Just as providers begin to accept that they must improve the "patient experience"—like always delivering care with courtesy and respect—to score well on their Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) surveys, a new approach to measuring quality has arrived on the scene. This one, however, promises to revolutionize the customer survey.
These new sampling tools ask patients to tell doctors the result of their treatment regimen, on their own terms after they returned home:
- Did they actually get better?
- Did they return to normal activities just like they could before their surgery? Can they walk up a flight of stairs or around the block or maintain the pace in the square dance routine?
- Did the medicine help?
- Was there pain, and if so how much, compared to what they experienced before?
In other words, patients get to evaluate their outcomes.
The change is coming gradually, in the form of specialty disease or procedure measure questionnaires such as WOMAC (the Western Ontario and McMaster Universities Arthritis Index), OMERACT (Outcome Measures in Rheumatology), and CCORP, (the California Clinical Registry for Orthopedic Procedures) a fledging effort that specifically includes patient self-reported functional outcomes after joint replacement surgeries.
There's also the SF-36 (Short Form-36) and the VR-12 (Veterans Rand 12-item Health Survey). And there are many mental status surveys that attempt to measure depression and fatigue. For Medicare Managed Care Patients, there's the federal Health Outcomes Survey. Some of these have been around for awhile, but recently, they're being adapted for new uses.
Now, there are overt signs that federal regulators want to do more to link such self-assessment surveys to incentive payments. Indeed, in the Centers for Medicare & Medicaid Services' proposed Meaningful Use rule stage 2, providers are being asked to attest that they obtained "patient reported" functional assessments both at baseline, (about 180 days before), and 60 days after undergoing any of three procedures or episodes of care:
- Total knee arthroplasty, for patients 18 years of age and older
- Total hip arthroplasty, for patients 18 years of age and older
- Care for patients with congestive heart failure who also have two or more high impact conditions, for patients 65 years of age and older.
The final rule is expected to provide more detail on which survey tools a provider might use to attest to their collection of such data by way of electronic health record (EHR) usage, and to specify how they will assure that the process is sound.
The Affordable Care Act also wants the use of measures that evaluate "health outcomes and functional status of patients" and "functional status improvement" to be part of the conversation, mentioning those phrases several times.
Even the National Institutes of Health is getting into the act to refine a non-proprietary, but very detailed survey tool it developed. It's called Promis (Patient Reported Outcomes Measurement Information System), and is now being tested by 13 academic medical centers. The initial idea for the survey was evaluate success or failure of a drug or procedure in clinical trials, from the patients' perspective. But the survey's use in other settings is being scrutinized now as well.
The decision tree demo, which may be viewed on the Promis website, uses hundreds of questions that guide the responder to an appropriate next question level, specific illness, or health status, whether they're a young and super-fit triathelete or an 85-year-old patient whose mobility depends on a wheelchair. Try clicking on "try a demonstration of the PROMIS CAT," and then "physical function" first, just to get an idea of how it works.
The NIH's Promis Global tool is much simpler, asking only 10 questions that perhaps more easily assess a patient's functional outcome before and after an episode of care. For example, question 7 asks: "To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?" Such a question would be appropriate to understand both a patient's baseline activities, and compare them with activities after a procedure.
"With this tool, one could know that the patient was, for example, just like an average person who gets a joint replacement, and that after (the operation) they indicated how they felt and whether they improved," explains, Melanie P. Mastanduno, Director of Population Health Measurement for the Dartmouth Institute for Health Policy and Clinical Practice. "That's not something the doctor can measure."
In theory at least, the patient would be able to answer these questions "in a private and confidential way, say, through their desktop computer, an iPad or a kiosk, and not have someone hovering over them while they answered," Mastanduno says.
The history of functional outcome surveys has been "kind of like a Tower of Babel," acknowledges San Keller, NIH principal research scientist for Promis, to explain the reason such survey tools are needed. "There have been so many different investigators and sponsors of these measures over the years, some developing different measures for the same thing, they come up with different questions, different answers and with scores in different domains...One asks about severity of pain, the other frequency."
To level the playing field at least somewhat, the NIH "wanted to develop a standard way of asking about pain, depression, physical and social functioning and fatigue that could be used in all NIH sponsored clinical trials," Keller says.
Cheryl Damberg, Rand senior researcher and quality measurement specialist in Santa Monica, acknowledges that the pace has quickened to make these functional outcome assessments ready for prime time.
"Five or six years ago, you would barely hear people mention it," she says. "But I think with the work going on at the level of the Office of National Coordinator and meaningful use, and various value-based purchasing measures, people are very focused on outcomes measures now. And providers themselves are saying 'that's the stuff we should be tracking.' "
In the meantime, Damberg says, people are really working hard at an operational level to build tools that ask the right questions" building a tool that takes us beyond patient perceptions of their care, and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems).
Please don't get me wrong. I think the HCAHPS are important. We want to know that when a patient pressed the call button, help came quickly. It's right that these answers account for 30% of the score to determine a provider's value-based purchasing incentive payment.
But we all know these so-called "hospitality" questions don't really tell us whether the patient got the right tests and diagnosis, the right medications and wound care, the right treatments and follow-up that optimized his or her chance of being healthier after their stay than before. We don't really know if the care that providers delivered actually worked for the patient after they were discharged. We just know that the service was great, or it wasn't.
We need reassurance that providers aren't just going through the motions, but are actually improving quality. Let's hope that functional outcome scoring tools are developed, tested and implemented in a way that answers these questions in a way that hastens improvement of care.