Why Separate Clinical Quality From Patient Engagement?

Philip Marshall, MD, MPH; Daniel Z. Sands, MD, MPH


April 06, 2015

Separate Silos Are Self-Defeating

Since the advent of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, "meaningful use of electronic health record (EHR) systems" has become a household phrase among physicians. Meaningful use and related Centers for Medicare & Medicaid Services (CMS) incentives and penalties have resulted in over 80% of physicians and hospitals routinely using certified EHR technology in patient care.[1] Such functions as computerized physician order entry (CPOE), eprescribing, and consistent documentation of medications, allergies, and patient demographics have become a standard of care.

In some domains in the meaningful use program, there has been pushback from physicians, including clinical quality measurement and patient engagement. These two domains have been kept separate and distinct under the EHR program—and yet, when you look at the requirements of these domains, it is clear that you can't achieve most of the quality measurement goals without patients being engaged, and you can't engage patients unless they understand and buy into the goals of their care.

The draft Federal Health IT Strategic Plan for 2015-2020 was recently unveiled, and once again the delivery-system goal (improving healthcare quality and supporting the delivery of high-value health care) remains separate and distinct from the patient-facing goal (to empower individual, family, and caregiver health management and engagement).[2]

But in an important public response to the plan, the Consumer Technology Workgroup (a federal health IT advisory committee) recommended that a new goal be established to bring providers and patients together around "shared goals" and to align our quality measurement and patient engagement efforts around those goals.[3] According to the committee[4]:

Health IT should play a crucial role in supporting care delivery systems and individuals coming together (e.g. partnership) around shared goals for their care, and aligning patient engagement efforts as well as quality measurement, reporting and payment efforts around those objectives. The end result will be a healthcare system that consistently, continuously, and collaboratively works with individuals to document, measure, refine, and communicate the objectives that are both meaningful to the patient and achievable by the delivery system."

In our opinion, this forecasts the next frontier in health IT—the alignment of patients and their care teams around shared goals. The implications are significant. Instead of clinical quality measurement and patient engagement happening in silos, these efforts would be coordinated. And instead of health care being sporadic and reactive, it would become more continuous and collaborative.

Patient Engagement and Blood Pressure Control

Most of the clinical quality measures that providers must select among to satisfy the requirements of meaningful use require their patients' participation to achieve, whether in getting timely services, treatment compliance, or successfully managing a chronic condition.

Take blood pressure control. About one in three American adults has high blood pressure. Over 75% of these patients require antihypertensive medications to achieve good control, and yet less than one half (47%) are actually in good control.[5] The meaningful use quality measure for blood pressure control reads: "The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year."[6]

Achieving improvements to this measure without patients setting goals in collaboration with their physician will probably result in the blood pressure measure being both meaningless and unachievable. A new approach is needed. When patients are continuously engaged and aligned around shared care goals, they have better outcomes. And if we stop requiring physicians to submit clinical quality measures in a vacuum, and instead focus on those goals that the patient understands and agrees to achieving, providers won't be held accountable for measures and outcomes that they have little control over.


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