexcessive spending on measurement. The growth of the measurement burdenis discussed in greater detail in Chapter 2 as a key challenge for health and health caremeasurement.
A Blurred Focus on Priority Issues
New knowledge, alternative care delivery vehicles, the development of newincentive approaches for providers, expanded public input, and otherfactors are intersecting to drive rapid change in the health system.Most of these changes, however, occur in an independent anduncoordinated fashion, and the introduction of each new measure forassessing their results and outcomes tends to diffuse the ability tofocus on what is most important. Fragmentation of the system leads tofragmentation of solutions, with different stakeholder groups andinstitutions working toward different goals with different tools andmeasures. For example, one study found that more than 30 percent ofmeasures surveyed were either modifications of existing measures orhomegrown, with 80 percent of programs modifying at least one measureand 40 percent of programs creating at least one new measure (Bazinsky and Bailit, 2013).This lack of coordination blurs focus, at every level, on the priorityissues and outcomes with the greatest potential to improve health.
Lack of Standardization in Measuring Similar Concepts
The growth over the past decade in measures that health careorganizations are required to report is due in part to redundancies andinefficiencies in data collection and measure specification, such thatdifferent organizations interested in assessing the same target orfeature require different measures with different specifications. Forexample, one study found that across six HHS measurement programs, 61different measures were in use for smoking cessation, 113 for HIV, 19for obesity, and 68 for perinatal health (HHS, 2014). The result is a healthmeasurement system that lacks standardization for the assessment andreporting of data on commonly assessed concepts.
Need for a Core Measure Set
A set of core measures is needed to promote improved health and healthcare. As defined in Box1-2, core measures, for present purposes, consist of aparsimonious set of measures that provide a quantitative indication ofcurrent status on the most important elements in a given field, and thatcan be used as a standardized and accurate tool for informing,comparing, focusing, monitoring, and reporting change. A core measureset is not intended to replace the full range of measures in use today,rather, it is intended to enhance the focus of central health careactors on critical goals and routes toward those goals. A core measureset has the potential to accelerate improvement by concentratingattention, reducing inefficiency, making reporting more powerful, andpromoting innovation in measurement and care. In other words, awell-designed core measure set can lead to better health care at lowercost.
BOX 1-2
Definition of Core Measures. A parsimonious set of measures that provide a quantitative indicationof current status on the most important elements in a given field,and that can be used as a standardized and accurate tool forinforming, comparing, focusing, (more...)
As detailed above, while the ability to measure discrete processes andfeatures in health care has grown increasingly sophisticated, theavailability of measures and data to enable direct comparisons ofbroader health outcomes and circ*mstances at the national, state,county, community, and institutional levels is a persistent challenge.Core measures present an opportunity to improve the nation'sability to measure and improve performance on health, health care,affordability, and engagement by providing common points around whichactivities can be oriented and outcomes compared. By virtue of theircentral nature, core measures can drive improvements that will have aripple effect on performance throughout the system; that is, ifstakeholders align around a common set of well-designed measures,attention to improvement on those measures can lead to system-wideperformance enhancement. The existence of a parsimonious core measureset also can free institutions to direct additional measurement focusand resources to issues tailored to their particular circ*mstances.
Relevance to Diverse Health Care Roles and Circ*mstances
To serve their purpose of focusing attention on overriding health careand health goals, core measures must be broad-based and high-level; theycannot, by definition, capture the particular concerns and perspectivesof each actor in the health system, regardless of the validity andcompelling nature of those interests. Nevertheless, the Committeebelieves that core measures are relevant to the work of virtually allstakeholders involved in advancing the health and health care ofindividuals and communities nationwide, even where the work of thoseactors is quite specialized and may call for legitimate, complementarymeasure sets. Specialists in allergy and immunology, for example, maynot immediately see their primary service activity directly reflected inthe core measure set. However, their work is directly related to, andaffected by, the profiles of their patients with respect to issues likewell-being, healthy communities, preventive services, care access,evidence-based care, care math with patient goals, personal spendingburden, and individual engagement.1 Furthermore, a core measure setthat includes indicators of community health may focus the attention ofthese providers on the environmental and cultural factors that can soheavily influence the burden of allergic and immunologic illness amongtheir patients. This awareness, in turn, can foster the sense of aprofessional opportunity to help address those community-wideinfluences. The process used to implement core measures must account forthe requirement to make these translations into terms relevant to themany diverse health care actors.
In many cases, core measures may also need to be translated in ways thatreveal their relevance and utility for actors at different levels of thehealth care system. For example, while the proportion of gross domesticproduct devoted to care provides a national view of health carespending, the concept of population spending burden is pertinent at thestate, local, and institutional levels. At the state and local levels,the burden of health care spending could be compared against overallbudgets or economic output, or spending levels could be assessedrelative to peer states or to a performance benchmark. At the level ofhealth care institutions, for example, the measure of total cost of careand resource use could provide actionable information on spending in thecontext of providing care services.
STUDY CHARGE AND APPROACH
Study Charge
To address the increasingly urgent need for a framework, measures, andprinciples around which the nation might transform the efficiency,effectiveness, and utility of the health and health care measuremententerprise, the IOM, with the support of three sponsoringorganizations—Blue Shield of California Foundation, theCalifornia HealthCare Foundation, and the Robert Wood JohnsonFoundation—appointed the Committee on Core Metrics for BetterHealth at Lower Cost. The charge to the Committee, presented in Box 1-3, was essentiallyto articulate basic measurement needs focused on what matters mostacross all levels of the health system; identify a parsimonious set ofcore measures in those areas; describe how these core measures shouldrelate to, shape, and enhance broader measurement efforts throughout thehealth system; and suggest strategic approaches to implementation. Theultimate goal of the Committee's work was to spur widespreadimprovement in health and health care through a more aligned andefficient measurement system. The breadth of the Committee'scharge reflected the extent of opportunities to achieve this goal.
BOX 1-3
Charge to the IOM Committee on Core Metrics for Better Healthat Lower Cost. An ad hoc committee will conduct a study and prepare a reportdirected at exploring measurement of individual and populationhealth outcomes and costs, identifying fragilities (more...)
Study Approach
The Committee convened to carry out this study comprised 21 individualswith a broad range of expertise, including health economics and policy,population health, health care delivery and safety net populations,state and community health improvement, health measurement, andinformation technology and data infrastructure, as well as individualswho understand the perspectives of health care payers and purchasers,clinicians, researchers, and patients and consumers. Committeemembers' biographies are presented in Appendix E.
Recognizing that success depends on concerted actions by all stakeholdersin the system, the Committee sought input and feedback from a broadrange of individuals and organizations. Staff contacted 126 leadinghealth organizations to solicit their thoughts on the current state ofmeasurement, challenges limiting its potential, and opportunities thatcould be transformative. The resources received from these organizationsinformed the Committee's deliberations on the needs andopportunities in the field. The Committee also held open sessions atthree of four of its meetings, during which stakeholders andpractitioners from various organizations with ties to health and healthcare measurement—such as NQF, NCQA, CMS, the Agency forHealthcare Research and Quality (AHRQ), the Centers for Disease Controland Prevention (CDC), and the Office of the Secretary ofHHS—provided additional perspective and background. Organizationsrepresenting patient and consumer perspectives also provided importantinput for these discussions.
The Committee deliberated during four in-person meetings and multipleconference calls over 2013 and 2014. The Committee's overarchingapproach to identifying core measures is illustrated in Figure 1-1. Its initialdeliberations focused on clarifying the scope of the study and gatheringinput, while later meetings focused on synthesizing conclusions andformulating recommendations that would move measurement forward. Toaccelerate its efforts, the Committee drew on related IOM work describedbelow, particularly an earlier IOM workshop on the core measurementneeds for better care, better health, and lower costs (IOM, 2013a). Furthermore,staff and Committee members reviewed the evidence related to measurementand case studies of measurement initiatives to inform the findings,conclusions, and recommendations presented in this report.
FIGURE 1-1
The Committee's approach to identifying the coremeasure set.
This report references and builds on the work of a wide range of otherindividuals and organizations devoted to addressing the nation'schanging health and health care measurement needs. These includeactivities stewarded through the HHS Secretary, the Secretary'sPrevention Agenda and Healthy People Leading HealthIndicators, the National Quality Strategy, the Joint Commission, theInstitute for Healthcare Improvement, and the organizations mentionedabove (CMS, CDC, AHRQ, NQF, and NCQA). These and other measurementactivities are discussed in Chapter2.
RELATED WORK OF THE INSTITUTE OF MEDICINE
The IOM has produced several reports aimed at strengthening the focus of thenational health agenda on matters of compelling urgency. These reports haveexplored approaches to measurement activities ranging from specificassessments of the needs for health care and public health to surveys thatcut across the entire health system. In so doing, these reports have drawnattention to the gaps in the nation's measurement capabilities andoutlined opportunities for improvement.
At various levels, the present report draws on the broader foundation of theIOM work articulating a vision and strategy for improving health and thehealth care system. The 1999 report To Err Is Human: Building aSafer Health System and the 2001 report Crossing theQuality Chasm: A New Health System for the 21st Centurytogether highlight some of the most significant challenges facing the healthsystem and outline a potential path forward in terms of governance, healthpractice, and health culture (IOM,1999, 2001). Thosereports galvanized the nation's attention to focus on thedeficiencies in health care and the importance of engaging themdirectly.
Also related is the work of the IOM Roundtable on Value &Science-Driven Health Care in bringing together the nation's healthleaders with the common purpose of accelerating achievement of the healthsystem's full potential. The 12-volume Learning HealthSystem series produced under the Roundtable includes discussionand ideas from a series of 15 workshops covering issues that range fromresearch and technology infrastructure to leadership to patientengagement.
More recently, the 2012 IOM report Best Care at Lower Cost: The Pathto Continuously Learning Health Care in America was issued.This report charts opportunities for marshaling advances in science andtechnology, as well as the market forces of increased public and patientinvolvement, to drive the health system toward the culture and practice ofreal-time and continuous improvement in the effectiveness and efficiency ofcare (IOM, 2012a). The presentreport outlines what steps are necessary and possible to track thenation's progress toward the transformation envisioned inBest Care at Lower Cost.
Another recent effort related directly to the work of this Committee was theconduct of an IOM workshop and production of a workshop summary on the coremeasurement needs for better population health, improved quality of healthcare, and lower health care costs. This 2-day workshop garnered perspectivesfrom patients and consumers, health care delivery organizations, clinicians,public health experts, researchers, purchasers and payers, healtheconomists, measure developers, regulators, clinical researchers, experts inhealth information technology, state governments, community organizations,and regional collaboratives. The workshop discussions drew on existingmeasurement initiatives, identified the limitations of current measurementefforts, and began to identify a framework for core measures and thenecessary infrastructure for implementation. The workshop summary,Core Measurement Needs for Better Care, Better Health, and LowerCosts: Measures That Matter, summarizes those discussions andserved as a first step in the process of identifying a common core measureset suitable for assessing the health system (IOM, 2013a).
In 2006, the IOM released Performance Measurement: AcceleratingImprovement. The purpose of that report was to build themeasurement infrastructure needed to advance the goals of the earlierQuality Chasm report (IOM, 2001). To that end, the authoring Committeeselected measures that would support quality improvement across the healthcare enterprise and identified the infrastructure necessary to support theimplementation of those measures at the regional and national levels. Thereport endorses a starter set of performance measures with a strong evidencebase, most of which were drawn from measure sets and individual measuresacknowledged by major stakeholder groups. The report also analyzes the gapsin current measurement capabilities, identifying the need for measures inseveral areas, including efficiency, equity, and patient-centeredness;longitudinal care and care transitions; systems-level measures; and measuresthat can be used to assess care across multiple clinicians and organizations(IOM, 2006).
The 2002 IOM study Guidance for the National Healthcare DisparitiesReport was developed to provide guidance to AHRQ as it workedto improve the measurement and reporting of data on health disparities. Thereport highlights a variety of key issues relevant to core measures andpresents potential approaches for measuring disparities consistently andaccurately, as well as improving the availability of data on disparities fora range of valuable health measures (IOM, 2002).
Another prior effort to identify a set of core measures is documented in the2009 IOM letter report State of the USA Health Indicators.This report was intended to support the nonprofit State of the USA Inc.,which was building an Internet site to assess the nation's progressalong several dimensions, including education, environment, and health. TheCommittee responsible for that report proposed 20 measures that couldprovide a broad picture of health and health care, encompassing overarchingindicators of health, social and environmental factors influencing health,health behaviors and risks, and the quality and cost of health care. Thereport emphasizes that these health measures should not be considered inisolation; rather, the nonprofit should show the interconnections betweenhealth and the other areas it is tracking, such as education and environment(IOM, 2009).
The IOM explores the social and environmental factors that affect overallhealth in the 2010 report For the Public's Health: The Roleof Measurement in Action and Accountability. The authoringCommittee found that the nation did not have the necessary tools to assessand respond to these factors, and that the lack of such information limitedthe nation's ability to improve Americans' health. To addressthese challenges, the Committee recommends that HHS provide greaterleadership, coordination, and guidance on population health information andstatistics; that HHS lead the creation of a core measure set focused onpriority health outcomes to improve alignment and enable comparisons amongdifferent communities, regions, and states; and that the nation adopt asingle summary measure of population health that yields an overall pictureof health and well-being at multiple levels. These recommendations wereintended to provide greater understanding of the factors that influencehealth and to galvanize action toward better health (IOM, 2011b).
In 2013, the IOM released an examination of HHS's public healthquality initiatives and the Leading Health Indicators for HealthyPeople 2020, with a particular focus on measures that canpromote integration of clinical care and public health. The reportToward Quality Measures for Population Health and the LeadingHealth Indicators suggests that every community should usemeasures to assess progress on the Leading Health Indicators and recommendsa systematic approach to developing and managing a portfolio of measuresthat span the entire health system. The authoring Committee also developed alogic model that shows the relationships among social, environmental, andbehavioral factors; resources and community capabilities; interventions; andoverall health outcomes. To show how this model translates to practice, thereport includes four case studies illustrating how the model could be usedto demonstrate the pathways from structure to process to outcomes and guidethe development of quality measures (IOM, 2013b).
In a complementary project, a series of IOM consensus studies has focused onintegrating population health factors into electronic health records. ThePhase 1 report, Capturing Social and Behavioral Domains inElectronic Health Records, identifies various domains andpotential candidates for assessing such issues as socioeconomic status, raceand ethnicity, sexuality, and health behaviors in the context of clinicalrecords (IOM, 2014a). ThePhase 2 report identifies with greater specificity 12 measures related tothe selected domains and addresses issues related to incorporating theseelements into electronic health records in a standardized way (IOM, 2014b). These recommendedmeasures include four that are already in widespreaduse—race/ethnicity, tobacco use, alcohol use, and residentialaddress—as well as an additional eight social and behavioralmeasures—education, financial resource strain, stress, depression,physical activity, social isolation, exposure to violence, and neighborhoodmedian household income.
These many prior IOM activities provided a strong foundation for theassessment and recommendations presented in this report.
CORE MEASURES AND ISSUES: PREVIEW
A brief preview of the Committee's recommended core measure set andapproaches to certain issues is warranted. Presented in Table 1-1 is the analyticframework for the core measures. Because the scope of concepts, activities,and priorities is broad for each aspect of the four domains outlined above(healthy people, care quality, care costs, and people's engagement inhealth and health care), the Committee's working assumptions on thedomains, their key elements, and associated core measure foci are presentedbelow. Also summarized are the approaches taken to the issues of bestcurrent measures, related priority measures, disparities, andimplementation, which are presented in detail in Chapter 4.
Domains
The Committee's charge was to identify measures that best reflecthealthy people, care quality, care costs, and people's engagementin health and health care. Implicit in that charge is the notion thatwhile the foundational societal aspiration is healthy people, populationhealth is a product of the dynamics in each of these vital andinterrelated domains of influence on health. The goal of healthy peoplecannot be achieved without quality care or engaged people. Gains in thequality of care and population health cannot be sustained withoutaffordable care. And care quality and affordability cannot be optimizedwithout engaged people.
Key Elements
Facilitating progress within and among these domains of influence dependson how their component elements are addressed. Although they may becharacterized in different ways and often are interrelated at somelevel, each of the key elements presented in Table 1-1 is central to progress in health andhealth care. Quality of life is a goal basic to every individual, andalthough length of life is not an immutable goal for every person atevery stage of life, it is an accepted standard for the overall healthof populations. It also is now well established that the health ofpopulations is substantially shaped by factors outside of health care,including patterns of health-related behaviors and social circ*mstancessuch as physical environments and socioeconomic status. High-qualitycare is a function of the interplay among access to care, prevention,and appropriate treatment.
Core Measure Set
The Committee proposes the core measure set presented in Table 1-1. Each core measurefocus identified by the Committee represents an important focus foraction at the national, state, local, and even institutional levels.
Measure development and standardization were beyond the scope of theCommittee's charge. However, to accelerate the development andapplication of a fully specified core measure set, the Committee hasspecified what in its judgment is the best currently available measurefor each core measure focus. This measure set, while imperfect,represents in the Committee's view a powerful starting set of“vital signs” for tracking progress toward improved healthand health care in the United States. The Committee believes furtherthat the core measure set recommended herein comprises the vital signson the status and progress of the nation's health and healthcare, that a single measure can be chosen or developed for each of thecore measure foci within each domain of influence, and that thedevelopment of a standardized measure is essential for each focus. TheCommittee also believes that, when applied, attention to these coremeasure foci will have the multiplier effect of improving performancebroadly throughout the health and health care organizations engaged intheir use.
Development Priorities
As noted above, the Committee has not specified each core measure indetail because, with few exceptions, the collaborative process ofdefinition and refinement needed to develop widely accepted and fullyspecified measures was beyond the resources and scope of this study.Standardized measurement approaches exist for life expectancy andoverweight and obesity, but such refinement has not yet beenaccomplished for measures in many other key areas, such as well-being,addictive behavior, healthy communities, evidence-based care, spendingburden, and individual and community engagement. This is particularlytrue for individual and community engagement measures. The Committeefocused considerable discussion on this focus, reflecting the relativelynascent state of conceptual and technical development of measures inthis field. Committee members' perspectives were divided on thequestion of whether the strength and precision of the definitions andmeasures available for engagement warranted their inclusion alongsidethe domains of health, care quality, and care cost. Still, there wasstrong sentiment within the Committee that individual and communityengagement are significant determinants of health and health care,clearly working in service to and as elements in the success ofactivities directed at the Triple Aim of better health, better care, andlower costs. Nonetheless, considerable definitional and analytic workwill be required to develop practical measures that can reliably capturethe extent to which individuals are prepared for and engage in effectiveparticipation in health and health care planning, delivery, andimprovement. Additionally, research is needed to explore how leversavailable for community-wide action are being employed effectively forimprovement in matters of central importance to the health of thepopulation. Given the identification of engagement as a domain in theCommittee's statement of task and the acknowledgment within theCommittee that engagement represents an important—ifunderdeveloped—element of the changing landscape of health, theCommittee's deliberations were guided by the four domains ofhealth, care quality, care cost, and engagement.
Best Current Measures
Because most of the core measure foci shown in Table 1-1 are not supported by standardizedmeasures accessible for application at every level of the health system,the Committee also specified, and presents for consideration in Chapter 4, best currentmeasures for the core measure foci. Examples include the use ofchildhood immunization as a best current measure of the delivery ofpreventive services and self-reported health status as an indicator ofwell-being. Many of these best current measures are currently imperfectbecause of limitations in scope, reliability, generalizability, orconceptual boundary and will require substantial work. For this reason,the Committee recommends in this report that, as stakeholders at variouslevels try out their own proxies for the core measure foci in the shortterm, the Secretary of HHS steward a broadly inclusive process tomarshal the nation's experience and expertise in the developmentof the standardized set of core measure foci, see Chapter 5.
Related Priority Measures
The Committee recognized that, while ripple or multiplier effects areanticipated as a result of the use of the 15 core measure fociidentified, those foci will not be sufficient to serve all of theinterests of given organizations. To begin to address this challenge,the Committee also identified 39 “related prioritymeasures” for consideration, presented in Chapter 4. These measures,together with the core measures, give a more detailed view of the healthsystem and are sufficiently granular and specific to be actionable bystakeholders as needed for their particular circ*mstances. The Committeebelieves that, as with the core measure foci, specification andstewardship of standardized approaches ought also to be undertaken forthese related measures, although as a follow-on activity to that for thecore measure foci.
Disparities
The Committee presents in Chapter4 and in discussion throughout this report data available forthe core measure foci, and well beyond, that highlight the substantialdisparities among subpopulations in the United States with respect tohealth status and health care. These include disparities based on race,ethnicity, income, education, gender, geography, and urban or rurallocation. In the aggregate, this issue represents one of the greatestsingle health and health care challenges to the nation. Accordingly, theCommittee considered recommending the development of a separate coremeasure aimed specifically at disparities. Instead, because the issue isso pervasive, the Committee discusses disparities in conjunction witheach core measure.
Implementation
The Committee emphasizes that the process of refining, applying, andimplementing the core measures is fundamental to success. Although facevalidity was a central criterion in identifying each measure, these coremeasures will not implement themselves. A carefully designed effortunder the stewardship of the HHS Secretary will be needed to focus thenation's attention in a manner that will accelerate progressacross the board. Therefore, the Committee's recommendationsplace particular emphasis on the roles, responsibilities, andopportunities for implementation—the critical features andactions necessary to achieve adoption and application of the coremeasures. At the same time, the multilevel and broad-based features ofthe implementation activities identified by the Committee are alsointended to reflect both content and processes that are as catalytic andopen as possible.
ORGANIZATION OF THE REPORT
This report summarizes the Committee's deliberations on the issues,options, and successful strategies with respect to advancing measurement andenhancing collaborative efforts around measurement in the four domains ofhealthy people, quality of care, costs of care, and people'sengagement in health and health care. The evidence is distilled intodetailed findings throughout the report that serve as the basis for theCommittee's conclusions and recommendations. Each recommendationdescribes a key goal for advancing measurement and is accompanied byspecific strategies that stakeholders should undertake in implementing therecommendation. Additional actions will be needed from multiple stakeholdersto sustain and advance the implementation process.
Following this introduction are five chapters. Chapter 2 describes the current use of measurement inhealth and health care in America. It includes discussion of existingmeasurement purposes and requirements, limitations in current measurementcapacity, and the burden of measurement on the care system.
Chapter 3 provides anintroduction and overview for the core measure set proposed by theCommittee, including a description of the Committee's deliberativeprocess in approaching and completing the task of identifying thesemeasures. Additionally, this chapter considers the potential benefits ofadopting core measures, how the focus of measurement can be expanded toencompass concepts meaningful to patients and the public, and desirablecharacteristics for a core measure set.
Chapter 4 presents the proposedcore measure set, along with best current measures for use while the processof refining these measures is under way. This chapter serves essentially asa handbook for the core measures by providing details on each of themeasures in turn, including the rationale for its selection, as well as theavailability and quality of current data and measures and the path forwardfor improvement.
Chapter 5 outlines issues andapproaches with respect to implementing the measure set and ensuring that itis updated and improved over time. Included is discussion of potential dataproduction for dissemination of the core measures, as well as the usesenvisioned for the measures by the Committee across stakeholder groups. Keychallenges for stakeholders are identified, and approaches for integratingthe core measures into existing programs, policies, and reporting activitiesand requirements are discussed.
The report concludes with an action agenda in Chapter 6 that summarizes the Committee'sfindings, conclusions, and recommended actions for different stakeholdergroups to achieve improved alignment and focus in measurement. This chapteralso identifies the contextual features important for successfulimplementation of the core measures.
Finally, the report's appendixes present prominent measurementinitiatives, the landscape for reporting initiatives, and current datacapabilities.
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