By Christopher Guadagnino, Ph.D.

Erik Muther is Executive Director of the Pennsylvania Health Care Quality Alliance.

PND: What are obstacles to more widespread consumer use of online health care quality information?

EM: People use health care information in a variety of ways, but not to the extent that they use information when they purchase other services or products. Most people don’t directly pay for their health care – they have health insurance – so in most cases they’re not directly purchasing at the "retail price" the services that they get. So, they tend to be focused more on ensuring that they get the service that they want, and don’t spend as much time looking up information to ensure that the service is of good quality relative to other services of a similar type. Also, each government or private insurance entity provides a source of quality information that tends not to be very standardized. One health plan may have a contract with HealthGrades, for example, whereas another health plan may have WebMD Health Services to provide health care quality information. There’s not a clear, single source for people to go to and obtain quality information. When things tend to be more disparate and less intuitive, it becomes overwhelming and a little daunting. In our survey, there was a very large number of people who came to our website and were surprised that it was relatively easy to use, that it was not more confusing and complex. That either means they had a perception that these sorts of websites are very confusing, or they had not been to other websites and were surprised to see that it was actually relatively straightforward.

PND: What is the goal of your organization?

EM: The Pennsylvania Health Care Quality Alliance is a multi-stakeholder collaborative of organizations that came together to develop a common statewide approach to transparency of hospital quality measurement using measures that are evidence-based and actionable. The goal was to help providers evaluate and improve the quality of patient care, give insurers the opportunity to assess and evaluate the performance of their provider networks in a common way, and ultimately enable consumers to see how their provider – hospitals, in this case – was performing, and also benchmark that performance against other hospitals. The website was the output of consensus measures the alliance developed. The alliance’s member organizations include the four Blue Cross Blue Shield plans in Pa. – Highmark, Independence Blue Cross, Capital BlueCross, Blue Cross of Northeastern Pennsylvania, the Hospital & Healthsystem Association of Pennsylvania, the Delaware Valley Healthcare Council, the Hospital Council of Western Pennsylvania, the Pennsylvania Medical Society, representatives from the Governor’s Office of Health Care Reform, and from the U.S. Department of Health and Human Services.

PND: How do the interests of these various stakeholders coincide, and how do they diverge?

EM: One alignment is an agreement that an effort to develop a standardized quality approach should build upon existing state, federal, private and public data sources, for example, using the Pennsylvania Health Care Cost Containment Council’s measure for hospital-acquired infections. The alliance would look at that measure, examine how it is collected and reported, and identify whether it should be adjusted or left the same. The goal is to avoid duplication of existing measures and not unreasonably burden hospitals with additional reporting standards. Payors and hospitals would then use the agreed-upon measure set as the primary basis for future quality improvement efforts. For example, if Independence Blue Cross is going to partner with the University of Pennsylvania to promote health care quality, to the extent possible, they should try to leverage the standard approach that was developed by the alliance, rather than having to recreate effectiveness measures for their program. Similarly, for pay-for-performance programs, there should be some attention paid to using these quality measures that they’ve collectively agreed on. Another issue of alignment is that the alliance should promote ways for lesser performers to learn from better performers – create a forum to share best practices – and not be just another ranking and reporting type of activity.

Points of divergence were about where price and cost comes into play – whether the alliance focuses on quality and cost in parallel, or separately. There was agreement that quality should be the primary focus and that, once we developed a consensus on how to measure quality, then we could start to entertain questions about how cost factors in, such as whether getting higher quality requires more resources. Another divergent point was how to calculate and identify who the benefits of quality care will go to, other than the patients, obviously. The question of cost savings coming from that improved care was a divergent point. Some of the hospitals felt that there should be additional compensation provided to them if they significantly improve quality, because it would be the health insurance company that benefits from the resulting lower cost. The perspective of the health plans was that it is often difficult to measure what the lower cost is of that improved quality because quality is measured across a fairly extensive period of time. There are member turnover and other issues, where people roll in and out of insurance, and there isn’t always a clear benefit to the insurance company from that improved quality.

PND: What about metrics, themselves – have there been instances in which insurers wanted to include a metric that hospitals objected to?

EM: There are two that come to mind. There are a few National Quality Forum (NQF) efficiency measures, and the health plans were interested in trying to introduce an efficiency measure into this agreed-upon approach to health care quality. The hospitals were hesitant to do that, primarily because the efficiency measures haven’t been vetted over an extensive period of time, and there is a question about whether they really measure efficiency well. The other category was health care-associated infections. Certain individuals on our measures and methods workgroup, which is made up of physician leaders from both hospitals and health plans, disagreed on the utility and usefulness of some PHC4 infection measures, primarily because of methodological concerns related to data collection. For example, surgical site infections that are counted and tracked by PHC4 are only those that are actually reported in the hospital. But, if somebody two or three days after discharge notices they are having swelling or discoloration in the area they had surgery – if their doctor looks at it and gives them antibiotics for an infection, the hospital may never know about that. You would be missing a lot of infections and there is no way in the PHC4 model to be able to count that data.

PND: Were any metrics excluded because they failed to meet the alliance’s "evidence-based and actionable" criteria?

EM: Two categories have been delayed, not necessarily discarded. One is preventive measures to address ventilator-associated pneumonia (VAP), many of which have conflicting clinical literature. There wasn’t a clear actionable list of ways that hospitals could specifically reduce their VAP rate, and we wanted to wait until the evidence had borne that out a bit more. The other delayed category is urinary tract infections (UTIs) because there wasn’t an adequate risk adjustment for that measure. Clearly, if a hospital has a larger number of patients who are in the ICU or are spending long periods in the hospital, they are more likely to develop a UTI related more to being on a device for a long period of time, rather than to direct quality of care issues. We felt it was worth waiting until there is a way to present that in a way that is clear and actionable for hospitals to address.

PND: What quality information is the alliance focusing on, and how is it different from what is already available from other entities?

EM: The measures cover heart attack, heart failure, pneumonia, infection prevention, and appropriate care measures – which indicate the percent of patients who received all of the evidence-based care for their respective conditions. Within each of those categories we have outcome and process measures. The process measures come primarily from the Centers for Medicare & Medicaid Services all-payer data (not just Medicare patients), and most of our outcome measures come from PHC4. We try to identify measures from all domains of quality: effectiveness of care, timeliness of care, safety issues, and patient experience data. We’re trying to get as broad a set as possible, and all of our measures are NQF-endorsed, except for readmission rate for heart failure for the reason of complication or infection.

The alliance convened for the first time in January 2007, so it is still in the early stages of its activities. But, as a first pass, there was a focus on avoiding recreating the wheel and duplicating areas that had been fairly well-covered by other reporting entities or sources of data. As we begin to look into areas where there has not been a long history of data collection or public reporting, we may have to look at other sources or collectively agree on how to measure something. At least for the moment, we’re more of a clearinghouse for measures that are otherwise available in other locations – offering data aggregation into a "one-stop shop" that adds value to users. The exception is the appropriate care measures, which are patient-level composite measures that our state quality improvement organization – Quality Insights of Pennsylvania – calculates for us because they have access to that patient-level database.

The decision to focus on hospital quality measures was primarily driven by the long history that Pa. has on hospital reporting to PHC4, and there was already groundwork laid by a variety of other initiatives like the Hospital Quality Alliance. So, it seemed like a logical starting point. There is an understanding that, at some point, our alliance will look at other settings of care, including outpatient and perhaps long-term care facilities.

We’re starting to go through the next set of potential measures to be included in a formally adopted consensus measure set of health care quality indicators for hospitals. We are looking at some that have recently gone through the NQF process and in some cases have already been adopted by CMS, for example, more granular mortality measures for heart attack and pneumonia. We may look in more detail at measures that are reported to a variety of physician specialty organizations, such as the Society for Thoracic Surgery database and the American College of Cardiology clinical registry.

PND: How is the alliance’s information disseminated?

EM: It’s disseminated through a website. According to our survey results, such a large number of health care decisions are made from doctor recommendations and from personal experience of friends and family, so it probably doesn’t make sense to spend a large amount of time or resources on direct-to-consumer marketing or communication. That’s sort of a double-edged sword because you also want the end consumer to become more aware of these sorts of resources. But, if they’re primarily making most of their decisions in consultation with their family and their physician, it makes more sense to explore ways to promote what the alliance is doing within the physician and professional realm.

Most of the national surveys that I’ve seen, including ones sponsored by the California Health Care Foundation and the RAND Corporation have shown that the number of consumers who look up health care quality information to help them make a health care decision has historically been in the mid- to low-single-digit percent range. We saw 10 to 12 percent on ours, and the Kaiser Family Foundation in a recent survey had seen their number break into the double digits for the first time. We’re still talking about a low number, but a very fast growth rate, which is fairly encouraging.

While our goal in creating the website was to communicate this information to the consumer, the real work of the alliance is collaboration to come up with a consensus measure set. Since that is the primary focus, and not necessarily to create a consumer resource, I think the alliance for the moment is comfortable with not spending a lot of time and resources in trying to raise awareness of the site’s availability.

PND: Is your primary focus the provider community, as a tool to improve their quality?

EM: I would say yes. It’s the providers, primarily, who are looking at this information and using it for benchmarking and other purposes. Right now our aggregated data can be looked at in a variety of ways: most recent, quarterly, and by individual hospital as far back as the data goes. What we are going to do, probably in the next year, is create something that allows for providers to do even more sophisticated analysis. One of the decisions the alliance is going to need to make fairly soon is how much more we want to invest in that capability. There has been some discussion about whether it would be worth collecting measures from hospitals for benchmarking purposes only, for example. There may be some measures that could be of tremendous value to hospitals or physicians to understand where their institution or practice is relative to others, both for the purposes of benchmarking and quality improvement, but maybe measures that you don’t necessarily want to get published until it’s understood how best to compare those measures across providers. Physicians and hospitals have a very good understanding of what happens within their own environment, but a very poor understanding of what happens outside of their environment. The only entities that can really help to fill that gap for them are the insurance companies, who follow people regardless of where they get care. Finding a way to align data and provide mutual data exchange between these organizations is going to benefit health insurance companies, hospitals and physicians.

Phillip Lubitz is the director of advocacy programs for NAMI New Jersey (National Alliance on Mental Illness).

PND: Could you explain what the new Mental Health Parity and Addiction Equity Act of 2008 says and what impact it will have?

JJ: After about 20 years of struggle, the final bill that was passed and signed has eliminated discriminatory practices by some insurance companies as it relates to providing coverage for people with mental illness. This law will expand coverage for about 82 million more people who are not protected by state laws and 31 million in plans that are subject to state regulations. That’s a very large number of people who are now going to benefit directly from the passage of this law, which becomes effective one year after its enactment. The law requires that insurance companies who provide coverage for mental health care and substance abuse disorders must now do it under the same terms and conditions as they do for all other medical conditions. That’s a major plus for people with mental illness who’ve had to deal with discriminatory practices for some time. Sometimes an insurance company would limit the number of inpatient days in a given year or limit the number of outpatient visits. Sometimes there is even a lifetime limit on the number of days covered. They might also require higher deductibles or cost-sharing with people for mental illness or addiction treatment. What the bill does is say that you can’t have that standard for people with mental illness if you don’t have it for all the people you cover for other illnesses. That’s been eliminated now and, if you’re providing mental health care under your policy, then you must do it equally and fairly. If plans provide out-of-network coverage for other illnesses, then they must do the same for people with mental illnesses. This law applies to commercial plans if they’re providing mental health care – if they do not provide mental health care or coverage, then they’re not mandated to do so. The law only applies to policies of employers with 50 or more employees.

PND: What practical impact will this law have on physicians?

JJ: If a physician is currently providing services to a carrier for patients who are under its coverage, they don’t have to have two different ways of doing their treatment. If you’re treating a physical ailment or a mental illness, you can do your treatment plan and write your prescriptions consistent with that plan and not have to deal with the discriminatory clauses and the limitations that were set in place before. You can make referrals out-of-network, if that’s what the treatment plan calls for. You can provide coverage without the restrictions as it relates to limits on inpatient services unless that plan provides that limit for everyone. It gives you greater flexibility and it allows you to handle patients based on the needs of the individual who you’re treating.

PND: A law like this has been advocated for quite some time. How did it pass now?

JJ: Yes, this has really been an ongoing struggle for about 20 years. The Mental Health Parity Act of 1996 eliminated annual and lifetime dollar limits for mental health care for companies with more than 50 employees, but it did not require health plans to offer coverage for mental, nervous or emotional disorders. Day and visit limits, as well as higher co-payments and deductibles, could still be applied to coverage if the coverage was offered.

I believe that there’s been a very strong campaign to fight stigma over the last 20 years and there’s a better understanding, and a more open and public discussions about mental illness as a disease. Diseases, Americans understand. Diseases are treatable. Throughout most of the history of the treatment for mental illness stigma has played a big role, and mental illness has been treated as something that was hidden in a back room or a closet, something that came from bad parents or a bad environment, or that individuals were lazy – sometimes in literature they’re even portrayed as being evil. People began to understand that we’re talking about a disease that doesn’t define who the person is, and that it is treatable. Research has increased and people understand more about definitions of mental illness. There’s hope in the lives of families and people with mental illness now because recovery is possible. Approximately 20 percent of the population is dealing with a mental illness at any given time during the year. So, better understanding about this from a disease perspective, better understanding that recovery is possible and that treatment works, and personal experiences of individuals have opened the door for wider public discussion, and the legislators who represent them have been more receptive to looking at strategies to deal with these illnesses.

PND: What were the issues that had to be resolved for this bill to pass and get signed into law?

JJ: We didn’t have the major issues that we had in the past, and we were very close to agreement on a final bill. One thing that had to be worked out was the preemption issue. There are a number of states that provide coverage at different levels and there was a fear that this bill might have a negative impact and take away some of the gains that had been realized. But the agreement that was finally reached was that a state law may be stronger than, but may not be weaker than, the law that was passed. So, you could have more stringent requirements for insurance companies in your state but you can’t undercut the federal legislation. That protects gains that were achieved in different states. We’re going to have to take a closer look at the state laws that are currently in effect and see what the benefits would be, but from our perspective it’s a very important step in the right direction and will have a positive benefit on all persons who need these services. Other issues that had to be worked out were out-of-network coverage, and impact on the federal ERISA law. The current financial crisis also provided support for passage of this bill because bipartisan efforts allowed for this bill to be attached to a 0 billion Emergency Economic Stabilization Act, which was the vehicle that allowed for it to be voted on, and which speaks to a deeper understanding and commitment by both parties to see that this legislation was passed.

PND: What are some of the limitations of the new law?

JJ: Again, it doesn’t apply to small employers with fewer than 50 employees. The law doesn’t mandate that health plans cover mental health services so, if you’re not providing mental health care, you’re not mandated to do it. Any group plan that sees a two percent increase in the cost of benefits during the first year, or a one percent increase in any subsequent year, can seek an exemption from the mandate. The law also does not apply to the individual health insurance market.

I believe that, as employers understand the benefits of investing in their employees and making sure they’re physically and mentally healthy, that will reduce the impact of any negatives in the bill. The Congressional Budget Office estimated that the total cost for payment of this coverage will be less than one percent – about 0.4 percent. For that 0.4 percent, you’re looking at enormous increases in productivity in the workplace and enormous benefits in the community with stabilized families who are receiving treatment. People at work who are with an untreated disease – mental illness in this case – you’ll find that they’re not as productive. Sometimes you spend years training a person who then has to leave the workforce. This small investment in that employee will give you a more productive employee and will extend the productive time that the employee spends with the company. That’s an incredible benefit and we think that employers, as they understand the benefits, will embrace this and give greater support to this concept. I’m not aware of a penalty that would prevent a carrier from dropping mental health coverage, but I would imagine that a carrier would have trouble with the company that it’s covering because stopping the coverage when you’re looking a 0.4 percent increase in overall costs would be very hard to justify.

PND: Do you have an appraisal of how this legislation will change the situation in Pennsylvania, specifically?

JJ: No, we’ll have to take a look at what the impact on insurance coverage for consumers and families will be. This law has just passed, and our national organization is taking a look at it to see what the true impact will be.

PND: What are the specific mental health care challenges we face in Pennsylvania?

JJ: Pennsylvania has roughly 12 million people – that’s 2.2 million people in the state who are dealing with some form of this problem, so we’re not talking a small issue here. Access to quality care for all Pennsylvanians is a goal that we have. Access in community settings. Access to community psychiatry, to medications. Access to adequate housing and supportive employment. Adequate transportation. These are some of the basic issues that face Pennsylvanians right now, and people all over the country. These are not small challenges, and this law will put a dent in some of them.

[caption id="attachment_1855" align="alignleft" width="162" caption="Ronald A. Paulus, M.D."][/caption] Ronald A. Paulus, M.D., is executive vice president and chief technology and innovation officer for Geisinger Health System.

PND: What was the genesis of Geisinger’s Care Model Redesign project, which was profiled in the September/October 2008 issue of Health Affairs?

RAP: Our board of directors asked our management team and senior clinician leaders to do something novel and valuable for our patients, and change the paradigm from some of the current, perverse payment incentives to something that was much more aligned across different stakeholder constituents for delivering the best care at the best possible price – basically increase the value that we offer to our community. In a way, it was a response to various pay-for-performance programs, in which each payor was coming up with their own plan of what "good care" was and choosing metrics that were often simply process-oriented and not outcome-oriented. The question was, Could we as an integrated health system and as a provider-led initiative come up with a better way of doing pay-for-performance?

PND: What are the core principles of the initiative?

RAP: Several-fold. First, we want to apply the most recent evidence about what should be done for patients to give them the best possible outcomes, translating the medical literature’s evidence and/or industry consensus into process steps that can be used to get patients all the things that they need, and hopefully none of the things that they don’t need during a care encounter. Number two is alignment and rationalization of incentives so that doing the right thing is actually rewarded, rather than punished. The third core principle is a multidisciplinary team-based approach to care: physicians, nurses, pharmacists and other care team members are interacting in a coordinated fashion. Fourth is that the right thing to do is "hard-wired" into the process, so that by using our electronic health record and other electronic infrastructure, we don’t rely on individual heroism or goodwill or memory to see that these right things get done. Lastly, the patient and his or her family is actively engaged in the care process and their preferences are taken into account, communicating in a peer-like way with the caregiving team. All of these principles are applied within a broader framework of accountable parties who are leading these initiatives, metrics of performance that can be tracked and trended over time, and a feedback loop that can enhance performance.

PND: What was the process used to develop these projects?

RAP: We started with a clinical business case that lays out the benefits we expected to accrue from an outcome standpoint, a patient satisfaction standpoint, and an efficiency standpoint. The second aspect of our process is that it’s collaborative, and we start with a multidisciplinary team that includes physicians, nurses, nurse practitioners, physician assistants. The third, and maybe most important aspect of all is that we started our innovation initiatives in what we call the "sweet spot" at Geisinger: focused where we can collaboratively work with Geisinger Health Plan and our provider group and focus first – not exclusively, but first – on the patients for whom we provide the majority of care and for whom we pay the majority of care. That sweet spot enables us to tweak incentives, look for alignments, and redesign our clinical processes around what adds the most value to the patient and to the system. We rolled out the clinical part of the programs to all patients, regardless of payor, and we can systematically choose whether to roll out the economic parameters to the other payors depending on our contract and on their level of interest. We try to incorporate very specific targets for our redesign initiatives so that we know what constitutes success or failure. We take pieces of care process improvement methodologies, like Six Sigma or lean reengineering, and try to learn as we go, reusing things we’ve deployed in other projects in the overall innovation architecture.

PND: Can you describe the specific projects involved?

RAP: Our Personal Health Navigator medical home demonstration project, which involves accountable primary care physician practices, is designed to help coordinate and facilitate care for a patient and their family – whether it is provided directly by that practice site, referred specialty care, end-of-life planning – over an entire lifetime. For each patient, there is a primary care physician "team captain" and a group of other caregivers and facilitators: nurses who work in that practice, mid-level practitioners like nurse practitioners and physician assistants, front office staff. They work to: (1) make sure that patient’s preventive health care, acute care and health maintenance are up to evidence-based standards; (2) make it comfortable and desirable, so that that patient or family can feel comfortable raising issues of concern, sharing personal information and the like in a way that achieves their outcome goals; and (3) deliver care in an efficient, close-to-home manner. Our doctors, our care management nurses and our health plan care managers all use the same information available electronically through our electronic health record.

The physician gatekeeper care model of the 1990s was basically designed to prevent the patient from getting referrals, or to keep costs under control with capitated payments. Instead of capitated reimbursement, we pay primary care practices fee-for-service, which encourages the doctor to bring the patient in to be seen, and to be more involved in their care. We didn’t give them a financial incentive not to refer, but we created a gainsharing pool of dollars, based upon how efficiently that patient was managed over the course of the year on a total expenditure basis – including primary care, specialty care and hospitalization. The pool was created based upon savings by using a more efficient, value-based referral network of low-cost specialists, imaging facilities and other ancillary providers. However, our doctors and practices can’t earn a dime from that pool unless they hit a variety of agreed-upon quality metrics. Did they properly screen the patient? Did they get them on the right preventive medicines? Did they control their blood pressure? Did they control their lipids? Did they control their blood sugar, if they’re diabetic? What was the hospital readmission rate for their patients? We are about to start tracking formal patient satisfaction survey information. So, the pool was created based upon value, but access to the pool is based upon quality.

We also provided a 24/7/365 personal navigator – almost like a concierge – that they can call, who is always going to get the patient to the right person. We also funded, through the health plan in advance, a dedicated care management nurse embedded within each practice site, as well as payments directly to the doctor and the practice for all this extra work that we’re asking them to do. Those are sizable amounts: about ,800 per doctor per month, and about ,000 per practice, per month, per thousand Medicare members – on top of the existing fee-for-service reimbursement. In return, we’re asking these practices to totally change the way they’re caring for people, such as staying open extended hours and on Saturdays, so that things that might have gotten shunted off to the emergency room are now being cared for by a patient’s regular doctor. We provide feedback data to all our practice sites that compare each site to all the other sites, to the best practices within Geisinger, and to where they’re trending. There is some peer competition there, but it’s also how can they learn from what’s working at the other sites.

Our thesis was that patients with multiple chronic diseases, who are using most of the dollars in the health care system, probably need to get more care, not less, and if they got more care up front, they would utilize fewer hospital admissions and high-cost services that really swamp the payment model. What we found is that, yes, the number of their office visits goes up, and their pharmacy costs go up. But that is more than compensated for by a decrease in hospital, nursing home, and other related costs. In preliminary data with two practice sites during the first year, we saw a 20 percent reduction in all-cause hospital admissions – readmissions as well as new admissions – and a seven percent reduction in total medical spending. We’ve since expanded the program from two to 30 different physician practice sites – including a non-Geisinger multispecialty group – and we’re seeing similar results in the expanded sites: a marked reduction in all-cause admissions, an increase in pharmacy spending, and an increase in office-based spending, netting out to reduced cost, overall.

PND: How essential is an integrated delivery system to the success of this program?

RAP: From a health plan perspective, we have the incentive to try to expand this wherever the health plan insures patients, regardless of whether Geisinger is providing the care or not. We believe this is translatable beyond an integrated delivery system because, in our scenario, we’re not acting as a delivery system, we’re acting as an insurance company that is working with other aspects of the delivery system which are non-Geisinger to create a similar medical home model. And we’re applying a very similar strategy, which is an embedded care management nurse, stipends related to the extra work we’re expecting practices to do, and so on. Our hypothesis is that you don’t need an integrated delivery system to do this, you just need a health plan and a physician practice that are willing to work collaboratively together, with the health plan realizing that they’re going to have to actually pay for these extra services, and the physician practice realizing that they’re going to have to work in a different way and be accountable for delivering quality and value together. We don’t have the same benefit of a common electronic health record platform there, so we’re looking at workarounds for how to do that – other ways of sharing claims data from the health plan with the doctors, and sharing some of the clinical information from the doctors with the health plan. We firmly believe that other insurance companies and other practices that don’t have anything to do with Geisinger could recreate a model like this, but those health plans have to be willing to fund these kinds of transformational changes because the practices don’t have the money to do it on their own and, even if they had the intellectual incentive – knowing it’s the right thing to do – they can’t do it without that help.

PND: What was the second care innovation project?

RAP: The chronic disease care optimization program was the second of three. We looked at a variety of diseases, including diabetes, chronic kidney disease, coronary artery disease, and most recently disease prevention, where we apply the same principles: what does the evidence say about what should be done for these patients and how can we ensure that all of those things are done 100 percent of the time. There are about eight to 10 performance metrics per disease state, except for the prevention bundle, which has significantly more. Here again is an intersection between our ability to mine our database to identify where the gaps in care are; to hardwire that into our electronic health record, including standard order sets; having our nurses check where the gaps in care are while they’re rooming the patient and prepopulate an order set that can go to our clinicians; tracking and setting up automated reminders. We made dramatic changes in the percentage of patients that are achieving a variety of process and outcome metrics. Then we align financial incentives, giving physicians the opportunity to earn a bonus by meeting targets for improvement. Our physicians are salaried, but they have on average about 20 percent of their compensation at risk, at least half of which is based upon quality measures – their ability to achieve substantial improvements in population-based health measures, and how they’re doing as a team.

PND: Would that model transfer to non-Geisinger physicians?

RAP: Other health plans have their own pay-for-performance programs for non-Geisinger doctors, but for the typical fee-for-service doctor out there, there is no way that they’re going to have 20 percent of their compensation at risk, or half of that 20 percent based upon quality. That’s just not the way that the world works and I think it’s one of its deficiencies. That’s one of the things that policymakers need to grapple with. Physicians are important professionals in our society, and they should be rewarded for outcomes, rather than being paid for widgets of service. We also have this perverse incentive where physicians and hospitals are, frankly, often paid more if things don’t go well. Hospitals are paid for a readmission that could have been avoided. Doctors are maybe paid for follow-up care from a problem that potentially could have been avoided.

PND: What results have you seen from the program?

RAP: We’ve seen statistically significant increases in many measures across time and we have more than doubled, and often tripled, the percentage of patients getting all the relevant measures associated with their disease. We’ve compared how the Geisinger doctors compared to non-Geisinger doctors who are serving the health plan, and with statistical significance we’re better 60 to 80 percent of the time than the non-Geisinger doctor group. That improvement has been steadily increasing from quarter to quarter.

PND: What is your third innovation project?

RAP: It is our ProvenCare acute program for those patients who, despite great care coordination, the medical home, and chronic disease care optimization, still need some major intervention – specifically, elective coronary artery bypass surgery. How do you optimize that intervention? The principles here are again the same: a multidisciplinary team, defining outcome goals – quality and efficiency metrics, and hardwiring into the electronic health record, and incentive alignments. We devised a single price for all services across an entire 90-day episode bundle – the hospital fees, doctor fees, consultant fees, follow-up fees – as the incentive package. The episode was defined from the start of the office visit where the decision is made to have surgery through a 90-day post-discharge from the hospital. That rewards the buyer because we looked at the historic readmission rate and added only half of that cost to the price, so the buyer of care is 50 percent better off on readmission cost, on average, than they were before the program started. Their payment is also completely predictable, and they have no risk of outliers – those unusually high-cost cases. At the same time, we had a financial incentive on the hospital side to get readmission rate and other costs down, because 50 percent of that amount was still bundled into the price. We are taking risk, at the provider level, for all of the care, any complications and any related readmissions for 90 days, which the press labeled as a "warranty."

PND: How is the single fee distributed among clinicians?

RAP: Our doctors are salaried, so reimbursement would not change for them. The big distribution was between the hospital and consulting physicians, who may not be Geisinger doctors. We set up an overall clinical enterprise incentive: if care could be improved, the incentive went to the clinical enterprise getting the lump sum payment – the cardiovascular service line – rather than to the doctors directly. We’re taking an active look at whether to have future incentives filter more directly to the individual caregivers.

PND: How does this program differ from traditional pay-for-performance programs for hospitals?

RAP: Traditionally, almost all pay-for-performance has been for ambulatory services and primary care. There’s very little, if any, specialist pay-for-performance programs and very little inpatient. Also, most pay-for-performance programs have been about, "if you do some process step a certain percentage of the time, you get some bonus." But because any given payor typically represents a small percentage of an overall practice’s revenue, and because patients who meet the criteria are even a smaller percent, you quickly go down to where you’re at less than one percent, in terms of dollars, so the incentives don’t make a difference. This program is quite different: providers initiated it, not the payor; it is focused on specialty care; it is inpatient care; and we assume risk for this whole bundle – which had not been done before.

PND: What results have you seen from the program?

RAP: On an overall basis, pretty much all of the clinical performance measures which were tied to the Society of Thoracic Surgeons clinical outcomes database improved between 15 and 60 percent, length of stay fell by about half of a day, the hospital’s financial status improved significantly, and readmissions fell by 44 percent. The program has now been expanded to hip replacement surgery, cataract surgery, bariatric surgery and percutaneous coronary intervention. We’re in the process of applying it to our first non-surgical area – perinatal care, and also to spinal surgery.

[caption id="attachment_1846" align="alignleft" width="160" caption="Eric Culley, Pharm.D., MBA"][/caption] Eric Culley, Pharm.D., MBA, is manager of clinical pharmacy services at Highmark Inc.

PND: Could you describe Highmark’s generic drug vending machine program?

EC: We partner with a company called MedVantx which provides the generic sampling machine – a stand-alone unit in physician offices, about the size of a bank ATM machine, which houses approximately 30 to 35 generic drugs. The goal of the program is to have high quality generic medications readily available to be given as samples to Highmark members at their primary care physicians’ office. Whenever a physician wants to give a sample to a patient, they have a mechanism by which they can scan the patient chart, pick whatever drug they want out of the machine and the member will be given a full course of therapy. In some cases, as with antibiotics, the drugs will only be sampled for seven to ten days. If it’s a long-term medication, for example, for high blood pressure, they could get a 30-day supply. The drug is given to the patient, along with a patient package insert with written instructions on how to take the drug, and benefits and side effects – the same type of information typically given at a retail pharmacy. There’s no charge to the physician to have this machine in their office and there’s no co-pay for our members who receive those samples.

PND: How did you select the types of drugs to include in the machines?

EC: It is standard across the machines. MedVantx has sample centers in multiple states in the Northeast, the Midwest and also in California. The system is a multi-payor model, and there are other health plans that participate, including UPMC Health Plan and Coventry. Right now, Highmark is the largest participant and we also have the largest sample volume for our membership. Participants have a voice in what generics are included, and we want to make sure that there’s enough flexibility that the machine is valuable for most primary care physicians, but primarily that is governed by the vendor, MedVantx. They are typically low-cost medications that are widely prescribed for major disease states such as blood pressure and depression.

PND: Regarding Highmark’s participation, how many physicians are involved and where are they located?

EC: They are located throughout western and central Pennsylvania. In 2006 we had 631 physicians, and this year there are around 700 physicians participating in western and central Pa., from approximately 186 practices.

PND: How do you choose which practices participate?

EC: We want to make sure that the practice sees a critical mass of Highmark members and we also look at the overall volume of drugs that a particular office prescribes. They need to be writing a fair number of prescriptions, and also have a representative Highmark population.

PND: Does Highmark offer this program to prospective physician offices, or can physicians request it?

EC: We’ve had both. This program started as a pilot in 10 physician offices. One of my staff, who is a pharmacist and a full-time employee of Highmark, went out to them with the vendor to pitch the program, trying to make sure it was valuable to those physicians. We now have a list of physicians who are interested in participating and we’re trying to get them into the program.

PND: What results has the program produced?

EC: We did a return on investment analysis that was published in the June 2007 Journal of Managed Care Pharmacy. We looked at our overall pharmacy claims. The amount saved per physician was relatively small, but when you look at changing utilization patterns – that’s really where the savings come from. Say their brand prescribing rate was around 50 percent – so half of their scripts were generic and half were brand – we would track and trend that over time and find that our physicians that were in the program had a significantly higher generic dispensing percentage than those in the network and those of their peers. The end result of the study is that having the sample center did change prescribing habits. They used generics more often, and it was financially advantageous for the member because they didn’t have a co-pay. Because generic co-pays are less than brands, long-term savings for the member was there, as it was for the plan and ultimately their employer groups. In 2005 we estimated the cost saving was 7,000, and in 2006 it was 3,000.

Again, there’s no cost to the doctor, there’s no cost to the member, but Highmark is still paying for the generic samples much like we would pay for a generic prescription in a pharmacy. We wanted to make sure that it still made sense financially for us and for our groups – the people paying for insurance. We continue to do a return on investment analysis every year. There’s been a three-to-one, or three-and-a-half-to-one ROI over the last couple of years, and that’s been pretty consistent, so we believe that there is financial value to our members and to our groups. As far as physicians from whom we’ve heard anecdotal feedback, they really like it. It is an alternative to a brand sample closet and many physicians buy into the fact that generics are still high-quality medication. Many of their patients like it because they’re walking out of the office with something in their hand, much like they would be given a brand sample starter pack. With this program, you can walk away with a month’s worth of therapy.

PND: Were there any data as to whether the frequency of prescribing itself changed – for example, physicians who may not have prescribed antibiotics did so because the drugs were readily available at no charge?

EC: That exact study is in peer-review right now. And what we found: the shortest answer to that is no. The overall prescribing didn’t increase more than that of their peers. For the physicians that had this in their office, their increases were the same. We did a second follow-up study on antibiotics for that reason. We were clinically concerned by having antibiotic samples in there and we wanted to make sure that people who would not otherwise have been prescribed an antibiotic didn’t get one, for example for a cold or for a flu, just because there were samples available. Our study, which hopefully will get published, showed that that really did not happen, and it was very encouraging.

PND: What are your plans for expanding the program?

EC: We wanted to make sure that all of our high-volume prescribers who were interested have a machine. The next step is to expand the program to those offices who are perhaps in the middle tier, who don’t prescribe as often but there’s still some opportunity. We’ve been working with our vendor to get more machines in the central Pa. area – Harrisburg, Camp Hill and regions north and south of that – and any other untapped markets in western Pa. as well. We have an ongoing analysis to make sure that we have these machines distributed appropriately.

PND: Are there any plans to expand into the southeastern Pa. region under the aegis of Highmark Blue Shield?

EC: Not in the immediate future. We’re looking at the markets that we understand and do very well in right now – and that’s western and central Pa.

PND: What are the advantages of increasing generic drug use, and what are the barriers?

EC: Whenever people talk about generics, I think we – the pharmacy and medical community – have done ourselves a disservice by calling them generics because it has a negative connotation and the public and sometimes physicians and pharmacists may perceive an inferior quality product. As a physician, you know there are drug reps in your office frequently, and often times there are large sample closets with brand-name drugs in the office. When you have the generic drug machine that competes in that same space, I think that’s been a real inroad for us in breaking down that barrier. What people tend to forget is that these are the same products that were multi-million dollar brand-name agents just five, sometimes ten years ago. They still work. The human body hasn’t changed that much in the last 100 years. They’re high-quality medications. The FDA has very rigorous manufacturing standards around these to make sure that what’s on the bottle is exactly what’s in that tablet. Just because they’ve lost their patent and are no longer marketed by pharmaceutical companies doesn’t mean that the drugs are less effective. They’re great alternatives and they are less expensive. The goal of health insurance, and certainly Highmark, is to keep health care affordable because we know that people who don’t have health care coverage don’t take their drugs and don’t see their physician. If cost is a barrier, generics are a great way to remove that barrier. It’s less expensive for the individual patient. It’s less expensive for the health plan. It’s less expensive for the employer. So in my mind, that’s really a win-win-win.

PND: What are other methods of increasing generic drug use?

EC: Benefit design is probably the intervention with the greatest impact. Generics are typically much less expensive. Generic copays can range from five to ten dollars, or less, versus typical brand-name copays that are to or more. So, there’s a financial incentive to encourage patients to seek out that treatment if it’s appropriate, especially since these are typically monthly medications. We’ve also done analysis and have seen market share shift from several other interventions. We have two counter-detailers – pharmacists who are out in the field promoting the value of generics, and who visit physicians in western and central Pa. as part of our pay-for-performance program, which uses a generic dispensing percentage measure to help give incentives to physicians who use high-quality, low-cost generics. They also visit the offices that have the generic sampling machines, as well as other offices. We have tip sheets on average costs because there are some physicians who don’t know the real cost of drugs. We can analyze particular offices and see what their top ten drugs have been and our pharmacists will sit down with them and go over that profile and show them where there’s opportunity. We also do direct mailings to our membership, for example, when a blockbuster drug becomes generically available. One that comes to mind is Zocor, for high cholesterol. We identified that as an opportunity for anyone who was on a branded statin. We sent them a letter saying that these are alternatives which may or may not be right for you, go talk to your physician. Direct mailings have been encouraged by a lot of our employer groups, because they certainly have a financial stake in the game as well.

DK: The survey was conducted between May and July 2007. Over the years, when we’ve answered questions from physicians about practice management issues, we have had to fax information to them because most of them didn’t have e-mail in their practices. This led us to believe that practices were not using applications connected to broadband at the same level as other industries. We also understood, in our efforts to expand health information exchange in the Commonwealth, that infrastructure was going to be necessary in order to do that. Despite whatever internal applications they may purchase, such as electronic medical record systems, physicians would be limited in their ability to connect to other physicians and hospitals without broadband. We pursued a Broadband Outreach and Aggregation Fund (BOAF) grant through the Pennsylvania Department of Community and Economic Development to do a statewide assessment of physicians’ use of broadband and other health information technology.

Broadband is a reference to the bandwidth of an Internet connection: the wider the bandwidth – the "pipe" that is delivering the telecommunications – the more data can be sent at the same time. For example, in a physician practice, if you’re just sending a text file, you don’t need a lot of bandwidth. But physician practices often use digital images, and those take a lot of bandwidth to communicate. DSL is the lowest level of broadband in the U.S., and is faster than the older dial-up connection to the Internet. Other types of broadband include cable modem, T-1, Residential Fiber, T-3, and OC-3. Right now on the commercial market, the fiber optic connections are some of the best, but they’re not widely available in Pennsylvania.

PND: Why is broadband connectivity important to physicians?

DK: In the past, physicians have talked to hospitals using a telephone and exchanged records manually. They started to do some electronic transmissions over the last 20 years as more and more physicians submitted claims electronically to insurance companies. Most physicians do that now. What we’re finding, however, is that physicians are not adopting health information technology such as electronic medical records and electronic prescribing at a rate that is going to meet the goals of the federal government. Doctors who adopt electronic prescribing are often told by their vendor that a DSL connection is sufficient. Technically, that’s probably correct. A single physician submitting a script to a pharmacy, which is a very small file, should really not need more than DSL. The problem comes when you have multiple physicians in the practice who are using this connection at the same time. Perhaps the practice is also doing billing, using the connection for submitting claims to payors, all of which diminishes the functionality of the connection. Physicians can buy and use electronic medical records in their practice and not need the Internet, but the real value is when those records can be exchanged rapidly with other physicians and hospitals. We need to build that infrastructure so we’re ready for when more physicians have EMRs and these health information exchanges are built.

PND: What were the major findings of the survey?

DK: The first category of findings was the use of broadband itself in physician practices. About two percent of practices in Pa. are located in areas where they cannot have access to broadband. That’s about 300 physicians, generally in rural areas. Eighty-eight percent of physician practices do have some sort of Internet access, and 74 reported having at least basic broadband, including 31 percent who have DSL. Just one percent have fiber optic service. Two percent are still using dial-up connections, and that’s not limited to rural areas – even in Philadelphia there are physicians who have just dial-up access from their practice.

Our survey also examined physicians’ health information technology adoption. A federal law passed in July should motivate every physician to seriously consider implementing e-prescribing in their practice: Medicare will pay a bonus to successful electronic prescribers beginning in 2009 and will reduce Medicare payments to physicians who do not meet the electronic prescribing requirement beginning in 2012. Sooner or later the federal and/or state government is going to require that physicians use electronic medical records. We do think our survey is biased towards the more-connected physicians – we know that some of the larger groups that answered were more likely to have electronic medical records and other telecommunications. About 19.7 percent reported having an EMR system in their practice. Forty percent of those had an integrated e-prescribing system. That translates to 11 percent of all respondents who had an integrated electronic prescribing system, while 10.3 percent had a stand-alone electronic prescribing system.

The third area of our survey findings was access to care. When you look at some specialties, there are vast access issues in the "T" region of Pa. We found, for example, that three million Pennsylvanians – about 24 percent – live over 25 miles away from the nearest high-risk pregnancy specialist. We found that 800,000 Pennsylvanians live over 25 miles away from the nearest dermatologist. We have high concentrations of senior citizens in the rural areas of the state. Senior citizens are more likely to develop lesions and malignant lesions. Trips to dermatologists over that distance are difficult; even getting an appointment in more populated areas is difficult because of a shortage of dermatologists. Here is a population that is at risk of life-threatening problems because of lack of physician specialists in their area. Telemedicine can be a solution to help provide specialty care to some of these patients in underserved areas, but it isn’t well-developed. It requires a very high level of broadband service because it is a real-time connection, where the patient and doctor can interact remotely. I’m told that lesions can be better visualized using digital equipment than they can with the naked eye and a magnifying glass. We believe that there are opportunities to improve the health care of Pennsylvanians through expansion of broadband and the resulting use of telemedicine.

PND: On the basis of these findings, what actions does the report recommend?

DK: First of all, we need to build awareness among physicians and staff of the need for broadband, and how it can make a difference in the way they practice medicine. We also realize that telecommunication companies are not going to build out to areas that do not currently have access, and doctors are not going to spend more money than they’re already spending to adopt a technology unless there is a business case to do so. So, there are two groups we have to build a business case for. The business case can be developed for physicians because they need broadband to do EMR, electronic prescribing and other technologies. As we build the case for physicians, then we can create a demand for broadband that builds the business case for the telecom providers to reach out, and allow physicians to get the broadband they need more economically.

PND: What are the key obstacles to building a business case for physicians?

DK: There are some general themes that we hear, for example, that the cost is prohibitive. These systems are expensive. There is a cost for the system itself, the training, the ongoing maintenance. Most physician practices find that there is a decrease in productivity anywhere from a few weeks to a year, until all the physicians and staff get used to the system and they’re up and running. Physicians may feel that perhaps other entities are reaping the benefit from the use of EMRs and electronic prescribing – insurance companies, the government – and that there should be some shared cost in this, as well. Another obstacle is that some physician practices do not have technological expertise in-house and they’re reticent to make changes because they feel like they don’t know what they’re purchasing. They are also concerned about interoperability with other systems, as well as privacy and security issues.

PND: How will the medical society attempt to address some of these obstacles?

DK: Several efforts can help offset the costs. We received a second grant to do outreach and to do demand aggregation. We are doing statewide education of physicians to help them assess their needs and to build the business case for broadband, including face-to-face meetings, podcasts, a DVD, videoconferences and Webinars. To address lack of technology savvy during our demand aggregation project, our plan is to bring a selection of vendors along with us that could help physicians feel more confident in what they’re doing in their practice with technology, and overcome concerns about security and interoperability. When you’re buying an electronic medical record system, you want one that has already been certified by the Certification Commission for Healthcare Information Technology (CCHIT). That doesn’t mean that today you can just plug into any hospital and they’re going to be able to exchange data, but it does show that it meets their criteria for interoperability and is on the road to evolve as the standards evolve. That’s not to say that every system that is CCHIT-certified is going to be the best one for your practice, but there are so many certified systems that there is going to be something available that you’re going to like.

With our survey, we have also identified a number of areas in Pa. that have a need for broadband expansion, and we presented those locations to the Department of Community and Economic Development. They selected two of those for us to target: the first area is about 12 counties in northwestern Pa., and the other is in the Bucks County area. We will be reaching out to physicians, hospitals, assisted living, nursing homes, pharmacies and other businesses to aggregate the demand for broadband and put in an RFP to the telecom companies. We feel confident that we are going to be able to get a better price for the participants.

Separate from our ConnectTheDocs project, the medical society is looking into ways that we could aggregate demand for electronic medical records that would help drive down the costs for physicians. We’re not recommending any specific EMR vendors, but we can make them available for physicians to talk to. The federal overnment also has some initiatives that provide funding for some physicians. Highmark has announced recently a million initiative to help pay for electronic prescribing.

Also, back in 2005 the medical society founded the Pennsylvania eHealth Initiative, a statewide group that is involved in the health information exchange area, and is working with the governor’s office to provide them with information – including interoperability, security and privacy issues – as they set forth on their own health information exchange initiative. The Pennsylvania eHealth Initiative is approaching these issues from a high level, and our ConnectTheDocs initiative is starting at the grassroots level. So, from both sides, we are working to expand adoption of EMR and to expand health information exchange in the Commonwealth.

[caption id="attachment_1848" align="alignleft" width="153" caption="Michael Doering"][/caption] Michael Doering is the executive director of the Pennsylvania Patient Safety Authority, which recently released its latest Annual Report.

PND: What progress has been made in improving patient safety in Pennsylvania?

MD: There has been significant progress among different entities in Pennsylvania and by facilities and providers themselves. In June 2004 the Patient Safety Authority began implementation of the Pennsylvania Patient Safety Reporting System (PA-PSRS), and we receive about 210,000 reports each year of incidents and serious events. A serious event is when there’s harm to a patient, and an incident is when there is no harm to a patient. About 96 percent of what we receive are incidents, where there is no harm. Our analysts take that information, review it and put out the Patient Safety Advisory, which is a quarterly publication. We may have direct contact with facilities. We may conduct special studies based on information that we see. We put together patient safety toolkits for folks to use. That’s primarily what we had done in the first three years.

Each issue of the Patient Safety Advisory has about eight to ten articles that have to do with different patient safety events that we see from the reports that are submitted to us. We provide a narrative of what some of these reports are, summarize what the literature says about the types of events, and provide some guidance to the facilities. We do an annual survey of patient survey officers, and 68 percent of those participating in the 2007 survey reported making or planning to make changes based on an Advisory article, and that’s up from 63 percent the previous year. Many of those facilities are implementing numerous pieces of guidance that come from the advisories. Of the 103 hospitals that responded, they said they made 364 changes. So, the information we’re putting out is being used. In 2006 we were awarded the John Eisenberg award by the Joint Commission and the National Quality Forum. That’s something that, among peers in patient safety, is a fairly prestigious national award. We aren’t just sitting back on the laurels of the award, though.

PND: Do you have any data as to whether the advisories drive more reporting of certain events or incidents?

MD: I think it does drive more reporting for a couple of reasons. One, I think facilities have been very responsive to the information that we send out through the Patient Safety Advisory and, in terms of the quality and content of information that we put out, we get graded very highly by the patient safety officers. I think that has led to more reporting. But also, whenever you focus a spotlight on a particular event, sometimes we actually see more reporting after that because facilities begin paying more attention to that type of event. They put processes in place, and they can identify more of the type of activity that can then be reported to us.

PND: Has the volume of events and incidents changed over the past few years?

MD: We’ve seen a significant increase in the volume of reports that we’ve received. That increase has primarily been with incidents, where there is no harm to a patient, and I attribute this to an increased understanding and awareness of reporting, the culture of reporting within facilities. For serious events, where there is harm to a patient, we have not seen an increase in the number or percentage of reports that we receive. What we would like to see, in the end, is the reduction of serious events where someone is harmed.

PND: Is there evidence to suggest that patient safety is actually improving in Pennsylvania.?

MD: It’s difficult to be able to put a number on patient safety because no-one has a baseline that says this is what patient safety is in Pennsylvania. There are no real statistics based on the types of events that I would consider to be patient safety events. So we have to, in some cases, rely on narrative. We have to rely on knowing that there are process improvements being made by facilities. Unfortunately, the data that we have are reports of events happening, and we don’t necessarily have a firm denominator for those events, nor can we be sure that we have all of the events that are actually taking place. We know that there are interventions that are in place. If the number of incidents – where there is no harm to a patient – goes up, we cannot be certain that that’s because the facility is less safe, or a group of facilities is less safe. It just may mean that more incidents are being reported. We’re not going to kid ourselves and think that all incidents are being reported in Pennsylvania facilities.

We just had a retreat with our board to take a look at how to measure patient safety in Pennsylvania. Right now we don’t feel comfortable, with the information that we have, to be able to say, "Here’s what patient safety was at one point, in terms of a statistic, and here’s where it is now." I don’t think that there are any practitioners in this field who would say that the data out there are perfect to be able to do that. So, we’re going to attempt to put together some sort of an algorithm that we can use to represent patient safety in Pennsylvania.

PND: Are there competing frameworks of definitions for patient safety, or is it a matter of the number of events and incidents going down from some baseline?

MD: It’s not just the number of what’s reported to us going down because, again, I don’t think that we receive everything that is out there. So, the fact that a number would go up doesn’t necessarily mean we’re less safe, and a number going down doesn’t necessarily mean we are safer, in terms of what’s being reported to us. We do have to try to look at a variety of things, including the culture of safety within facilities. That’s something that various organizations are attempting to measure. In some cases we can look at outcome information. In some cases we can look at administrative information. We can also look at things like wrong site surgery – that’s something we believe has a high degree of reporting; we don’t think a lot of those are missed. Where there’s an event that we think is being highly reported and we can have some sort of program to try to reduce it, that’s something that we believe can become part of the algorithm. We would like in our next annual report to be able to define how we’re going to do it and attempt to form a baseline.

PND: What have been the limitations and obstacles to knowing, with confidence, that the number of reported events and incidents correspond to the entire universe of reportable events?

MD: As we pointed out in our 2007 Annual Report, there is a discrepancy between the rates of reporting by facilities – some facilities are reporting up to 50 incidents and serious events per 1,000 patient days and others are reporting much less. There is a variety of possible reasons for that, including the culture of reporting within a facility and how many systems are in place to be able to identify potential errors. But I think a lot of it has to go back to Act 13: the definition of what is reportable as a serious event. Frankly, there are some ambiguous terms, including the word "unanticipated." Whether or not an event is anticipated or unanticipated largely defines whether it is reportable or not. There’s also the language for a serious event that it has to be something where the patient is injured and additional health care services are provided to the patient. Folks read "additional health care services" in different ways. So, the facilities themselves have interpreted these definitions in different ways, and I think that accounts for a significant portion of the differences in reporting between facilities.

PND: How much variation is there in volume of reported events and incidents?

MD: There’s a significant amount of difference. There are outliers, of course, in all of this, but I would say that the top quartile of hospitals reports between 36 and 300 incidents and serious events per thousand days and the median is around 20. If we go down to the lowest quartile, there are a few hospitals that are zero, and others well into the single digits. A large urban teaching hospital may report five serious events per thousand patient days while another similar hospital might report less than 0.1. So, the difference is not because of the type of hospital.

PND: Your organization has been providing educational guidance to attempt to provide clarity. Why have those efforts failed to substantially decrease reporting variability?

MD: I don’t know that it has failed to decrease variability from where it was before because we never measured it before, but it obviously hasn’t taken it to where it should be. One of the reasons is that the Patient Safety Authority is an educational and training organization. That is our goal. We don’t have any regulatory authority. The Department of Health is the regulator for Act 13. We did put out a memo that said just because something is on the patient consent form doesn’t mean that it is an anticipated event. However, we believe there are facilities that still say, "Well if it’s on the patient consent form, then it was obviously anticipated." I have been in contact with the Department of Health and we’re about to begin an effort with them to try to define some of these terms better and provide more concrete guidance to the facilities. And then we need to make sure that the surveyors from the Department of Health are trained and are all applying this guidance in the same manner when they do the licensure reviews of the facilities.

We want to be able to understand the characteristics of facilities that are reporting a lot – and again, this doesn’t mean necessarily that they are less safe facilities, because most of what they’re reporting are incidents where there is no harm – because those facilities appear to have a comfort about reporting that information. And they’re not just reporting it to us, they’re reporting it to themselves, because PA-PSRS allows them to review their data and run a variety of reports that most of them will send to their patient safety committees and to their boards of trustees. We’re going to do a survey of facilities that are high reporters and facilities that are low reporters and try to figure out if there are any common characteristics among each group. We’re going to do this anonymously; our goal is not to identify who the high or the low reporters are, but just to be able to understand things like whether the patient safety officer or organization has access to the executive management within the facility, how involved are the chiefs of the various specialties, how involved are the physicians, what is the culture of disclosure at these types of facilities. We think we may be able to gain some valuable insight we can pass along to other facilities.

PND: What other new initiatives do you have planned?

MD: Our board in 2007 said we want a strategic plan going forward. We looked at the work we’d done the last couple of years and it has been focused on getting the reporting system in place, being able to do some analysis, conducting some training and providing guidance through the advisories. We wanted to expand beyond that into more collaboration and into more education and training. We came up with 11 initiatives. One is training and education for hospital boards of trustees, which we are piloting this fall together with the Hospital & Healthsystem Association of Pennsylvania. The Patient Safety Authority is also going to hire a director of educational programs and hire up to six patient safety liaisons, the job of whom is to get out into the facilities to help them to understand what types of education or training we can help them with; as well as to be able to share process improvements, procedures and policy changes between facilities; and to be a resource for those facilities in various regions.

Another initiative is the Patient Safety Knowledge Exchange (PasSKEy). There are so many people undertaking quality patient safety efforts in hospitals and ambulatory surgical facilities within Pennsylvania and you don’t want to have to re-invent the wheel at all of these different facilities. The goal of PasSKEy is to provide an online community for the patient safety officers to be able to discuss different patient safety events and to be able to post and share different policies and procedures that folks have implemented in their particular facility that may be of value and help to others. If something works in a particular area in one facility, it would be great to be able to share that information across many different facilities.

Another new initiative is nursing home reporting, which grew from Act 52’s mandate to collect information on hospital-acquired infections (HAIs). That’s a pretty big job because we have 500 facilities in PA-PSRS right now, and there are an additional 700 or 750 nursing homes, so it’s a significant amount of new facilities that would be reporting to us, and also to the Department of Health. Along with the Department of Health, we have defined a draft of what is reportable and we’re in the comment period right now for that. We were charged with setting up an HAI Advisory Panel in the Commonwealth and we’ve done that: we have a great group of 15 clinicians from around the state who are experts in this field. Five of them were appointed to a long term care committee on reporting, and they helped establish what would be reportable. We’re also working with the Advisory Panel in terms of what type of training we should have for people in facilities. We don’t believe you should just tell them to report and then wait and see what comes in. We want to make it as understandable and easy as possible for them, and we will hold training sessions around the state to help these folks do reporting.

[caption id="attachment_1849" align="alignleft" width="181" caption="Joseph R. Betancourt, M.D., M.P.H."][/caption] Joseph R. Betancourt, M.D., M.P.H., is director of The Disparities Solutions Center, program director for multicultural education, and a practicing internist at Massachusetts General Hospital.

PND: Why is cultural competency an important component of patient-centered care?

JRB: Over the last 10 to 15 years, a significant literature has emerged documenting several factors that make the issue of cultural competency particularly important. We know that our nation is becoming increasingly diverse, and social and cultural factors do matter in the clinical encounter. Issues of patient expectations of care, their health beliefs and their behaviors all may be apparent during the clinical encounter, and the literature supports the fact that it is important for physicians to be skilled to both ascertain what these issues are, and to be able to manage and negotiate them. A significant literature has also emerged in the area of racial and ethnic disparities in health care. This literature documents that patients, even with the same level of education or insurance, who may be of a different race or ethnicity, might receive a different quality of care. Minorities may receive lower quality of care than their white counterparts for some of the same conditions – for example, when they present to the emergency room with chest pain. The Institute of Medicine Report, Unequal Treatment, in which I had had the honor of participating, studied this issue for the better part of two years and found that communication between the doctor and the patient was one potential target area that would help us address these disparities. So, what we’ve seen over the last 10 to 15 years is a realization that we as physicians can build our skills in the area of communicating effectively across cultures, asking particular questions of our patients, and being able to negotiate in ways that we think will improve the outcomes for these patient populations.

PND: What is cultural competency, and what is its trajectory, from a policy standpoint?

JRB: This field basically is an expansion of patient-centered care – the need to be attentive to the health beliefs, values and perspectives of the patient. What has been absent in that discussion is particular attention to social and cultural factors, and that’s the gap that cultural competency hopes to fill. What cultural competency attempts to do is give the doctor a set of tools – questions and skills for negotiation – that they can incorporate into their history of present illness and shed light on what health beliefs a patient may have, what particular complementary or alternative medicine a patient might use, how a patient and their family might make decisions that may be culturally-based. Once that information is revealed, the physician could engage in a negotiation with a patient to improve outcomes. The set of tools and skills are built on a foundation of research: cross-cultural interviewing, medical anthropology, social psychology, patient-centered care. A melding of these different fields has built a set of questions that are taught, although it’s not completely standardized yet. We do know that, on the policy side, New Jersey has taken the lead on making the issue of cultural competency a requirement for licensure. We see about six to eight states that are engaging this issue as a significant policy movement. Like other fields, such as the patient safety movement, this field will become more standardized and I think will become an essential part of licensure. We are beginning to see questions in specialty board exams about racial and ethnic disparities and cross-cultural communication. Another area where this issue is being explored is risk management and prevention of malpractice, in which there is an understanding that building tools and skills in this area might be beneficial. There are certain medical malpractice companies across the country that are looking to give discounts for health care providers who have taken courses in patient-centered care, and hopefully soon in the area of cross-cultural communication.

PND: How does a physician strike a balance between being sensitive to the cultural background of their patients and treating each individual as a unique person without stereotyping them?

JRB: In years past, a lot of what was done in the area of cultural competence was what we called the manual-based approach, where you’d pick up a small text that would have five to seven key things you needed to know to take care of an Hispanic or African-American patient, for example. I’m Puerto Rican, myself, and I would often read these things and a lot of them didn’t apply to me or my family. A lot of them were stereotypical and I worried about that. It became clear to many people in the field that there’s no five-to-seven unifying facts that you could teach about any large racial, ethnic or cultural group. The way to walk the balance is to learn about a particular community and whether there are prevalent health beliefs and behaviors, but also to have a set of tools and skills to explore the particular social and cultural factors that impact that patient in front of you. As an example, if you’re taking care of an Hispanic patient, you may have read that Hispanics are fatalistic. That can be helpful, but it would be detrimental to make an assumption that all Hispanics are fatalistic. The better thing might be to assess whether that patient in front of you is fatalistic. For physician training, what we strive to do is increase awareness with particular clinical examples about how social and cultural factors impact clinical conditions, for example, how might a patient’s health belief about their hypertension dictate how they take their medications; or, how a patient’s understanding of their diabetes might dictate how they follow a physician’s recommendations. Once we establish that awareness among clinicians, we try to give them tools to ask patients questions such as, "In your culture, do you have any particular perspectives or practices around managing condition X?" or "Do you take any particular remedies for this condition?" or "In many cultures, people involve their family in decision-making. Do you involve family, or do you make decisions on your own?" These things don’t have to take a lot of time. We’ve built the curriculum in a way that really gives doctors "surgical-strike" questions that they use to shed light, say, on an issue of nonadherence.

PND: Can you give some examples of these questions?

JRB: Sure. It’s important to remember that we all have culture, and these particular skills are going to be helpful for all patients, not just for minority patients, but they may be particularly helpful for those who are a greater distance from the Western medical model. There are a set of core cross-cultural issues that vary across cultures but are important hot-button issues for all patients, such as styles of communication – the stoic patient versus the very expressive patient; issues of mistrust that might be more prevalent among certain populations; issues of decision-making; sexual and gender issues; traditions, customs and spirituality – those are all issues that might play a role. Let me give you a clinical example. In my social history-taking, I will ask patients, "Are there any traditions or customs that might impact the care that I provide to you? For example, patients with certain religions won’t accept blood products if they needed a transfusion. Or some people may fast for a month while the sun is up. Do you have any customs like that that I should know about?" Issues like those may be particularly important, for example in the area of fasting, if you’re managing a patient who has diabetes. It would be really important, for example, for you to assess whether the patient was observing Ramadan and fasting for a month during daylight hours for you to be able to adjust their insulin regimen. Or, if a patient has congestive heart failure and has a particular tradition of eating salty foods – you might be able to discuss that with them or adjust their medications.

Clinicians should also ask about issues related to how a patient understands their condition, or what they expect as treatment. We see this a lot in patients who have conditions that are, for the most part, asymptomatic – hypertension is key among these. We see many patients who understand hypertension as a condition that is symptomatic. They feel like they know when their blood pressure is high, and that dictates when they take their medications. Being able to explore that with a patient, asking an open-ended question – "How do you understand your hypertension?" – might reveal a lot of very important information that might improve your ability to help them understand their condition and help them manage it. Those issues may be culturally-based. A person may be raised and have heard certain things about high blood pressure or diabetes or asthma that might lead them to manage their condition in a particular way.

PND: What role does discovering these issues play in promoting patient compliance?

JRB: Compliance is a huge issue. We’ve developed certain tools in the field to help screen for noncompliance among cross-cultural populations. We know that only about half of all hypertensives in the U.S. are at target. You as a physician might ask the patient, "Are you taking your medications?" and they may say, "Yes, yes, yes," but they may be going home and taking the medications at different times, depending on how they feel, and may not really make that obvious to you. A simple question might get at the root of nonadherence: "You know, you’ve really had a tough time controlling your blood pressure. Before I go on and explain the pros and cons, and the evolution of hypertension, I want to get an understanding of how you view hypertension. What do you think makes your condition better or worse, and how do you think it should be treated?" By exposing the patient’s perspective in a very patient-centered way, you could then engage in a negotiation with them about how they can best address their hypertension, perhaps letting them know that, "Yes, your blood pressure can be higher in particular situations, but in fact, it’s higher than others almost all the time, and so medication will help it." I think sometimes, as clinicians, we might be too quick to check "Patient noncompliant" or "Patient refusing" and not take the time to ask that second- or third-level question about the root of that nonadherence.

PND: When negotiating with patients over treatment recommendations, how should physicians strike a balance when cultural traditions clash with evidence-based treatment?

JRB: We shouldn’t let the perfect be an obstacle to the good. Obviously, if you have an individual in front of you, and you want to gradually build their trust and get them to buy into what you’re offering, it may require some negotiation up front. I don’t think that is necessarily at odds with evidence-based medicine. We engage in this type of work every day, where a patient may accept a mammogram but may be refusing a colonoscopy and a pap smear. You don’t want to shun a patient because they refuse two out of three. You obviously try to get the mammogram, then try to work with them on the importance of health promotion and disease prevention, and over time negotiate with them and try to secure those other two important screenings. What we’re trying to accomplish with the concept of negotiation is that it’s much better to keep the patient in care and chip away at these issues over time, especially given some of the recent research about the importance of a medical home and patients developing a relationship with a clinician. What we’re trying to avoid is having a patient say, "I feel uncomfortable. I didn’t feel that that doctor understood me, so I’m not going to follow-up." That’s the worst-case scenario, and negotiation provides a door to keeping people engaged in the care, gradually leading to the evidence-based standards.

PND: From a practical standpoint, how serious an obstacle is the time burden of a typical 15-minute clinical encounter to doing this right?

JRB: Without a doubt, time is a challenge. In our 15-minute patient visits, it’s challenging to do anything well. Clearly, this is an added dimension that poses an additional challenge. All that being said, asking some of these questions – asking about a patient’s health beliefs, getting at their understanding – might, in fact, save time in the clinical visit. Too often, we’ll sit and explain things to a patient using the medical model and take up a lot of those 15 minutes speaking our medicalese, when in fact a cross-cultural patient-centered question might reveal a patient’s perspective quicker, put you in a position to negotiate faster, and use your time more effectively. Now, I’m not trying to be pollyannaish or naEFve about this. I clearly think that this is an issue that we need to be careful about, but I do think that some of the better curricula around the country is cognizant of that practical challenge and tries to give providers key questions that they could use, in an as-needed fashion, that could help them save time. Also, this type of work should be done with an eye towards continuity – you don’t necessarily need to do it all in one visit. Effective communication actually saves time and makes the visit generally more efficient and higher quality. In fact, some health insurers are offering pay-for-performance incentives for completion of cultural competency training, including Blues plans in Florida and Massachusetts, Aetna, as well as several larger employer groups around the country – such as Marriott, which understands that a quarter to a third of their employee base may be from ethnic minority groups.

PND: What tools are there to deal with language barriers?

JRB: There’s no doubt about it, when seeing a patient with a language barrier in the absence of an interpreter, your ability to get a good history is significantly limited. But there’s also no doubt that that visit will likely take more time. We’ve seen a significant movement toward the use of tools such as telephone interpreters in the doctor’s office that could provide that service for you. Hospitals are developing professionally-trained interpreter services that they can use with their patients. In the individual doctor’s office, some type of telephonic interpreter service is probably the most effective. Payment issues are being worked out, as health plans, hospitals and others are trying to figure out how to appropriately compensate for these types of encounters. You could imagine a doctor needing to use a language line and footing the bill him- or herself all the time. I don’t think that’s necessarily tenable.

PND: How do physicians go about getting cultural competency information and training?

JRB: There are a variety of tools out there. I and my colleagues have been working in the area of e-learning as a quick, effective mechanism to improve cross-cultural communication. We’ve developed a Web-based program called Quality Interactions that is a practical, case-based, applied approach to cross-cultural communication, and offers continuing medical education credit. There are a variety of other individuals who have developed training modules in this regard. We’re seeing more and more in the area of e-learning because it’s an easy modality and there’s significant evidence to support the fact that it’s is a very effective teaching tool. Hospitals are also bringing in experts to do training for clinicians. Some of the professional societies are doing this as well – I know the American Academy of Orthopaedic Surgeons has developed some DVDs in this regard. It could be as simple as clinicians Googling "cross-cultural care" or "cultural competence" and looking at potential options, and also checking their profession societies or their state boards to see what’s available out there. Physicians do need to be discriminating about the type of learning that they engage in – work that’s built by clinicians and individuals who’ve walked in their shoes. Programs that have a proven track record are important as well – that the tools and skills are in fact practical, not preachy, and give the individual clinician a chance to learn and apply them in a clinical setting. I would hope that clinicians don’t see the issue of cultural competence or cross-cultural education as a burden, but instead, an opportunity to improve their capacity to deliver high-quality care to any patient they see regardless of their background.

By Christopher Guadagnino, Ph.D.

Erik Muther is Executive Director of the Pennsylvania Health Care Quality Alliance.

PND: What are obstacles to more widespread consumer use of online health care quality information?

EM: People use health care information in a variety of ways, but not to the extent that they use information when they purchase other services or products. Most people don’t directly pay for their health care – they have health insurance – so in most cases they’re not directly purchasing at the "retail price" the services that they get. So, they tend to be focused more on ensuring that they get the service that they want, and don’t spend as much time looking up information to ensure that the service is of good quality relative to other services of a similar type. Also, each government or private insurance entity provides a source of quality information that tends not to be very standardized. One health plan may have a contract with HealthGrades, for example, whereas another health plan may have WebMD Health Services to provide health care quality information. There’s not a clear, single source for people to go to and obtain quality information. When things tend to be more disparate and less intuitive, it becomes overwhelming and a little daunting. In our survey, there was a very large number of people who came to our website and were surprised that it was relatively easy to use, that it was not more confusing and complex. That either means they had a perception that these sorts of websites are very confusing, or they had not been to other websites and were surprised to see that it was actually relatively straightforward.

PND: What is the goal of your organization?

EM: The Pennsylvania Health Care Quality Alliance is a multi-stakeholder collaborative of organizations that came together to develop a common statewide approach to transparency of hospital quality measurement using measures that are evidence-based and actionable. The goal was to help providers evaluate and improve the quality of patient care, give insurers the opportunity to assess and evaluate the performance of their provider networks in a common way, and ultimately enable consumers to see how their provider – hospitals, in this case – was performing, and also benchmark that performance against other hospitals. The website was the output of consensus measures the alliance developed. The alliance’s member organizations include the four Blue Cross Blue Shield plans in Pa. – Highmark, Independence Blue Cross, Capital BlueCross, Blue Cross of Northeastern Pennsylvania, the Hospital & Healthsystem Association of Pennsylvania, the Delaware Valley Healthcare Council, the Hospital Council of Western Pennsylvania, the Pennsylvania Medical Society, representatives from the Governor’s Office of Health Care Reform, and from the U.S. Department of Health and Human Services.

PND: How do the interests of these various stakeholders coincide, and how do they diverge?

EM: One alignment is an agreement that an effort to develop a standardized quality approach should build upon existing state, federal, private and public data sources, for example, using the Pennsylvania Health Care Cost Containment Council’s measure for hospital-acquired infections. The alliance would look at that measure, examine how it is collected and reported, and identify whether it should be adjusted or left the same. The goal is to avoid duplication of existing measures and not unreasonably burden hospitals with additional reporting standards. Payors and hospitals would then use the agreed-upon measure set as the primary basis for future quality improvement efforts. For example, if Independence Blue Cross is going to partner with the University of Pennsylvania to promote health care quality, to the extent possible, they should try to leverage the standard approach that was developed by the alliance, rather than having to recreate effectiveness measures for their program. Similarly, for pay-for-performance programs, there should be some attention paid to using these quality measures that they’ve collectively agreed on. Another issue of alignment is that the alliance should promote ways for lesser performers to learn from better performers – create a forum to share best practices – and not be just another ranking and reporting type of activity.

Points of divergence were about where price and cost comes into play – whether the alliance focuses on quality and cost in parallel, or separately. There was agreement that quality should be the primary focus and that, once we developed a consensus on how to measure quality, then we could start to entertain questions about how cost factors in, such as whether getting higher quality requires more resources. Another divergent point was how to calculate and identify who the benefits of quality care will go to, other than the patients, obviously. The question of cost savings coming from that improved care was a divergent point. Some of the hospitals felt that there should be additional compensation provided to them if they significantly improve quality, because it would be the health insurance company that benefits from the resulting lower cost. The perspective of the health plans was that it is often difficult to measure what the lower cost is of that improved quality because quality is measured across a fairly extensive period of time. There are member turnover and other issues, where people roll in and out of insurance, and there isn’t always a clear benefit to the insurance company from that improved quality.

PND: What about metrics, themselves – have there been instances in which insurers wanted to include a metric that hospitals objected to?

EM: There are two that come to mind. There are a few National Quality Forum (NQF) efficiency measures, and the health plans were interested in trying to introduce an efficiency measure into this agreed-upon approach to health care quality. The hospitals were hesitant to do that, primarily because the efficiency measures haven’t been vetted over an extensive period of time, and there is a question about whether they really measure efficiency well. The other category was health care-associated infections. Certain individuals on our measures and methods workgroup, which is made up of physician leaders from both hospitals and health plans, disagreed on the utility and usefulness of some PHC4 infection measures, primarily because of methodological concerns related to data collection. For example, surgical site infections that are counted and tracked by PHC4 are only those that are actually reported in the hospital. But, if somebody two or three days after discharge notices they are having swelling or discoloration in the area they had surgery – if their doctor looks at it and gives them antibiotics for an infection, the hospital may never know about that. You would be missing a lot of infections and there is no way in the PHC4 model to be able to count that data.

PND: Were any metrics excluded because they failed to meet the alliance’s "evidence-based and actionable" criteria?

EM: Two categories have been delayed, not necessarily discarded. One is preventive measures to address ventilator-associated pneumonia (VAP), many of which have conflicting clinical literature. There wasn’t a clear actionable list of ways that hospitals could specifically reduce their VAP rate, and we wanted to wait until the evidence had borne that out a bit more. The other delayed category is urinary tract infections (UTIs) because there wasn’t an adequate risk adjustment for that measure. Clearly, if a hospital has a larger number of patients who are in the ICU or are spending long periods in the hospital, they are more likely to develop a UTI related more to being on a device for a long period of time, rather than to direct quality of care issues. We felt it was worth waiting until there is a way to present that in a way that is clear and actionable for hospitals to address.

PND: What quality information is the alliance focusing on, and how is it different from what is already available from other entities?

EM: The measures cover heart attack, heart failure, pneumonia, infection prevention, and appropriate care measures – which indicate the percent of patients who received all of the evidence-based care for their respective conditions. Within each of those categories we have outcome and process measures. The process measures come primarily from the Centers for Medicare & Medicaid Services all-payer data (not just Medicare patients), and most of our outcome measures come from PHC4. We try to identify measures from all domains of quality: effectiveness of care, timeliness of care, safety issues, and patient experience data. We’re trying to get as broad a set as possible, and all of our measures are NQF-endorsed, except for readmission rate for heart failure for the reason of complication or infection.

The alliance convened for the first time in January 2007, so it is still in the early stages of its activities. But, as a first pass, there was a focus on avoiding recreating the wheel and duplicating areas that had been fairly well-covered by other reporting entities or sources of data. As we begin to look into areas where there has not been a long history of data collection or public reporting, we may have to look at other sources or collectively agree on how to measure something. At least for the moment, we’re more of a clearinghouse for measures that are otherwise available in other locations – offering data aggregation into a "one-stop shop" that adds value to users. The exception is the appropriate care measures, which are patient-level composite measures that our state quality improvement organization – Quality Insights of Pennsylvania – calculates for us because they have access to that patient-level database.

The decision to focus on hospital quality measures was primarily driven by the long history that Pa. has on hospital reporting to PHC4, and there was already groundwork laid by a variety of other initiatives like the Hospital Quality Alliance. So, it seemed like a logical starting point. There is an understanding that, at some point, our alliance will look at other settings of care, including outpatient and perhaps long-term care facilities.

We’re starting to go through the next set of potential measures to be included in a formally adopted consensus measure set of health care quality indicators for hospitals. We are looking at some that have recently gone through the NQF process and in some cases have already been adopted by CMS, for example, more granular mortality measures for heart attack and pneumonia. We may look in more detail at measures that are reported to a variety of physician specialty organizations, such as the Society for Thoracic Surgery database and the American College of Cardiology clinical registry.

PND: How is the alliance’s information disseminated?

EM: It’s disseminated through a website. According to our survey results, such a large number of health care decisions are made from doctor recommendations and from personal experience of friends and family, so it probably doesn’t make sense to spend a large amount of time or resources on direct-to-consumer marketing or communication. That’s sort of a double-edged sword because you also want the end consumer to become more aware of these sorts of resources. But, if they’re primarily making most of their decisions in consultation with their family and their physician, it makes more sense to explore ways to promote what the alliance is doing within the physician and professional realm.

Most of the national surveys that I’ve seen, including ones sponsored by the California Health Care Foundation and the RAND Corporation have shown that the number of consumers who look up health care quality information to help them make a health care decision has historically been in the mid- to low-single-digit percent range. We saw 10 to 12 percent on ours, and the Kaiser Family Foundation in a recent survey had seen their number break into the double digits for the first time. We’re still talking about a low number, but a very fast growth rate, which is fairly encouraging.

While our goal in creating the website was to communicate this information to the consumer, the real work of the alliance is collaboration to come up with a consensus measure set. Since that is the primary focus, and not necessarily to create a consumer resource, I think the alliance for the moment is comfortable with not spending a lot of time and resources in trying to raise awareness of the site’s availability.

PND: Is your primary focus the provider community, as a tool to improve their quality?

EM: I would say yes. It’s the providers, primarily, who are looking at this information and using it for benchmarking and other purposes. Right now our aggregated data can be looked at in a variety of ways: most recent, quarterly, and by individual hospital as far back as the data goes. What we are going to do, probably in the next year, is create something that allows for providers to do even more sophisticated analysis. One of the decisions the alliance is going to need to make fairly soon is how much more we want to invest in that capability. There has been some discussion about whether it would be worth collecting measures from hospitals for benchmarking purposes only, for example. There may be some measures that could be of tremendous value to hospitals or physicians to understand where their institution or practice is relative to others, both for the purposes of benchmarking and quality improvement, but maybe measures that you don’t necessarily want to get published until it’s understood how best to compare those measures across providers. Physicians and hospitals have a very good understanding of what happens within their own environment, but a very poor understanding of what happens outside of their environment. The only entities that can really help to fill that gap for them are the insurance companies, who follow people regardless of where they get care. Finding a way to align data and provide mutual data exchange between these organizations is going to benefit health insurance companies, hospitals and physicians.