Transformation of Health Care at the Front Line
Authors: Patrick H. Conway
Journal: JAMA (2009)

CONCERN ABOUT ESCALATING COSTS AND THE quality of health care delivered in the United States continues to mount. This has led to an increasing focus on pay-for-performance, valuedriven health care and public reporting of quality and cost information. However, several authors have questioned the effectiveness of pay for performance and public reporting to improve patients’ outcomes and have highlighted the potential for unintended negative consequences. Currently, frontline clinicians are exposed to disparate pay-for-performance programs that are often uncoordinated and not clearly aligned with producing better outcomes for patients. Evidence is produced at an astonishing rate, but its incorporation into clinical practice is difficult. For patients, the current transparency efforts often have little useful information for decisions regarding a specific disease and selection of clinician or treatment option. However, policy makers and purchasers are faced with an underperforming health care system and untenable cost estimates, so maintaining the status quo is not an option. Recently, 82% of Americans indicated that the health system needs fundamental change or complete restructuring. Health care is now at a critical fork in the road. One option is to continue down a path that too often frustrates clinicians, confuses patients, and fails to align incentives with improving quality and value. The other is to take the path that aligns quality and value efforts with care where it matters, at the front line with clinicians and patients. The Agency for Healthcare Research and Quality (AHRQ) has a role to play in developing the science of measurement, research on quality improvement, and informing how to transform the system successfully, but leadership and collaboration from all stakeholders and a clear vision are needed. The approach described in this Commentary is by no means exhaustive. Each key driver to engage and enable frontline clinicians and their patients to transform care and achieve better outcomes could be the subject of multiple articles, but at the least, a vision must be outlined, the best path and methods to make progress debated, and the focus shifted to the front line of care. Quality Measurement and Payment The multitude of quality organizations (eg, National Quality Forum, National Committee for Quality Assurance, Ambulatory Care Quality Alliance) have each made contributions to the quality enterprise, but there is a need to move beyond simply developing more measures and to focus on developing high-priority measures such as those that influence outcomes on high-prevalence diseases, demonstrate baseline performance variability, and have potential mechanisms to improve results. A mix of process and outcome measures is needed, but measures should increasingly focus on patient-centered outcomes, including appropriate risk adjustment that is improved over time. Occasionally, a given measure may not be appropriate because of patient preference or clinician knowledge of information not captured in claims or electronic data. In these cases, exception reporting should be allowed to minimize “unfair penalization” and the potential unintended consequence of clinicians avoiding complicated cases. However, exception reporting will need to be monitored so it is truly the exception and provides information for requisite refinements. The measurement enterprise needs to be linked to a strategy for capturing high-priority data with minimal workflow disruption. Instead of chart review–based measurement, functional electronic health records (EHRs) are needed, along with patient registries that capture quality measurement data, such as monthly reports, to provide feedback to clinicians. Measurement is the first step in clinicianand practice-based improvement. Current measures often focus on individual patientclinician interactions at a single point in time and, therefore, undervalue teamwork and patient outcomes over time. Measures focused on adherence to process in single interactions, when implemented widely, may have unintended negative consequences for patients. Measures need to focus more on the patients’ outcomes over an episode of care, such as from hip fracture through recovery. If a patient with