The National Committee for Quality Assurance doesn't want to hear anymore how impossible it is for health plans to muster useful measures of performance given the state of their information systems.
The Washington-based evaluator of managed-care plans has a time frame in mind to get more sophisticated about the clinical indicators it adds to the Health Plan Employer Data and Information Set, or HEDIS.
That timeline is linked to a parallel path of evolution in the electronic data and communications systems required of health plans to support performance measurement. And new measures will be developed under the assumption that health plan information systems are keeping up alongside the advancing HEDIS effort.
Last week the NCQA released the fourth and final document comprising HEDIS version 3, the latest retooling of the industry-standard performance measurement blueprint.
The volume unfolds a road map for information systems, detailing steps that can be taken immediately as well as a framework for construction with a three- to five-year timeline and a long-term vision of computerized records five to 10 years from now.
"NCQA initiated this road map to communicate directly to the managed-care industry what upgrades in information systems would provide the greatest increase in performance measurement capacity and thereby accelerate the creation of an environment in which advanced performance measures could be implemented," the report said.
If health plans don't go along, the eventual result will be higher costs to hunt down medical records data that otherwise would be easily available through better technology and linked data systems, the report warned.
"NCQA will not slow the process of putting new measures into the marketplace," the report said. "New sets of performance measures will require the levels of automation described in this report."
Cary Sennett, M.D., vice president for performance measurement, said the NCQA isn't out to force a separate performance-measurement project on health plans. He said the computer framework described in the HEDIS report is "much the same body of work involved in managing the provision of care."
For example, a key emphasis is the ability to capture data at the point of service, which gets information into electronic form and allows pertinent organizations "to use it for all purposes thereafter," Sennett said.
Although performance measurement is served by that requirement, the most important beneficiary is the clinical management process, which is similarly handicapped by the lack of timely patient history and encounter data, he said.
Another emphasis in the HEDIS framework is on gaining electronic access to databases maintained by contracted providers in a health plan such as laboratories, pharmacies and clinics.
Those sources are loaded with data that can help HEDIS get past the surface-level measurement of health plan services and into an analysis of how successful the services are in improving care, Sennett said.
For example, a measure on immunization of children captures only whether a set series of vaccines was administered to a child by age 2. The NCQA would like to be able to measure the status of immunization at the time of enrollment in a plan and the timeliness of immunizations on a monthly basis during the vulnerable period of infancy and early childhood leading up to age 2, Sennett said.
In another example, a measure of preventive treatment for stroke associated with a heart condition called atrial fibrillation was put on the back burner because of problems determining if a patient was a proper candidate for the treatment and whether the right amount of an anti-coagulant called warfarin was being prescribed.
Access to patient history, lab-test values and pharmacy information could make assessment of that treatment a routine process, Sennett said.
Though health plans and provider systems are starting to focus on getting more clinical data to analyze, one trend in healthcare administration may be working against data gathering, the report warned.
Much of the current base of clinical data is generated through the claims process, backing up payments with documented services. But the shift to capitation as a payment scheme is reducing the incentive to keep records of clinical encounters, Sennett said.
And even when billing forms are important to the process, workers are passing up chances to record clinically valuable information in the spaces provided because the data are not essential to payment of individual claims, he said.
That's why the NCQA is recommending immediately that all diagnoses and procedures be entered into a health plan's information system whether or not the information is required for claims adjudication (See chart, p. 36). And it urges a contractual standard of encounter reporting by all outpatient providers.
The short-term steps can wring the most out of a health plan's current information-gathering capacity and position the organization to meet current HEDIS reporting requirements while planning for the next level of capital investment, Sennett said.
Many health plans have a continuing problem with gathering data to report HEDIS measures because they don't plan for the rigors involved in data collection, he said. The road map for information systems is intended to head off a "hectic, every-year scramble to put Band-Aids on the process to get the measures out."
Besides suggesting priorities that will improve data reporting now, the HEDIS blueprint "is an early warning to help them understand what changes are going to be needed" to supply more sophisticated data for future versions of HEDIS, Sennett said.
Other developments in the healthcare information systems and medical records sectors are likely to prod the development of comprehensive medical information systems, the report said. Those factors include:
n*Federal standards for structure, content, definition and coding of the elements of the medical record, and for privacy of individually identifiable health information. Those objectives are part of the Health Insurance Portability and Accountability Act passed last year.
n*Healthcare information systems developed by vendors that automate the patient record in compliance with standards.
n*Communications technology for data sharing that makes practical the transfer of clinical data through phone lines, the Internet and methods that may not yet exist.
The potential for rapid change in information technology and standards is so great, in fact, that the HEDIS report calls for a pause about three years into the evolution timeline for reassessment and appropriate adjustment of objectives.