FOR HEALTH AND HEALTH CARE PROGRESS
Committee on Core Metrics for Better Health at Lower Cost
David Blumenthal, Elizabeth Malphrus, and J. Michael McGinnis, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Grant No. 7954757 between the National Academy of Sciences and the Blue Shield of California Foundation, Grant No. 10001457 between the National Academy of Sciences and the California HealthCare Foundation, and Grant No. 70991 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
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Suggested citation: IOM (Institute of Medicine). 2015. Vital signs: Core metrics for health and health care progress. Washington, DC: The National Academies Press.
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INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
Advisers to the Nation on Science, Engineering, and Medicine
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COMMITTEE ON CORE METRICS FOR BETTER HEALTH AT LOWER COST
DAVID BLUMENTHAL (Chair), President, The Commonwealth Fund
JULIE P. W. BYNUM, Associate Professor of Medicine, The Dartmouth Institute
LORI COYNER, Director of Accountability and Quality, Oregon Health Authority
DIANA DOOLEY, Secretary, California Health and Human Services
TIMOTHY FERRIS, Vice President, Population Health Management, Partners HealthCare
SHERRY GLIED, Dean, New York University Robert F. Wagner Graduate School of Public Service
LARRY A. GREEN, Epperson-Zorn Chair for Innovation in Family Medicine, University of Colorado at Denver
GEORGE J. ISHAM, Senior Advisor, HealthPartners
CRAIG A. JONES, Executive Director, Vermont Blueprint for Health
ROBERT KOCHER, Partner, Venrock
KEVIN L. LARSEN, Medical Director of Meaningful Use, Office of the National Coordinator for Health Information Technology
ELIZABETH A. McGLYNN, Director, Center for Effectiveness and Safety Research, Kaiser Permanente
ELIZABETH MITCHELL, President and CEO, Network for Regional Health Improvement
SALLY OKUN, Vice President for Advocacy, Policy, and Patient Safety, PatientsLikeMe
LYN PAGET, Managing Partner, Health Policy Partners
KYU RHEE, Chief Health Director, IBM Corporation
DANA GELB SAFRAN, Senior Vice President, Performance Measurement, Blue Cross Blue Shield of Massachusetts
LEWIS G. SANDY, Executive Vice President, Clinical Advancement, UnitedHealth Group
DAVID M. STEVENS, Associate Chief Medical Officer and Director, Quality Center, National Association of Community Health Centers
PAUL C. TANG, Vice President, Chief Innovation and Technology Officer, Palo Alto Medical Foundation
STEVEN M. TEUTSCH, Chief Science Officer, Los Angeles County Department of Public Health
ELIZABETH MALPHRUS, Study Director
ELIZABETH JOHNSTON, Senior Program Assistant
MINA BAKHTIAR, Senior Program Assistant
KATHERINE BURNS, Senior Program Assistant
CLAUDIA GROSSMANN, Senior Program Officer
DIEDTRA HENDERSON, Program Officer
ROBERT SAUNDERS, Senior Program Officer (until March 2014)
SOPHIE YANG, Senior Program Assistant (until December 2014)
J. MICHAEL McGINNIS, Senior Scholar, Executive Director, Roundtable on Value & Science-Driven Health Care
RONA BRIERE, Briere Associates, Inc.
ALISA DECATUR, Briere Associates, Inc.
REBECCA MORGAN, National Academies Library/Research Center
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
MARC BENNETT, HealthInsight
HELEN BURSTIN, National Quality Forum
JIM CHASE, Minnesota Community Measurement
JAMES B. CONWAY, Health Policy and Management, Harvard School of Public Health
STEVE FIHN, Office of Analytics and Business Intelligence, VA Puget Sound Health Care System, VA Health Services R&D, Center of Excellence
TRACY A. LIEU, Division of Research, Kaiser Permanente, Northern California
LINDA A. McCAULEY, Nell Hodgson Woodruff School of Nursing, Emory University
PATRICK REMINGTON, School of Medicine and Public Health, University of Wisconsin
JOSHUA M. SHARFSTEIN, Maryland Department of Health and Mental Hygiene
MARK D. SMITH, California HealthCare Foundation
KURT C. STANGE, Case Western Reserve University
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by coordinator Eric B. Larson, Group Health Research Institute, and monitor Donald M. Steinwachs, Bloomberg School of Public Health, Johns Hopkins University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
In the enormously complex U.S. health care system, even progress often creates problems. After years of debate over whether and how to measure the health system’s performance, consensus now holds that measuring performance is essential to performance improvement. This consensus, however, has unleashed a multitude of uncoordinated, inconsistent, and often duplicative measurement and reporting initiatives. Federal agencies, states, payers, employers, and providers have their own approaches, often focusing on different measures, or the same things measured differently.
The result is the danger that, in the name of promoting improvement, another source of health care inefficiency will be created. The full benefits of investments in measurement also are being lost, because variation leads to results that cannot be compared across geographic areas, institutions, or populations. The purpose of this report is to promote the effectiveness of the measurement enterprise in the United States by identifying a parsimonious set of core metrics that deserve widespread implementation and to suggest how that implementation might occur. In producing the report, the study committee learned some important lessons.
First, current measurement efforts are truly problematic. A preliminary survey conducted in support of this study found that health systems require an average of 50 to 100 full-time equivalent employees, including physicians, at a cost ranging from $3.5 to $12 million per year, to carry out these efforts. Surveys of measure requirements and reporting programs have found significant inefficiencies and redundancies, due in part to minor variations in measure methodologies that lead to multiple different reporting requirements for the same target.
Second, as valuable as it is, measurement is not an end in itself. It is a tool for achieving health care goals. Readers will note that the core metric set proposed in this report starts with goals, proceeds through elements that embody or contribute to those goals, and then associates measures with those elements. In many cases, the Committee could not find existing measures that precisely capture valued ends. The Committee views this not as a shortcoming but as a major step forward. Identifying these gaps made it possible to support improvement in areas that may be neglected because, for whatever reasons, measure developers have not focused on them.
Third, measurement will fail if it is left to the experts. Because measures reflect goals and aspirations, their development is fundamentally a political process in the best sense of that term. In the pluralistic, decentralized U.S. health system, agreement on goals and aspirations and corresponding measures of their attainment must involve key stakeholders at every level of the system. The Committee believes the framework proposed herein is useful for facilitating consensus on goals and specific measures, but it understands that the process of reaching agreement on measurement approaches is as important as the technical specifications of the measures themselves. In that sense, this report should be seen as the beginning, not the end, of the journey toward a widely accepted set of core metrics for better health at lower cost.
Fourth, for a number of reasons, the report does not lay out a final, finely specified, parsimonious set of core metrics that will immediately solve all of the nation’s measurement problems. The Committee did not have the time, resources, or expertise to specify metrics or to develop composite measures where consensus does not already exist on those indicators. Also, although the Committee consulted widely with stakeholders, both publicly and privately, it did not represent all o the stakeholders whose views should influence, and who should embrace, a final set of core metrics. Furthermore, the Committee increasingly came to believe that the core metrics set may need to vary slightly (although with forethought and coordination) at different levels of the health care system, depending on the varying responsibilities and capabilities of stakeholders at those levels. Thus, the core metric set used by state public health agencies to hold themselves accountable would likely vary from the core metric set used by an independent group of five cardiologists practicing in a suburban community. The Committee simply did not have the resources to develop the several related core metric sets that would be required, but it does believe that all of those sets should be aligned in demonstrating how each stakeholder is contributing to a set of overarching goals such as those elaborated in this report.
The Committee is grateful to the sponsors of this project—the Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation—and to the Institute of
Medicine (IOM) for supporting its work. It is also grateful to Dr. Michael McGinnis for his leadership of the study process on behalf of the IOM, and to the incredibly talented and hardworking IOM staff who supported this study—Elizabeth Malphrus and Elizabeth Johnston—who deserve the lion’s share of whatever credit the report receives.
Finally, I would personally like to thank the remarkably insightful and hardworking members of the Committee. They took time from other pressing responsibilities to volunteer their expertise for the purpose of improving Americans’ health and health care. The future of the nation’s health system depends in no small part on the willingness of citizens such as these to contribute to the common good.
David Blumenthal, Chair
Committee on Core Metrics for Better Health at Lower Cost
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This report reflects the contributions of many people. The Committee would like to acknowledge and express its appreciation to those who so generously participated in the development of this report.
First, we would like to thank the sponsors of this project, the Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation, for their financial support.
The Committee’s deliberations were informed by presentations and discussions at four meetings held between August 2013 and June 2014. Additional input was sought from numerous outside stakeholders, and we would like to thank the 126 leading health organizations that provided their input on Committee directives.
A number of the Institute of Medicine (IOM) staff played instrumental roles in coordinating the Committee meetings and the preparation of this report, including Kate Burns, Elizabeth Johnston, Melinda Morin, Valerie Rohrbach, Julia Sanders, Robert Saunders, Francesco Sergi, and Sophie Yang. The Committee would like to acknowledge the contributions and insights of the Robert Wood Johnson Foundation health policy fellows who participated in this study—Jennifer Devoe and Samuel Johnson. The Committee would also like to thank Laura DeStefano, Chelsea Frakes, Greta Gorman, and Rebecca Morgan for helping to coordinate the various aspects of report review, production, and publication. Committee consultant Rona Briere, Briere Associates, Inc., made indispensable contributions to the report production and publication processes. Additionally, we would like to thank both Jay Christian and Casey Weeks for their contributions to the graphic portrayal and cover of this report. The Committee would
especially like to thank Elizabeth Malphrus, study director, for her overall guidance and support. Finally, we would like to acknowledge the guidance and contributions of Michael McGinnis, IOM senior scholar, throughout the study process.
With meaningful coordination, measurement can realize its potential as a tool for driving and enabling improvements in the nation’s health and health care and managing costs. We look forward to building on the ideas presented in this report toward achieving a continuously learning health system.
Measurement in Health and Health Care
Better Health at Lower Cost: Domains of Influence
People’s Engagement in Health and Health Care
Challenges to Meaningful Measurement
The Changing Measurement Landscape
Increasingly Burdensome Measurement Requirements
A Blurred Focus on Priority Issues
Lack of Standardization in Measuring Similar Concepts
Relevance to Diverse Health Care Roles and Circumstances
Core Measures and Issues: Preview
2 HEALTH AND HEALTH CARE MEASUREMENT IN AMERICA
Policy Initiatives Prompting Attention to Measurement
Current Measurement Purposes and Activities
Monitoring of Population and Community Health Status
Quality and Patient Experience Assessment
Transparency, Public Reporting, and Benchmarking
Performance Requirements (Accreditation, Safety, and Payment)
Limitations of Current Measurement Activities
Lack of Provision for Continuous Improvement
Limitations of Measurement for Accountability
Limitations in Data Quality and Availability
Limited Measurement of Cost and Affordability
Growth in Requirements and Narrow Focus
Implications for Care Organizations
Core Measures and Reduction of Burden
3 IMPROVING THE IMPACT OF MEASUREMENT
Change as a Product of Targeting the Core Issues
Systems Approaches and Composite Measures
Strength of Linkage to Progress
Understandability of the Measure
Potential for Broader System Impact
Utility at Multiple Levels of Focus
Related Experience with Sentinel Measures
Approach to Identifying the Core Measure Set
Addressing the Criteria for the Set
Addressing the Criteria for the Measures
Choosing a Best Current Measure
Developing, Applying, and Improving the Core Measures
Applying the Available Measures
Establishing an Ongoing Process
5 IMPLEMENTATION: PUTTING THE CORE MEASURES TO USE
Informing and Raising Public Awareness
Fostering Diverse Data Linkages
Facilitating Informed Patient Choice
Establishing Targets for Community Efforts
Use in Assisting and Assessing Large Societal Initiatives
Use in Leveraging Existing Programs and Requirements
Health Care Payers and Purchasers
Community Health Planning and Community Benefit Requirements
Implementation Challenges for Stakeholders at Multiple Levels
Existing Measurement Infrastructure
Variable Approaches to Measurement
Need for Financial and Personnel Investments
Need to Assess Relevance to Multiple Circumstances and Stakeholders
Updating and Retiring Measures
Updating and Amending the Core Measure Set
Findings, Conclusions, and Recommendations
All People—as Individuals, Family Members, Neighbors, Citizens, and Leaders
Governors, Mayors, and Health Leaders
Clinicians and Health Care Delivery Organizations
Employers and Other Community Leaders
B EXISTING REPORTING REQUIREMENTS
E BIOSKETCHES OF COMMITTEE MEMBERS AND STAFF
* Please also see the Appendix D Supplement available at www.nap.edu/catalog/19402 under the Resources tab.