Health Performance Measurement in the Public Sector Principles and Policies for Implementing an Information Network (1999) / Chapter Skim
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4 Data and Information Systems: Issues for Performance Measurement
4 Data and Information Systems: Issues for Performance Measurement
Pages 83-131
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From page 83... ...
, the panel is hopeful that the current interest in performance measurement, reflected in reports such as this one, will encourage policy makers and health professionals at the federal, state, and local levels to transform the many different existing data sources into a more efficient and effective health information system with the capability of responding to varied information needs. Collecting and assembling data is expensive, and expanding data collection efforts carries the risk of reducing the resources available for program services.
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From page 84... ...
The panel emphasizes, however, that if performance measurement activities are to succeed, they should fit into a broader agenda for collecting and using health data to protect the health of the public, as well as for guiding the development and implementation of health policies at the local, state, and federal levels. Although the panel did not attempt to address measurement of the quality and performance of individual health care providers or health plans, it should be noted that these activities are generating similar concerns about such matters as the selection of suitable performance measures, the limitations of administrative data sets for assessing health outcomes, the need for greater standardization of measures and data and for methods to improve data quality, and broader use of new information technologies (see, e.g., Iezzoni, 1997a; National Committee for Quality Assurance, 1997; Palmer, 1997; Foundation for Accountability, 1998; and Joint Commission on Accreditation of Healthcare Organizations, 1998~.
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From page 85... ...
patient records that contain clinical information obtained in the course of providing health care; and (4) administrative data, such as billing records, that are collected as part of the operation of a program (although these records may include data on health status or clinical care, that is not their primary purpose)
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From page 86... ...
Continuing survey programs that have a defined schedule (e.g., the National Immunization Survey, the Behavioral Risk Factor Survey) can combine a stable core of questions, yielding results that can be compared over time, with changing sets of questions that can address topics of special interest.
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From page 87... ...
Similarly, studies of the Behavioral Risk Factor Surveillance System suggest that its telephone-based methods are sufficiently reliable to justify continued use of this less expensive method (e.g., Arday et al., 1997~. In contrast, a study focusing on health insurance coverage suggests that reliance on telephone interviews alone may not be adequate for some analyses (Strouse et al., 1997~.
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From page 88... ...
The CPR holds the promise that documentation of the process and outcomes of care will become a byproduct of the use of such an information system in the delivery of care, and that patient records will become a more practical source of data for performance measurement for both the health care industry and health agencies at the federal, state, and local levels. Major advances are needed in at least three areas, however, if more extensive use is to be made of clinical data in computerized form: standards defining the structure and content of electronic clinical records must be established, technology for converting natural medical language into standardized coding systems must be developed, and privacy concerns must be resolved.
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From page 89... ...
Administrative data produced by various other activities that are not specifically health related can also provide useful information for health programs. For example, traffic safety records can provide data on motor vehicle crashes resulting in injuries, and state corrections records can provide information on incarcerated adults with serious mental illness.
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From page 90... ...
Information on outcomes and events that occur outside the framework of the program are rarely available. For example, the records of a substance abuse treatment program can produce data such as the number of participants who complete treatment, but will not directly capture the drug-related arrests of program drop-outs or the subsequent employment history of people who have successfully completed treatment.
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From page 91... ...
With nearly universal participation in Medicare among those aged 65 and older, Medicare claims files have been more complete than other claims databases and therefore often more useful for state and local analyses. However, claims records are generally not available for Medicare services provided through prepaid managed care plans.
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From page 93... ...
Use of unique personal identifiers might simplify the process of establishing exact matches, but such identifiers have not been uniformly employed. Provisions of HIPAA now call for adoption of these identifiers, especially for use in electronic health care data transactions, but there is serious concern that stronger privacy protections must be enacted before unique personal identifiers can be used with confidence or comfort (see National Committee on Vital and Health Statistics, 1997b)
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From page 94... ...
Other obstacles included the technical complexity and expense of community-based systems, concerns regarding the confidentiality of patient records, and the reluctance of some health care organizations to share information with business competitors. An alternative model, sometimes referred to as the Community Health Information Network (CHIN)
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From page 95... ...
For example, the use of observational and administrative data for performance measurement poses analytic challenges that differ from those for studies that can rely on more carefully controlled experimental data. Although opportunities to redesign the existing data systems that will provide much of the data for performance measurement will be limited, expert advice can help maintain or improve the quality of those systems.
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From page 96... ...
Random Variation and Bias In collecting and using performance measurement data, policy makers and program staff must keep in mind the effects of random variation and bias. Some degree of random variation should be expected among otherwise similar measurements.
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From page 97... ...
Financial incentives associated with variations in reimbursement rates may also influence the way diagnoses or health services are characterized in health insurance claims. Although bias is undesirable, it may not make data unusable.
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From page 98... ...
The National Committee for Quality Assurance (1997) has specifically recommended that health plans implement routine data-quality audits to improve the accuracy and completeness of their clinical and administrative data sets.
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From page 99... ...
Results can be affected, for example, by differences in methods of collecting the data, in the health care or program environments, and in the underlying characteristics of the populations being measured. A study designed specifically to test the ability of five states to report comparable data for a set of mental health performance measures demonstrated that such differences are currently an obstacle for performance measurement (National Association of State Mental Health Program Directors Research Institute, 1998; see also the discussion of this study in Chapter 3~.
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From page 100... ...
Concerns Related to Differences in the Characteristics of Populations Health outcomes are often closely linked to biological and social risk factors. Since the nature and distribution of these factors can be expected to vary across the populations being served in various programs and geographic areas, some of
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From page 101... ...
With this method, population-wide rates are calculated by applying the observed subgroup measurements from each population of interest (e.g., age-specific rates for smoking or completion of substance abuse treatment) to the equivalent subgroups (e.g., age groups)
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From page 102... ...
, an extensive patient interview instrument, is being used to collect information about the characteristics of the substance abuse patients served, including employment, legal involvement, family, and psychiatric problems, as well as the nature and extent of their illegal drug use. Implications for Data Analysis What are the implications of the preceding observations for data analysis and for policy that flows from that analysis?
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From page 103... ...
Although standards can be imposed through regulation and legislation, the panel favors a collaborative approach based on the participation of interested parties at the national, state, and local levels to ensure consideration of a broad range of views. Standardization Activities Although much remains to be done to improve standardization in methods of data collection, in the coding of health data, in the formats for storing and transmitting data, and in the definition of performance measures, many activities in the public and private sectors are making useful contributions in these areas.
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From page 104... ...
The National Notifiable Diseases System, which relies on state reporting of new cases of specific conditions, was enhanced in 1990 by the development of standard case definitions for nationally reportable conditions (Centers for Disease Control and Prevention, 1997~. SAMHSA compiles the Treatment Episode Data Set from a minimum set of data collected by states on clients admitted to substance abuse treatment programs that receive funding through the state substance abuse agency.
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From page 105... ...
As interest in treatment outcomes and performance measures has grown, state mental health and substance abuse programs have recognized the need to develop new and more comparable measures. In 1997, the members of the National Association of State Mental Health Program Directors (NASMHPD)
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From page 106... ...
Health Insurance Portability and Accountability Act of 1996 HIPAA should result in substantial advances in the standardization of health care data and data systems. The administrative simplification provisions of HIPAA direct the Secretary of Health and Human Services (DHHS)
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From page 107... ...
Standardization of data elements, data definitions, transaction formats, and code sets should aid the conversion of health encounter data into public health data. For example, with a standardized transaction format and standardized electronic data interchange, it should be possible to piggy-back notices of reportable illness on an electronic transaction.
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From page 108... ...
There is a risk that setting standards for performance measures or data sources will discourage improvement and innovation. Current limitations on the availability of data could, for example, encourage adoption of "least common denominator" measures for which data are widely available, rather than better measures for which new data collection efforts would be required.
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From page 109... ...
Federal, state, and local governments should ensure that policy, program, and technical perspectives are all represented, and might work with various organizations to identify representative participants from these constituencies for such an effort. Examples of these organizations include the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, the Association of Maternal and Child Health Programs, the National Association of State Mental Health Program Directors, the National Association of State Alcohol and Drug Abuse Directors, the National Association of Local Boards of Health, and the Association of Public Health Laboratories.
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From page 110... ...
For example, responses from a state's Behavioral Risk Factor Survey might be grouped by county or other substate region to gain additional insight into possible differences in risk behaviors and program impacts or needs across the state. It may also be useful to include geographic information, such as the distance between a substance abuse client's residence and treatment site, in analyses of program outcomes.
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From page 111... ...
As discussed earlier, there is great potential for CPRs to meet the need for timely and accurate clinical information that is difficult to access with traditional paper records (Institute of Medicine, 1997~. Prototype CPR systems can convert natural medical language into medical procedure and diagnosis codes.
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From page 114... ...
Fears that disclosures such as HIV test results or records of mental health or substance abuse treatment could lead to loss of employment or refusal of insurance may be especially acute. This concern is creating pressures for stricter technical and policy controls on access to and use of health data.
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From page 115... ...
The proposed use of unique personal identifiers in health records discussed earlier would facilitate record linkage, but many observers oppose their adoption until more effective privacy protections are in place (e.g., Institute of Medicine, 1994; National Committee on Vital and Health Statistics, 1997b; National Research Council, 1997b)
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From page 116... ...
and the National Committee on Vital and Health Statistics (1997a)
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From page 117... ...
Because publicly funded health programs often face serious funding constraints, the panel emphasizes the importance of mobilizing the resources needed for data and information system development in ways that do not compromise funding for program services. At the same time, it is important to emphasize that only with good data and good program monitoring is it possible to assess whether program services are effective and being used appropriately.
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From page 118... ...
Opportunities may also exist to expand data collection within an existing framework, which would tend to be less costly than establishing a new freestanding activity. For example, the National Center for Health Statistics has proposed the State and Local Area Integrated Telephone Survey (SLAITS)
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From page 119... ...
If the public sector is not to be left behind, it, too, must make a significant investment in information systems. Estimates of the current spending on state and local health data systems are not readily available,2 but a reference point 2The Association of State and Territorial Health Officials, the National Association of County and City Health Officials, the National Association of Local Boards of Health, and the Public Health Foundation are collaborating in a federally funded project aimed at developing a methodology for measuring state and local public health expenditures in support of the essential public health functions (see Chapter 3 for a list of these functions)
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From page 120... ...
Strategies to realize this potential and reinvest some portion of the savings in data systems and performance measurement for publicly funded health programs should be explored. Training and Technical Assistance The adoption of performance-based systems of accountability for publicly funded health programs will require staff who oversee and operate these programs to apply skills in planning and assessment that may be unfamiliar to them.
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From page 121... ...
In a recent activity of particular relevance to the interests of this panel, CDC and HRSA worked with the Association of State and Territorial Health Officials and the National Association of County and City Health Officials to develop an "investment guide" to assist states in planning and developing integrated health information systems (Centers for Disease Control and Prevention and Health Resources and Services Administration, 1998~. A review of technical assistance activities in DHHS led to the conclusion that these activities could be enhanced by greater coordination and evaluation of the effectiveness of current forms of assistance (U.S.
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From page 122... ...
Likewise, the panel applauds the advances that HIPAA is expected to bring to standards for electronic health care transactions, but also urges support for efforts that will encourage the development of standards for an even broader range of health data elements, such as those likely to be used in performance measures for a variety of publicly funded health programs. 4This suggestion was also made to the panel in the background paper "Improving Federal-State Data Collection to Monitor Program Performance Measures." 5A summary of state efforts to integrate health information was compiled by DHHS and The Lewin Group.
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From page 123... ...
One concern is the tension between the program-specific perspective that is often the basis for funding and oversight of publicly funded health programs and a more functional perspective on the operation of data systems that focuses on the commonalities among the data collection and management tasks to be performed for many program areas. Categorical grant programs help ensure that funds are directed to specific needs, but they may hinder both a broad view of health and the efficient organization of data systems at the state and local levels.
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From page 124... ...
These collaborations stand as examples for efforts that could be undertaken in other areas, such as enhancing the comparability of states' behavioral risk factor data. Another source of tension is the burden associated with the reporting requirements for the federal block grants (e.g., the Preventive Health and Health Services Block Grant or the Substance Abuse Prevention and Treatment Block Grant)
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From page 125... ...
, as reflected in that organization's recommendations in support of a National Public Health Surveillance System and for enhanced usefulness of state and local data collection by the National Center for Health Statistics. Those recommendations included improving access to surveillance data through better coordination of data systems, and planning surveillance and other data collection activities at the state and local levels in a standardized but collaborative fashion that includes local, state, and federal partners from relevant organizations.
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From page 126... ...
The panel is convinced that this interest could and should be translated into the sustained commitment of time and resources needed to develop a more comprehensive and coherent approach to health data and health data systems that would build effectively on existing data resources and be capable of meeting health information needs at the federal, state, and local levels. The panel has focused primarily on the public-sector perspective, but recognizes that there are closely related private-sector interests and developments that must not be overlooked.
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From page 127... ...
. Centers for Disease Control and Prevention and Health Resources and Services Administration 1998 Integrated Health Information Systems Investment Analysis Guide.
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From page 128... ...
Washington, D.C.: National Academy Press. Joint Center for Poverty Research 1998 Administrative Data for Policy-Relevant Research: Assessment of Current Utility and Recommendations for Development.
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From page 129... ...
Alexandria, Va.: National Association of State Mental Health Program Directors Research Institute. National Committee for Quality Assurance 1996 NCQA Issues Final Technical Specifications for HEDIS 3.0.
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From page 130... ...
Stroup 1994 Future directions for comprehensive public health surveillance and health information systems in the United States. American Journal of Epidemiology 140:383-397.
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From page 131... ...
U.S. Department of Health and Human Services 1991 Healthy People 2000: National Health Promotion and Disease Prevention Objectives.
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