Quality is the degree to which health care services, both for individuals and populations, increase the likelihood of desired health outcomes. Quality does not measure one aspect of care, but rather looks at the whole picture of how care is being delivered and the outcomes of that care.

Focus areas of quality include:

  • Effectiveness: Providing care processes and achieving outcomes as supported by scientific evidence
  • Efficiency: Maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used
  • Equity: Providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care
  • Patient-centeredness: Meeting patients’ needs and preferences and providing education and support
  • Safety: Mitigating actual or potential bodily harm to patients, providers, and other staff
  • Timeliness: Minimizing delays and streamlining necessary care

Mass General Brigham is committed to making patient care better each day, across all parts of our system. Population Health works closely with Mass General Brigham Quality, Safety, and Value, particularly on Ambulatory Quality Measurement, which encompasses prevention, chronic care, and patient experience in primary care settings. We work together to leverage new technologies, identify areas for improvement, and scale successful best-practices across the Mass General Brigham system.

Rethinking The Way to Measuring Quality In Primary Care

Advancements in clinical redesign including participation in Accountable Care contracts, implementation of the Patient-Centered Medical Home model, and advancements to our shared electronic medical record (EMR), have enabled Mass General Brigham to rethink the way quality is measured in primary care. Most recently, Mass General Brigham has moved away from the traditional claims-based quality measures known as HEDIS, or the Healthcare Effectiveness Data and Information Set, and has adopted an internally-defined set of quality measures, focused on chronic diseases such as diabetes and hypertension, as well as cancer and depression screenings. Unlike traditional, claims-based measures,  this approach allows Mass General Brigham to broaden its quality measures scope to include: The Full Patient Population: Traditional quality measurement reporting relies on administrative claims data from payers. This approach is limited to those patients with private (or “commercial”) health insurance, which can be less than one-half of all patients. Mass General Brigham quality measures are based on the entire patient population, providing a more comprehensive and representative assessment of the patient care. Better Disease Identification: We are using the full spectrum of clinical information to identify chronic diseases like diabetes and high blood pressure, and nuances of screening exams such as those for colorectal cancer screening. This includes leveraging physical examination findings such as blood pressure, medication prescription information, and laboratory and pathology results. This provides a more accurate and detailed picture of the whole patient. Physician Judgment: This new measurement system allows providers to document when patients should not receive a standard recommended care plan. For example, a patient with metastatic cancer is not appropriate for colon cancer screening, even if they appear to be age-appropriate for such screening. Real-Time Feedback for Providers: This measurement system allows physicians to view their quality scores in real time, which allows them to better engage and improve on their scores more rapidly. This is a vast improvement over traditional measurement approaches, which rely on administrative claims data that are often lagged in time. In addition to leveraging new chronic disease measures, Mass General Brigham also uses patient experience surveys to provide important insights into their quality of care in areas such as care coordination, timeliness, and communication. Mass General Brigham provides feedback and data transparency at both the physician organizational level and the practice level so practices can work towards improving performance on these metrics. Visit Mass General Brigham Quality, Safety & Value to explore quality reporting.

Utilizing Patient Registries To Improve Quality

Registries are meaningful tools that make sense of the “big data” provided by the Epic Electronic Medical Record (EMR). Registries help providers identify patients for targeted interventions at an individual level. At a larger level, they also help Mass General Brigham to identify cohorts, and examine health trends at the patient population level. Provider Registries are utilized to organize data in the Electronic Medical Record (EMR) and identify patients who have chronic diseases and need specific care, such as blood pressure checks or diabetic monitoring. In addition, Provider-Facing Registries can be used to identify patients who need wellness care, such as preventative screenings like depression, colonoscopy and cervical cancer screening. Analyst Registries are utilized to analyze the patient EMR and report outcomes in a standard way. Analyst Registries, also known as “workbench reports” leverage data from the Epic Electronic Medical Record (EMR) and the Enterprise Data Warehouse. Much of the data relevant to registry and quality reporting is  captured while clinicians provide care to patients. Registries are also leveraged for clinical care and internal quality improvement purposes such as measuring performance, identifying variability, and focusing on improvement. Registries Currently Tracked in Epic:

  • One View Pediatric Registry
  • One View Primary Care Registry
  • Diabetes Registry
  • Wellness Registry
  • Anesthesia Record Registry
  • Cardiovascular Disease Registry
  • HCC Risk Adjustment Registry
  • Hypertension Registry

Examples of Registry Measures:

  • Adult BMI Assessment
  • Cervical Cancer Screening
  • Childhood Immunization Status
  • Adolescent Immunization Status
  • Colorectal Cancer Screening
  • Diabetes
  • Controlling High Blood Pressure
  • Weight Assessment and Counseling for Nutrition
Sharing Best Practice for Quality Improvement

The Quality Improvement (QI) Collaborative was established to facilitate shared learning and collaboration between providers across the Mass General Brigham network. Population Health supports participants of the Collaborative to plan and succeed in local quality improvement efforts. The Quality Collaborative meets quarterly and is comprised of Ambulatory Quality team members from across the network, Population Health Coordinators, Primary Care Practices, and staff from Population Health and Partners Community Physicians Organization (PCPO). Starting in 2019 the Quality team began collecting program feedback from the Collaborative to help improve measurement, user experience, and exception use standards. In 2020 we will implement a number of program changes. We will use the Collaborative as a forum to educate and collect feedback in the following areas:

  • Health Maintenance updates
  • Improved eCQM logic
  • Exception Use guidelines
Capturing The Patient Perspective With Patient Reported Outcome Measures

Patient Reported Outcome Measures (PROMs) measure health from the patient perspective, without being filtered through the view of a provider. The PROMS program is supported by Mass General Brigham Quality, Safety & Value and captures population Health program analytics for Shared Decision Making and Social Determinants of Health Screening. To complete a PROMs questionnaire, patients digitally answer questions designed to assess the health outcomes that matter most to them, including their functional status, symptoms, and quality of life (e.g. How much did pain interfere with your day to day activities?). These validated questionnaires are collected in the clinic via tablets and/or from home on the web or mobile patient portal. Real-time results and trends are available to the care team in the Electronic Medical Record (EMR). Read an Op-Ed on the value of PROMs from a Brigham & Women’s Physician. Objectives

  • To improve the care of individual patients through better monitoring and improved responsiveness: Providers can focus the conversation around the items that are most relevant and pertinent to the patient.
  • To help set patient expectations and guide better shared decision making: Longitudinal data collected pre- and post- procedure (for up to 10 years) can help guide treatment decisions, including surgery or alternative treatment options. Imagine that a patient needed surgery with two different options available. By looking at PROMs scores for a patient (or a specific patient demographic) the doctor and patient can look at trade-offs in speed of recovery, sustainability of recovery and other factors.
  • To compare effectiveness between modalities, institutions, individuals, and match patients more appropriately to interventions: Many traditional hospital measures focus on mortality or readmissions, but that data fails to capture whether the treatment positively affected the patient’s health outcomes. In fact, using these traditional measures, it can appear as though the average and the best medical centers deliver the same quality of care. PROMs, on the other hand, tell a much different story.  When you compare incontinence and impotence across medical centers (assessed via PROMs), the data shows significant variation in quality.
  • To measure quality more appropriately and demonstrate value to external audiences: The data can drive quality improvement and internal and public reporting through population-level PROMs data sets.

Watch this video to learn more about the Mass General Brigham PROMs program.

Championing Appropriateness

As Population Health strives to provide better care at lower cost, it’s critical that we have a framework and tools to help our doctors determine the most suitable treatment for each individual patient. The term “appropriateness” is often used to broadly describe this process. By focusing on appropriateness of care, we can assure that patients get the right care at the right time and avoid any unnecessary costs. Health providers across the country are increasingly focusing on better ways to assess and ensure that patients are receiving the most appropriate care. Appropriateness includes both surgical and non-surgical interventions such as tests or x-rays. For example, is it appropriate to order an MRI for a patient with a headache? How long should a patient pursue physical therapy before considering back surgery? These are complicated questions and many factors weigh into these decisions ranging from evidence-based clinical guidelines, risk factors, and patients’ personal goals and preference. To make it harder, these decisions are not always clear-cut, especially when dealing with complex cases. To learn more about appropriateness and other best-practices for health care decision making, visit our Care Decisions website.

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