Finally, Quality We Really Care About

Patient-centered care and patient engagement have become central to the vision of a high value health delivery system. The delivery system is evolving from a fee-for-service transactional payment model to a value-based purchasing model using outcome data and quality improvement and attainment. The Centers of Medicare and Medicaid Services (CMS) and private payers have spurred delivery redesign of networks that focuses on a set of clinical quality measures and patient care experiences along with efficiency measures.

However, the questions we ultimately really care are: “Did I get better? Am I healthier?”

With the advent of Facebook, PatientsLikeMe® and Avado, consumers and patients are sharing their healthcare experiences openly with their support system and strangers with similar illnesses. Our delivery system has yet to leverage the power of patient/consumer reported data in feeding back to care deliverers in the quality improvement cycle.

Clinical quality measures have traditionally consisted of process or surrogate measures and centered on providers and hospitals. As we move toward a system based on value, the measurement system must shift as well. Part of this movement will be utilizing outcomes directly reported from patients and their caretakers and incorporating these outcomes into quality improvement initiatives and payment models. The widespread adoption of standardized and validated patient-reported outcomes measures (PROMs) would accelerate the development of a patient-centered health system. However, new standards; patient-friendly, digitally-enabled instruments; secure portals; and more research will be required to facilitate adoption.

Patient-Centered Care And Patient Engagement As National Priorities

The Institute of Medicine’s 2001 landmark report, “Crossing the Quality Chasm,” listed patient-centered care as one of its six aims. The Affordable Care Act reaffirmed the import of patient-centered care through a number of its provisions, including the piloting of patient-centered medical homes and the creation of the Patient-Centered Outcomes Research Institute.  The National Quality Strategy enumerates “Ensuring that each person and family are engaged as partners in their care” as one of six priorities to help achieve the three aims of better care, better health, and lower costs.

Simultaneously, a movement among patients and a number of organizations, such as the Society for Participatory Medicine and Institute for Patient- and Family-Centered Care, around these goals has flourished. In response to these currents in health care, hospital administrators across the country have launched of a number of initiatives targeting patient-centered care and patient engagement.

Additionally, the Affordable Care Act mandates the use of quality and patient care experiences as part of the qualification of health plans in the new State Insurance exchanges. The type of data and their uses are still to be determined during the ongoing insurance exchanges setup process. Undoubtedly, PROMs would be powerful and robust data to empower consumers in the selection of networks, plans or future ACOs.

Patient-Reported Outcome Measures Used In Limited Settings

PROMs, which measure a specific construct, such as health status, symptoms, functional status, or quality of life, have been developed over time and used in research and by payers. For example, in 2004 the National Institutes of Health created PROMIS (Patient Reported Outcomes Measurement Information System). Collaborative research across a number of centers led to the creation a series of brief, valid measurements of physical, mental, and social health.

The VR-12, which measures physical and mental health, has been used by the Veterans Health Administration, CMS, and the National Committee for Quality Assurance for quality assessment. Numerous disease specific measures exist as well.  As David Lansky, Executive Director of Pacific Business Group on Health, points out, Sweden adopted PROMs for orthopedic procedures and has data collected from 90 percent of patients one year after their surgery. The Kansas City Cardiomyopathy Questionnaire measures health status for heart failure patients, and the Seattle angina questionnaire assesses those with coronary artery disease.

Despite the use of PROMs for research and quality assurance in select populations, adoption across larger populations have been limited by a number of factors, including complexity of instruments, resources necessary for administration, and a lack of recognized value by payers, providers, and patients. With the importance of patient-centered care, patient engagement, and PROMs becoming increasingly recognized, we recommend the following to encourage the adoption of PROMs.

  • Develop standards to capture structured data from patients and families. The Office of the National Coordinator for HIT (ONC) and the HIT Standards Federal Advisory Committee have done a laudable job in creating standards for data inputted by providers. The certification process has reinforced the use of specified standards, such as rxNorm and SNOMED, for provider-reported data in EHRs as structured data. Similarly, patient-reported data will need a standardized data model to capture patient symptoms and health, such as difficulty breathing, functional status, or mental health. The need for standards will become increasingly important as we begin to move beyond capturing simple information, such as five-point Likert scales in PHQ-9 for depression, to more complicated information.
  • Create patient-friendly, digitally enabled instruments. Given the varying levels of health literacy and technology comfort across populations, we need to develop reliable and valid tools that are simple, quick, and optimized for health IT.  Priority should be given to high-impact conditions, such as heart failure, diabetes, ischemic heart disease, depression, and cerebrovascular disease.
  • Develop portals for patient reporting optimized for mobile devices. We also need to develop secure portals enabling patients to report outcome data seamlessly either from home or at their provider’s office. Ideally, these portals would be optimized for smartphones or tablets. Already one-third of Americans are smartphone owners, and this number will likely continue to increase. Similarly, tablet ownership has been rapidly rising, notably from 3 percent in May 2010 to 19 percent in January 2012. As more Americans continue to access the Internet via mobile devices, we need to develop the tools to leverage these relatively easy-to-use technologies. Data submitted via these portals could be stored in a patient’s electronic health record and then used for quality improvement or reporting, or both.
  • Research whether adoption of PROMs translate into better health and better care. As numerous studies have pointed out, the evidence supporting the ability of health IT to improve quality and health IT is mixed. Health IT may indeed have unintended consequences, such as resulting in more frequent diagnostic testing. We need to better understand whether the adoption of PROMs will lead to better care and better health. We also need to develop electronic clinical decision support tools that will be needed to drive quality improvement on these measures and the electronic reporting structure to submit them to payers.

Interest in PROMs continues to grow rapidly. The proposed regulation for Meaningful Use Stage 2 underscores CMS’s interest in PROMs through its requirement for patient engagement functionality and inclusion of three proposed electronic quality measures incorporating patient-reported functional status. Some of the ONC Beacon communities are piloting PROMs and implementing them in clinical practice. Care Partners Plus®, a for-profit company, created a patient-feedback system for use in provider offices immediately after patient appointments, which could be used for PROMs as well.

Our ability to capture information from patients and integrate it into electronic health records and clinical care is rapidly evolving. As we move toward a patient-centered, high value health system, PROMs can play an integral role if we develop the needed standards, tools, portals and evidence base.

Thomas Tsang, MD, FACP, led the quality strategy within ONC and worked with the Center for Medicare and Medicaid Innovations on innovative delivery system reforms. He is currently a clinical advisor to Avado, SA Ignite and Acupera, new HIT companies focused on lowering cost and improving quality.

Faraz Ahmad, MD, graduated from the University of Chicago School of Medicine with honors in 2009, and he completed his Internal Medicine Residency in 2012. He is a member of both the Center for Healthcare Improvement and Patient Safety and the Center for Therapeutic Effectiveness Research at the University of Pennsylvania Perelman School of Medicine.

15 replies »

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  3. @NatalieClifton: Hi Natalie, I’m sorry to hear that you’ve had a rough week. There is no need to apologize about feeling pessimistic, especially when you are exposed to the circumstances you mentioned above. I wanted to first let you know that my article was not intended to “compare” hospitals to hotels. The article was meant to elicit best practices from the hospitality industry that healthcare can benefit from. The bottom line is that no one goes to a hospital on vacation. I understand the fundamental differences between the two industries, and while I do not compare them, I do think that there are some best practices that can be leveraged to benefit both industries.

    Also, I will say from personal experience that crazy things happen in the luxury hotels too! and although not nearly as severe as the examples you gave, guest have on occasion verbally or physically assaulted employees- I was personally affected. Regardless, the instances you’ve described are severe and I don’t know if anyone can ever solve such problems completely. However, I do believe that creating a culture of service is a part of the resolution. The hospital must be able to make certain commitments to its employees and put policies and procedures in place to prevent certain patients from taking advantage of the staff or the hospital. Healthcare systems should [in an ideal situation] be able to turn away fraudulent or abusive patients, and employees must feel comfortable and feel that they work in a safe environment- this is the “employee promise” a hospital must be able to guarantee to its employees. I will further research this specific area, and try to find healthcare systems that have successfully implemented such measures to protect their employees.

    Please know that I identify with the view one tends to develop once exposed to the dealing with abusive patients. However, it is worth noting that in reality most patients are honest and good-natured individuals. I know its hard to remember that, but most studies have proven that fraudulent customers account for a few percentage points of the entire population.

    Regardless, I hope that the good patients continue to motivate you and your team to deliver the best care your able to deliver. It is just a matter of time before healthcare systems begin implementing changes and improving the status quo for employees and patients.

    Have a great weekend, and I look forward to staying in touch!


  4. John:

    Yes, I also beg forgiveness in my delayed response, as well, and did read your post about the parallel of hospitals and hotels. I did see a lot of ways in which healthcare staffing can be improved and in many ways I see the changes taking place at my facility as we speak.

    The organization I am employed by has gone to great lengths in providing and becoming an industry leader in patient satisfaction. I have been through Senn Delaney, attend several coaching workshops, and feel I minored in human behavior and perception in college and my mom owned several successful restaurants (one featured in the movie The Firm), so I grew up aiming to please. However, as you and I both have some sense in customer satisfaction, hotels and restaurants have a target audience in mind when setting accomodation pricing and sevices offered.

    In a non-profit hospital, some people come in for the soul purpose of taking advantage of our meager facilities and expect “red carpet treatment.” Well first of all, at most luxury hotels where service is the epitomy of excellence, most guest usually make reservations far in advance and have prepaid reservations. In the setting of a hospital we rarely know what each day will bring, so the hosptial must staff on averages which are usually below what should be required to facilitate exceptional patient care. Plus the person making reservations for a hotel usually knows how much they can afford, which means rhe difference betwwen Holiday Inn and The Waldorf.

    Then most of what the patient wants are not condusive to their healthcare needs…. For instance, they want better tasting food, but they have a heart condition or are diabetics and so we must offer them healthier choices, which usually conflict with their taste preferences. They also want more plush beds, but we must provide air mattressesthat adjust to pressure to prevent pressure wounds.

    Also in the hotel environment, even the hotel would not allow a guest to pee on an employee, hit them and break bones, or call their staff derogatory names. Just recently a patient broke a new nurses hand because he felt the blood pressure cuff was pumped up too tight and slammed his fist down on her hand which was resting on a bedrail. It broke 4 of her knuckles with no reprecussion to the patient. Another patient bit 4 nurses to the point of drawing blood on seperate days for seperate reasons, just because the doctor diagnosed her with heart failure. I had a man throw his full urinal at me becuase he did not get bacon after i explained to him he would be on a low salt and heart health diet while in the hospital. I do not work on a psyche floor and these patients I am speaking of do not have grossly diagnosed psychological problems. However, they know they can get away with it without reprocussion because they need care.

    We also see people come in and they are positive for every drug imaginable and get mad when we give them nitroglycerin for their chest pain and not morphine. Or the 29 year old who just had a $300,000 valve replacement procedure comes in positive for cocaine, who did not have any insurance.

    It is curcumstances like these which make the comparison to hotels a little preposterous. Those who serve the public healthcare system to better patient circumstances start out very optimistic, but when are exposed to the fraudulent nature of many patients and providers we become jaded and feel very uncircumstantial to the big picture of healthcare.

    Hate to be pessimistic… Guess its been a tough week :-/

  5. @NatalieClifton Hi! I apologize for the delay in responding!

    So while “Office Space” is one of my favorite movies!, SEERhealth is a technology company and not technically a consulting service. While we do offer consulting services, we specialize implementing the SEER technology platform to improve the Credentialing, Healthcare Quality Assurance, Privileging, Operational Performance, Multi-Facility Healthcare Delivery Systems, Risk Management, and Centralized & Standardized Process Management for healthcare systems.

    Everyone in my organization is very passionate about improving different facets of healthcare operation, and are committed to sharing our knowledge with the healthcare community- this is why we blog, write white papers, and spend a tremendous amount of time listening and learning about the industry challenges. I, in particular, am passionate about the outcome, and how it relates to the patients. Perhaps it is because of my prior background in the service industry.

    Unlike most other consulting or technology companies, we do things much differently at SEERhealth. Our proven approach has assisted some of the largest healthcare organizations in the United States to successfully transform their operations. The way we have succeeded is by partnering with the organization, and being there to see our solutions implemented successfully. We are not interested in giving firms a strategy document and wish them good luck. It is much more effective to listen to experts ( like you) and design a specific solution that fits your unique needs.

    Having the technology to support all these initiatives is key. and like you said, if your iPhone is more advanced than the hospital’s technology, then its going to be very difficult to implement any changes that affect the patient experience- even if young leaders are pushing for change. For example, a robust system with some CRM capability is needed in order to be able to record patient preference, and share files and records seamlessly.

    I thoroughly enjoy this conversation and hope to keep it going. Last week, I wrote an article that was picked up by MedCity News on Lessons healthcare CEOs can learn from the Hospitality industry. I would love your thoughts. http://buff.ly/PMUNqX

    Best regards,


  6. @JohnDamouni – Thank you for your response. I did look at SEERhealth’s website and it appears you all are a consulting service. I always think of the movie “Office Space” when I hear about these services. It just grinds my nerves a bit when an organization has to get an outsider to solve the problems they pay so many within the organization to do. No offense to you or your employer, but many of the problems I see are “as plain as the nose on our faces.” Many young leaders are pointing out our shortcomings and bringing fiscally responsible and sound solutions to the table, but they will not listen.

    From what I am seeing in my organization, our biggest hurdle is the technology we use. One would think putting all the information in a computer would make our lives in healthcare easier, but it has doubled, if not tripled the work of those staff who are in direct patient care. Because of regulations and policies and poorly integrated technology, nursing staffs must chart in several different places on several different tabs and open many different windows and scroll and click through thousands of different boxes, which was once just your initials on sheet of paper. When I go to meetings all I hear is “fall out” because of lack of documentation. But was the patient cared for? I would rather see my staff in the patient rooms, than down the hall clicking away like zombie secretaries.

    Even evidence-based practice has called attention to the inefficiency of the high-tech hospital. I am curious to know how your company (and I am assuming you come from a non-clinical background) could possibly get an organization to listen about “eliminating unproductive and repetitive administrative procedures,” when I am providing them solutions and advice for almost free. Healthcare as a whole is very behind on technology and I say all the time my iPhone is more sophisticated than any technology in our hospital, but I feel this is the case because those providing the technology never consulted those providing the care.

    Anyways, I look forward to your response and know I am not taking any jabs at your organization because I do understand that sometimes one can see things more clearly as an outsider because they are not directly involved.

  7. @NatalieClifton- Your perception is spot on. I can tell that you are passionate about delivering exceptional service to patients!

    You are right, it all begins with a cultural change. The parameters of that culture of service are best defined by the professionals who interact daily with patients. However, that change must be driven by the hospital administration. At the end of the day, the administration has the responsibility for ‘allowing’ that service culture to flourish. They must ensure that all Healthcare professionals working within their systems have the necessary tools and are empowered to deliver exceptional service to patients. Everyone must be on board!

    You mentioned Ritz-Carlton in your reply, and I must say that I happy to see that. I actually began my career at the Ritz-Carlton, and understand the positive impact a culture of service can have on the organization’s brand, employees, and “customers.” Everyone at my current company, SEERhealth believes in bringing a world-class level of quality and service to every Healthcare system we work with.

    I have written blogs about this subject matter, and in the process of finalizing a white paper on “service culture.” If you’d like to check it out, please let me know. I would also love to hear more about your experiences and what you think would improve your organization’s service delivery model? My e-mail is address is jdamouni@seerhealth.com. I look forward to continuing this conversation.


    John Damouni

  8. @JohnDamouni – ‘the patient’s experience drives their perception of the care being delivered” As a nurse working at the bedside, I very much agree with your statement. It is amazing the difference in perspective of those nurses and other healthcare professionals who graduated 5-10 years ago and those who have graduated since the patient and family centered approach started being reinforced.

    I find bedside reporting, hourly rounding, setting patient and family expectations, involving them in the plan of care, and just smiling and being personable have made dramatic improvements to the system I work for along with the unit. Many healthcare providers who have been around a little longer really do have trouble with this though and it is hard to fathom, but many hospitals are spending extraordinary amounts of time and resources in educating staff on creating a culture of service.

    I explain to my staff in terms of a hotel room… If you go to Motel 6 and pay $49/night you may not expect much, if you go to a Hilton and pay $99/night your expectations are higher, if you go to the Ritz Carlton and pay $700 or more/night you expect phenomenal service. So if a hospital bed per night is somewhere around $3500 imagine the persons expectations.

    However, the biggest barriers to this change in culture need to start with those who have direct contact with the patients and to do that we have to have more staff to be in direct contact than administrators to tell us how to provide service.

  9. I admire your take on improving the overall patient experience in healthcare. I share your view on this issue, and would also add that it all begins with linking patient experience to quality. ultimately, the patient’s experience drives their perception of the care being delivered. Healthcare systems must be able to identify and articulate their patients’ value proposition, and then measure and tackle the areas in need of improvement.

    I personally think that using the available technology to measure patients satisfaction, track service breakdown issues and report that information is key to achieving a higher standard of service and quality. It is also vital that Healthcare organization focus on creating a “service culture,” and tie their team’s financial incentive directly to Patient Experience.

    I blog often on the Patient Experience issue. If you’d like to read more and share this message, please visit http://www.healthcareboardroom.com. I will be promoting your excellent blog and hope to read more about this from you in the future.


    John Damouni

  10. @rbaer – It’s a reasonable complaint that much of the industry seems to have profit as a higher motive than improving the system. Patient satisfaction is also a hugely important variable.

    While it’s not mentioned in the post per se, I don’t think that Tsang is going for an infomercial approach. I’m guessing he’s writing about the area of research that he has worked on and believes in, and now he’s an advisor to companies who are trying to solve these issues from a business perspective.

    Much of the current assesment tools out there (including 30dy mortality or complications, readmisson rates, and reputation) as used by USNWR or other ratings goups are really unsatisfactory to get at the core outcomes we really care about – are we happy (patient satisfaction as rbaer points out) and did I get better/am I healthier (functional outcomes that the authors reference).

    There’s no one fix that’s going to resolve all the issues in healthcare but this is a fair issue to raise as we try to improve many of the problems. And given the complexity of the system, finding ways to reconcile the motivations and harness the resources and abilities of private industry, non-profits, academic centers and govenmnt is going to be necessary to make change happen.

  11. So why don’t you say anything of substance i/o just unverifiable claims? (“The kind of second and third generation approach to outcomes reporting the authors describe will have a revolutionary effect on the care.”)

    “anybody who-is-in-business-is-horribly- tainted-and-must-be-evil-therefore-everything-they-are-saying-doesn’t-apply-because-I-don’t-like-them-nyah-nyah-nyah- crap.”
    This is also called “conflict of interest”. If you think this concept is outdated or for soe reason not of concern, try to make your point, but na-na, na-na, boo-boo, stick your head in doo-doo like arguments don’t cut it.

  12. @ Rbaer. So what?

    The problem with your argument is that in your desire to score cheap points you skip the entire conversation about quality and the very real need for better measures.

    The kind of second and third generation approach to outcomes reporting the authors describe will have a revolutionary effect on the care. The data we’re using is shockingly inadequate for the task at hand – and in many cases worse than nothing at all.

    Seriously, enough already with the anybody who-is-in-business-is-horribly- tainted-and-must-be-evil-therefore-everything-they-are-saying-doesn’t-apply-because-I-don’t-like-them-nyah-nyah-nyah- crap.

  13. Thomas Tsang “is currently a clinical advisor to Avado, SA Ignite and Acupera, new HIT companies focused on lowering cost and improving quality”.

    These companies also focus on profit, and this post is an infomercial. Major problems such as poor utility of satisfaction as outcome measure
    http://archinte.jamanetwork.com/article.aspx?articleid=1108766 are unmentioned. And to postulate “we need to develop reliable and valid tools that are simple, quick, and optimized for health IT” is a meaningless proposition.

  14. It is very fine blog about health care. In here the description about patient care is very beautiful and inspired.