This is difficult, despite the level of practice consolidation in collecting standardized data in Minnesota, because medical records do not reflect that consolidation.

Early on, HERF recognized that hospitals and the health plans were good at making physicians and providers aware of changes. However, HERF found that health care organizations and health plans had a great deal of trouble with the implementation of change across systems. For example, there is considerable acceptance of guidelines for the treatment of acute myocardial infarction by cardiologists, but there are many problems with fully integrating these guidelines into practice.

To overcome these problems, HERF identified opinion leaders in given areas by surveying physicians about to whom they turn with questions on the study topics. These physicians are recruited for participation in "spreading the word." HERF's opinion leaders are topic and site specific. Additionally, HERF recruits informal and formal administrative champions because system and process delays cause many difficulties in implementing change.

Many gaps between knowledge and practice can be explained by clinicians' previous negative experiences or personal attitudes and judgments. For example, in explaining why β-blockers may not be used as widely as is indicated, one cardiologist said that "in giving [a β-blocker] a physician cannot say he has saved a life, but if the patient has a stroke [as a result] he can say he caused it." It is very difficult for a group at a health plan level or even at a hospital department level to deal with these underlying attitudes and fears that can influence some clinical priorities on a day-to-day basis.

The value of HERF has been providing a neutral forum for community collaboration and economies of scale. If plans and providers choose to collaborated through a consortium like HERF, they will have access to the comparative standardized data increasingly requested by purchasers of care, some shared funding, and increased fund-raising capabilities. If they do not choose to engage in this type of activity and stay independent in quality measurement efforts, they will have more control and perceive that they will have a competitive advantage.

The Employers' Managed Health Care Association

Donald M. Steinwachs, Ph.D.

The Employers' Managed Health Care Association (MHCA) comprises Fortune 250 companies and their personnel benefits staffs. After hearing Dr. Paul Ellwood speak about outcomes management at a conference in 1989 or 1990, several members became intrigued by the idea of trying to capture the patient's experience in terms of outcomes and trying to look at health status as an indicator of quality of care.

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