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The PRO community strongly supports the call for the development of a comprehensive patient outcome data base. Historically, as Morford (1991) mentions, the PRO data base has been fragmented and incomplete, and the changes in the focus of the review have further fragmented the PRO data base. This has not permitted the PRO community to come up with any concept of outcomes, nor has it allowed for the development of an efficient or effective patient care review methodology across the continuum of care.

Historically the PRO community has been extremely uneasy with looking at a snapshot of care as we have for the last several years. The emphasis in the IOM report on the continuum of care is to be applauded. In the Third Scope of Work the PRO community is beginning to look outside the acute hospital environment. As it develops expertise in the non-acute hospital review, the PRO community could make a definite contribution to the data accumulating on non-acute hospital care.

The PRO community likewise applauds the shift from focusing on the single event, and on the outlier, to looking at patterns of care. In looking at patterns of care the PRO can focus on institutions, hospital administrations, and hospital medical staffs as deliverers of care, rather than focusing on the single practitioner.

The PRO community certainly agrees that an internal institutionally based quality assurance program must be encouraged and that, at a minimum, good performers should be rewarded with less review. Particularly in the Third Scope of Work the PRO program clearly identifies the problems in the acute hospital environment; problems will be assigned to the hospital, as well as to the practitioner, no matter the source. This is an effort in the PRO program to look at institutionally based delivery of care and to look at patterns of care rather than focusing on the practitioner or the ''bad apple.''

The development of a comprehensive Medicare outcome data base is not going to come easy. I am pleased to hear, according to Morford (1991), that we will be able to implement the Uniform Clinical Data Set in the near future. However, I think we have to be very careful about using data alone to make judgments about practitioner and provider performance. The American Medical Peer Review Association (AMPRA) believes that, both in the transition period when the data base is being developed and in the long term when the data base is operational, local physician peer review of medical records must continue to play a significant role in the program's ability to validate outcomes and to make final determinations about practitioner and provider performance. Moreover, as Morford (1991) mentions, the PROs have a statutory obligation to take appropriate action in individual cases of unnecessary and poor quality care. The PROs will greatly appreciate a broad data base because it will help them target their review of suspected deficiencies and should lead to a more efficient and effective external monitoring system that is less intrusive on the provider community.

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