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Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

VITAL
SIGNS

_____________________

CORE METRICS

FOR HEALTH AND HEALTH CARE PROGRESS

Committee on Core Metrics for Better Health at Lower Cost

David Blumenthal, Elizabeth Malphrus, and J. Michael McGinnis, Editors

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

THE NATIONAL ACADEMIES PRESS    500 Fifth Street, NW    Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Grant No. 7954757 between the National Academy of Sciences and the Blue Shield of California Foundation, Grant No. 10001457 between the National Academy of Sciences and the California HealthCare Foundation, and Grant No. 70991 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

International Standard Book Number-13: 978-0-309-32493-9
International Standard Book Number-10: 0-309-32493-9
Library of Congress Control Number: 2015947572

Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2015 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2015. Vital signs: Core metrics for health and health care progress. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

Knowing is not enough; we must apply.
Willing is not enough; we must do.
”      

                                                —Goethe

image

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

COMMITTEE ON CORE METRICS FOR BETTER HEALTH AT LOWER COST

DAVID BLUMENTHAL (Chair), President, The Commonwealth Fund

JULIE P. W. BYNUM, Associate Professor of Medicine, The Dartmouth Institute

LORI COYNER, Director of Accountability and Quality, Oregon Health Authority

DIANA DOOLEY, Secretary, California Health and Human Services

TIMOTHY FERRIS, Vice President, Population Health Management, Partners HealthCare

SHERRY GLIED, Dean, New York University Robert F. Wagner Graduate School of Public Service

LARRY A. GREEN, Epperson-Zorn Chair for Innovation in Family Medicine, University of Colorado at Denver

GEORGE J. ISHAM, Senior Advisor, HealthPartners

CRAIG A. JONES, Executive Director, Vermont Blueprint for Health

ROBERT KOCHER, Partner, Venrock

KEVIN L. LARSEN, Medical Director of Meaningful Use, Office of the National Coordinator for Health Information Technology

ELIZABETH A. McGLYNN, Director, Center for Effectiveness and Safety Research, Kaiser Permanente

ELIZABETH MITCHELL, President and CEO, Network for Regional Health Improvement

SALLY OKUN, Vice President for Advocacy, Policy, and Patient Safety, PatientsLikeMe

LYN PAGET, Managing Partner, Health Policy Partners

KYU RHEE, Chief Health Director, IBM Corporation

DANA GELB SAFRAN, Senior Vice President, Performance Measurement, Blue Cross Blue Shield of Massachusetts

LEWIS G. SANDY, Executive Vice President, Clinical Advancement, UnitedHealth Group

DAVID M. STEVENS, Associate Chief Medical Officer and Director, Quality Center, National Association of Community Health Centers

PAUL C. TANG, Vice President, Chief Innovation and Technology Officer, Palo Alto Medical Foundation

STEVEN M. TEUTSCH, Chief Science Officer, Los Angeles County Department of Public Health

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

IOM Staff

ELIZABETH MALPHRUS, Study Director

ELIZABETH JOHNSTON, Senior Program Assistant

MINA BAKHTIAR, Senior Program Assistant

KATHERINE BURNS, Senior Program Assistant

CLAUDIA GROSSMANN, Senior Program Officer

DIEDTRA HENDERSON, Program Officer

ROBERT SAUNDERS, Senior Program Officer (until March 2014)

SOPHIE YANG, Senior Program Assistant (until December 2014)

J. MICHAEL McGINNIS, Senior Scholar, Executive Director, Roundtable on Value & Science-Driven Health Care

Consultants

RONA BRIERE, Briere Associates, Inc.

ALISA DECATUR, Briere Associates, Inc.

REBECCA MORGAN, National Academies Library/Research Center

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

MARC BENNETT, HealthInsight

HELEN BURSTIN, National Quality Forum

JIM CHASE, Minnesota Community Measurement

JAMES B. CONWAY, Health Policy and Management, Harvard School of Public Health

STEVE FIHN, Office of Analytics and Business Intelligence, VA Puget Sound Health Care System, VA Health Services R&D, Center of Excellence

TRACY A. LIEU, Division of Research, Kaiser Permanente, Northern California

LINDA A. McCAULEY, Nell Hodgson Woodruff School of Nursing, Emory University

PATRICK REMINGTON, School of Medicine and Public Health, University of Wisconsin

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

JOSHUA M. SHARFSTEIN, Maryland Department of Health and Mental Hygiene

MARK D. SMITH, California HealthCare Foundation

KURT C. STANGE, Case Western Reserve University

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by coordinator Eric B. Larson, Group Health Research Institute, and monitor Donald M. Steinwachs, Bloomberg School of Public Health, Johns Hopkins University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

Preface

In the enormously complex U.S. health care system, even progress often creates problems. After years of debate over whether and how to measure the health system’s performance, consensus now holds that measuring performance is essential to performance improvement. This consensus, however, has unleashed a multitude of uncoordinated, inconsistent, and often duplicative measurement and reporting initiatives. Federal agencies, states, payers, employers, and providers have their own approaches, often focusing on different measures, or the same things measured differently.

The result is the danger that, in the name of promoting improvement, another source of health care inefficiency will be created. The full benefits of investments in measurement also are being lost, because variation leads to results that cannot be compared across geographic areas, institutions, or populations. The purpose of this report is to promote the effectiveness of the measurement enterprise in the United States by identifying a parsimonious set of core metrics that deserve widespread implementation and to suggest how that implementation might occur. In producing the report, the study committee learned some important lessons.

First, current measurement efforts are truly problematic. A preliminary survey conducted in support of this study found that health systems require an average of 50 to 100 full-time equivalent employees, including physicians, at a cost ranging from $3.5 to $12 million per year, to carry out these efforts. Surveys of measure requirements and reporting programs have found significant inefficiencies and redundancies, due in part to minor variations in measure methodologies that lead to multiple different reporting requirements for the same target.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

Second, as valuable as it is, measurement is not an end in itself. It is a tool for achieving health care goals. Readers will note that the core metric set proposed in this report starts with goals, proceeds through elements that embody or contribute to those goals, and then associates measures with those elements. In many cases, the Committee could not find existing measures that precisely capture valued ends. The Committee views this not as a shortcoming but as a major step forward. Identifying these gaps made it possible to support improvement in areas that may be neglected because, for whatever reasons, measure developers have not focused on them.

Third, measurement will fail if it is left to the experts. Because measures reflect goals and aspirations, their development is fundamentally a political process in the best sense of that term. In the pluralistic, decentralized U.S. health system, agreement on goals and aspirations and corresponding measures of their attainment must involve key stakeholders at every level of the system. The Committee believes the framework proposed herein is useful for facilitating consensus on goals and specific measures, but it understands that the process of reaching agreement on measurement approaches is as important as the technical specifications of the measures themselves. In that sense, this report should be seen as the beginning, not the end, of the journey toward a widely accepted set of core metrics for better health at lower cost.

Fourth, for a number of reasons, the report does not lay out a final, finely specified, parsimonious set of core metrics that will immediately solve all of the nation’s measurement problems. The Committee did not have the time, resources, or expertise to specify metrics or to develop composite measures where consensus does not already exist on those indicators. Also, although the Committee consulted widely with stakeholders, both publicly and privately, it did not represent all o the stakeholders whose views should influence, and who should embrace, a final set of core metrics. Furthermore, the Committee increasingly came to believe that the core metrics set may need to vary slightly (although with forethought and coordination) at different levels of the health care system, depending on the varying responsibilities and capabilities of stakeholders at those levels. Thus, the core metric set used by state public health agencies to hold themselves accountable would likely vary from the core metric set used by an independent group of five cardiologists practicing in a suburban community. The Committee simply did not have the resources to develop the several related core metric sets that would be required, but it does believe that all of those sets should be aligned in demonstrating how each stakeholder is contributing to a set of overarching goals such as those elaborated in this report.

The Committee is grateful to the sponsors of this project—the Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation—and to the Institute of

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

Medicine (IOM) for supporting its work. It is also grateful to Dr. Michael McGinnis for his leadership of the study process on behalf of the IOM, and to the incredibly talented and hardworking IOM staff who supported this study—Elizabeth Malphrus and Elizabeth Johnston—who deserve the lion’s share of whatever credit the report receives.

Finally, I would personally like to thank the remarkably insightful and hardworking members of the Committee. They took time from other pressing responsibilities to volunteer their expertise for the purpose of improving Americans’ health and health care. The future of the nation’s health system depends in no small part on the willingness of citizens such as these to contribute to the common good.

David Blumenthal, Chair
Committee on Core Metrics for Better Health at Lower Cost

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
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Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
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Acknowledgments

This report reflects the contributions of many people. The Committee would like to acknowledge and express its appreciation to those who so generously participated in the development of this report.

First, we would like to thank the sponsors of this project, the Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation, for their financial support.

The Committee’s deliberations were informed by presentations and discussions at four meetings held between August 2013 and June 2014. Additional input was sought from numerous outside stakeholders, and we would like to thank the 126 leading health organizations that provided their input on Committee directives.

A number of the Institute of Medicine (IOM) staff played instrumental roles in coordinating the Committee meetings and the preparation of this report, including Kate Burns, Elizabeth Johnston, Melinda Morin, Valerie Rohrbach, Julia Sanders, Robert Saunders, Francesco Sergi, and Sophie Yang. The Committee would like to acknowledge the contributions and insights of the Robert Wood Johnson Foundation health policy fellows who participated in this study—Jennifer Devoe and Samuel Johnson. The Committee would also like to thank Laura DeStefano, Chelsea Frakes, Greta Gorman, and Rebecca Morgan for helping to coordinate the various aspects of report review, production, and publication. Committee consultant Rona Briere, Briere Associates, Inc., made indispensable contributions to the report production and publication processes. Additionally, we would like to thank both Jay Christian and Casey Weeks for their contributions to the graphic portrayal and cover of this report. The Committee would

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press. doi: 10.17226/19402.
×

especially like to thank Elizabeth Malphrus, study director, for her overall guidance and support. Finally, we would like to acknowledge the guidance and contributions of Michael McGinnis, IOM senior scholar, throughout the study process.

With meaningful coordination, measurement can realize its potential as a tool for driving and enabling improvements in the nation’s health and health care and managing costs. We look forward to building on the ideas presented in this report toward achieving a continuously learning health system.

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Thousands of measures are in use today to assess health and health care in the United States. Although many of these measures provide useful information, their usefulness in either gauging or guiding performance improvement in health and health care is seriously limited by their sheer number, as well as their lack of consistency, compatibility, reliability, focus, and organization. To achieve better health at lower cost, all stakeholders - including health professionals, payers, policy makers, and members of the public - must be alert to what matters most. What are the core measures that will yield the clearest understanding and focus on better health and well-being for Americans?

Vital Signs explores the most important issues - healthier people, better quality care, affordable care, and engaged individuals and communities - and specifies a streamlined set of 15 core measures. These measures, if standardized and applied at national, state, local, and institutional levels across the country, will transform the effectiveness, efficiency, and burden of health measurement and help accelerate focus and progress on our highest health priorities. Vital Signs also describes the leadership and activities necessary to refine, apply, maintain, and revise the measures over time, as well as how they can improve the focus and utility of measures outside the core set.

If health care is to become more effective and more efficient, sharper attention is required on the elements most important to health and health care. Vital Signs lays the groundwork for the adoption of core measures that, if systematically applied, will yield better health at a lower cost for all Americans.

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