HI-FIVE (Health Informatics For Innovation, Value & Enrichment) Training is a 12-hour online course designed by Columbia University in 2016, with sponsorship from the Office of the National Coordinator for Health Information Technology (ONC). The training is role-based and uses case scenarios. Also, it has additional, optional modules on other topics of interest or relevance. Although we suggest to complete the course within a month's timeframe, the course is self-paced and so you can start and finish the course at anytime during a month's time period. No additional hardware or software are required for this course. Our nation’s healthcare system is changing at a rapid pace. Transformative health care delivery programs depend heavily on health information technology to improve and coordinate care, maintain patient registries, support patient engagement, develop and sustain data infrastructure necessary for multi-payer value-based payment, and enable analytical capacities to inform decision making and streamline reporting. The accelerated pace of change from new and expanding technology will continue to be a challenge for preparing a skilled workforce so taking this training will help you to stay current in the dynamic landscape of health care. This course is one of three related courses in the HI-FIVE training program, which has topics on population health, care coordination and interoperability, value-based care, healthcare data analytics, and patient-centered care. Each of the three courses is designed from a different perspective based on various healthcare roles. This first course is from a clinical perspective, geared towards physicians, nurse practitioners, physician assistants, nurses, clinical executives and managers, medical assistants, and other clinical support roles. However, we encourage anyone working in healthcare, health IT, public health, and population health to participate in any of the three trainings. If you would like to obtain continuing medical education (CME) or continuing nursing education (CNE) credits, you will need to have eligible credentials, complete the entire course, and complete the evaluation survey at the end. The HI-FIVE team verifies after each month that these requirements have been met and then a separate certificate (fee may apply) is distributed to you from our accreditation office. Please allow time for processing. If you have any further questions about continuing education, please see our website at www.hi-fivetraining.org. Accreditation Statement The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The College of Physcians and Surgeons designates this enduring material for 12.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The planning committee members are: Rita Kukafka, DrPH, MA, FACMI; Bruce Forman, MD; Gil Kuperman, MD, PhD; Virginia Lorenzi, MS, CPHIMS, FHL7, and Victoria Tiase, MSN, BN. None of the members of the committee, who planned this CME Activity, have any relevant financial relationships to disclose. The release date is 2/1/17 and the expiration date is 1/31/18. This activity is eligible for 12 continuing nursing education (CNE) credits. Columbia University School of Nursing, Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Regulatory Environment: Rationale for Reform
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来自 Columbia University 的课程
HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)
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Columbia University
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从本节课中
Role-Based Content (OPTIONAL) - Physicians / Nurse Practitioners / Physician Assistants / Clinical Executives / Clinical Managers / Public Health Professionals
This module is optional, but has additional topics that you may be interested based on your role. We encourage you to explore any of these topics and there are also quizzes to test your learning.
与讲师见面
Rita KukafkaAssociate Professor
Biomedical Informatics
Welcome to Value-Based Care, Regulatory Environment.
This is lecture a, this lecture will provide you with an overview of some of
the problems facing US healthcare today.
Much of the focus will be on describing concerns with healthcare quality and
healthcare spending.
In addition, the lecture will outline policy recommendations that seek to
improve quality and reduce spending.
The objectives for this lecture, rationale for reform,
are to describe the state of healthcare quality in the United States.
Describe reasons for growth in healthcare spending, and
describe policy recommendations to improve healthcare quality and reduce spending.
The Institute of Medicine now known as the National Academy of Medicine
which is a part the National Academy of Sciences,
established the quality of healthcare in America project in June 1998.
The project and it's working committee were charged with reviewing and
synthesizing findings in the literature on the quality of care in the United States,
and developing a policy framework to guide develop strategies to improve care.
The quality of healthcare committee delivered to landmark reports.
The first report produced in 1999 called to err is human reviewed the evidence
of safety issues and quality concerns that had been produced at that point in time.
Crossing the quality chasm, the second report, provides a road map for
system redesign.
The focus on healthcare system redesign really began with these two reports.
The quote on the screen from the chasm report very nicely summarizes the quality
concerns that efforts and system redesign and
the new models of care delivery are intended to address.
The crossing the quality chasm report, was spurred on in part by prior reports.
The first report, mentioned earlier,
called to err is human provided substantive evidence of quality problems.
An oft quoted number from this report is that at least 44,000
Americans die in hospitals each year because of preventable medical errors,
and that this number could be as high as 98,000.
A report produced by the president's advisory commission on consumer
protection and
quality in the healthcare industry, noted that there are several kinds of errors.
This report summarized the research literature from around the 1990s and
concluded that, at that time,
there was no guarantee that patients would receive high quality care.
And report noted that there are four kinds of errors.
Avoidable errors include missed or delayed diagnosis perhaps due to mistakes and
interpreting laboratory reports, it also includes medication errors.
Under utilization of services occurs when the patient did not receive a service or
the benefits likely exceed the risks.
Underuse can lead to limitations in functioning and
quality of life, or perhaps even lead to death.
Overuse of services happens when a service is provided to a patient
that poses significantly greater risks than the benefit to a patient.
Finally, research documents wide variation in healthcare practice across regions,
within smaller areas in a specific region, and across subgroups of individuals.
Aside from the harm that can come to patients, medical errors and
poor quality care have significant financial implications.
The to err is human report estimated that at the time,
national costs of adverse events were around $38 billion
and preventable adverse events, or about $17 billion.
This was about 4% of national health expenditures in 1996.
The recognition of the amount of money being spent,
all quality was still sub-optimal, lead to more interest in new models of
care that could address both quality and cost.
In 2011, the Commonwealth Fund surveyed 18,000 adults,
18 years and older, in 11 countries including the United States.
Adults were considered sicker if they rated their health as fair or poor.
Reported receiving medical care for serious chronic illness, injury, or
disability, had surgery or had been hospitalized in the past two years.
The 11 countries are considered high income,
that is, they look a lot economically like the United States.
As this slide shows, sicker adults in the U.S.
are more likely to report a medical error compared to adults in the other countries.
The quality chasm report provides some underlying reasons for
poor quality of care.
Healthcare is a complex, highly technical industry.
Medicines knowledge-based as well as the number of drugs, medical devices and
other technologies has grown exponentially.
No nurse, doctor, pharmacist or other healthcare professional can acquire or
retain all the knowledge and evidence necessary for sound decision making.
We are also living longer and living longer with chronic long-term conditions.
Treating chronic conditions can require collaborations across a variety of
healthcare professionals and
healthcare organizations, and this brings us to the third bullet on the slide.
Our healthcare delivery system is not well organized to work
with individuals with chronic disease.
Episodic care systems are designed to cater to acute conditions
rather than long-term chronic diseases.
The delivery system is comprised of a variety of public and
private care organizations and financing and insurance mechanisms.
A patient with a chronic condition may see multiple providers
who do not interact with each other.
The fragmented system also results in a lack of accountability for patients and
their outcomes.
In addition, in the late 1990s the U.S. lagged behind other countries
in the use of information technology, such as, electronic medical records.
One problem is that the EMR systems, even today, have difficulty exchanging
information across providers because of the lack of interoperability.
This means that similar systems from different vendors, or sometimes
different systems from the same vendor, cannot communicate with each other.
For example, a 2010 article by O'Malley and colleagues.
In the journal of general internal medicine noted that primary care
physicians, reported that EMRs are not able to support coordination
between clinicians and practice locations, because there was a lack of
standardization of key data elements across the various systems.
As reported by the Commonwealth Fund in 2011, the percent of primary care
providers in the US who reported using electronic medical records
was behind that of doctors in other countries Although this is improving,
these problems can lead to an increased likelihood of medical errors and
poor quality of care.
In addition to concerns about health care quality and patient safety, the US
health care system is very expensive and sometimes very difficult to access.
Let's discuss health care cost a bit.
The Kaiser Family Foundation analyzed the national health expenditure data
from the Centers for Medicare and Medicaid Services, or CMS.
The Kaiser Family Foundation concluded that this graph shows that
health spending totaled $74.9 billion in 1970.
By 2000, when those quality reports from the IOM emerged,
health expenditures had reached $1.4 trillion.
And in 2013, the amount spent on health had doubled to $2.9 trillion.
Total health expenditures represent the amount spent on health care and health
related activities, such as administration of insurance, health research, and
public health, including expenditures from both public and private funds.
The Kaiser Family Foundation also produced this graph, that shows that the proportion
of the economy that is devoted to health has also been increasing over time.
As they said, in 1970, the US devoted 7% of its gross
domestic product to total health spending, both through public and private funds.
By 2001, this represented 13%.
And in 2013, the amount spent on health had increased to 17% of GDP.
There are numerous reasons for the increase in health care spending,
including some of the issues we discussed earlier.
Increasing use of technology and
pharmaceutical therapies, the aging of the population.
Along with the rise and the prevalence of chronic disease, medical errors and
patient safety concerns.
Suboptimal quality health care and
a complicated delivery system hampered by waste and fragmentation.
Another underlying problem with US health care
is that many people have a difficult time getting access to health care.
According to Healthy People 2020, the nation's set of objectives for
improving the health of Americans, access to health services means the timely
use of personal health services to achieve the best health outcomes.
In order to have access, individuals must gain entry to the health care system.
Find and locate a place where health care services are provided, and
find a health care provider with whom the patient can communicate and trust.
Healthy People notes that health care access is unreliable, and
is so because not everyone has the financial means to pay for health care.
The lack of availability of providers in certain areas and
specialties, and not being able to get a timely appointment, or
to obtain specific tests and treatment in a timely manner.
One issue of concern is that only 77% of people
have an identified usual primary care provider, or PCP.
PCPs are important because they help patients integrate care across providers,
and increase the likelihood that patients will receive appropriate care.
Some of the new delivery models are designed to help improve
health care access.
We will now discuss the findings of the Crossing the Quality Chasm report.
The IOM, in its Crossing the Quality Chasm report,
provided six aims for transforming the US health care system.
Health care should be safe.
That is,
it should avoid injuries to patients from care that is intended to help.
Effective, and provide services based on scientific knowledge to all who
can benefit, and avoid providing services to patients who will likely not benefit.
Patient-centered, which means providing care that is respectful and
responsive to individual patient preferences, needs, and values.
Timely, that is, waits and harmful delays should be reduced for
those who receive and give care.
Efficient, reducing waste and unnecessary cost.
Equitable, which means providing care that does not vary in quality because of
personal characteristics such as ethnicity or socioeconomic status.
The IOM was quite high reaching in its recommendations by calling all
organizations in health care to adopt these aims, and
to work toward reducing the burden of illness in the United States.
In addition, the report called on Congress to authorize and
appropriate funds to track and monitor national progress toward these aims.
These six aims very clearly address the quality,
cost, and access problems we discussed earlier.
Donald Berwick, in a 2002 article for the journal Health Affairs,
reviewed the Quality Chasm report, and summarized the aims for improvement and
overarching recommendations into four levels of interest.
The first two areas address patients and microsystems of care.
According to Berwick, changes need to occur
that will focus on patient experiences and need to be patient-centered.
>> A good definition of patient-centered care
comes from another article by Dr. Berwick.
Where he defines such care as the experience, to the extent the informed
individual patient desires it, of transparency, individualization,
recognition, respect, dignity, and choice in all matters.
Without exception related to one's person,
circumstances, and relationships to health care.
The next area for change is within health care organizations.
According to Berwick, health care organizations must assure that
they find and adopt best practices in clinical delivery.
Information technology is use to improve access to information and data, and
to aid in clinical decision making.
Improvements are made in workforce knowledge and teamwork.
There is better coordination among services and settings within and
across settings of care, within and external to the organization.
And sophisticated and valid approaches of measuring performance and
outcomes of care are utilized.
Berwick also addresses the health care environment, which includes health system
financing, regulation, accreditation, litigation, education and social policy.
The regulations and legislation leading to new models of care adopt these principles
of improving patient experiences with care or focusing on patient-centered care.
Reducing fragmentation,
improving care coordination, and holding organizations accountable for
the quality of care they deliver to patients And their outcomes of care.
In 2007, the Institute for Healthcare Improvement, which was led by Dr. Berwick,
proposed and promulgated The Triple Aim for improving the healthcare system.
The Triple Aim refers to improvements in patient experiences with care
including quality and satisfaction, improving the health of populations and
reducing the per capita cost of care.
Work on these three improvements needs to occur simultaneously and
across organizations.
The National Quality Strategy or NQS was mandated by the Patient Protection and
Affordable Care Act, otherwise known as the ACA and is updated annually.
The three aims for the NQS mirror those promulgated by the IHI Triple Aim.
NQS has three broad aims that are used to guide local state and
national efforts to improve quality.
Better care, to improve overall quality by making healthcare more patient centered,
reliable, and safe Healthy people, healthy communities.
Improving the health of the US population by supporting proven interventions
to address behavioral, social and
environmental determinants of health, as well as high quality care.
Affordable care to reduce the cost of quality health care for
individuals, families, employers and government.
The NQS is operationalized through a series of priorities and strategy levers.
The priorities include making care safer by reducing harm caused in the delivery of
care, insuring that each person and family is engaged as partners in their care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for
the leading causes of mortality starting with cardiovascular disease.
Working with communities to promote wide use of best practices
to enable healthy living.
Making quality care more affordable for individuals, families, employers and
governments by developing and spreading new health care delivery models.
Levers represent the core business functions organizations can use to pursue
improvement.
Recall the slide on Levels of Change that illustrated Don Berwick's suggestions for
needed changes micro-systems and
organizations work two of the levels of change.
The levers, provide guidance for organizations and
businesses who are working to align with the NQS.
Organizations can provide performance feedback to plans and
providers to improve care.
Publicly compare treatment results, costs, and patients experience for consumers.
Provide learning and technical assistance and
foster learning environments that offer training, resources, tools and
guidance to help organizations obtain quality improvement goals.
Seek certification accreditation and regulation and in doing so
adopt or adhere to approaches to meet safety and quality standards.
Health consumers adopt healthy behaviors and make informed decisions
through the use of consumer incentives and planned benefit designs.
Reward and incentivize providers
through payments to deliver high quality patient centered care.
Improve communication, transparency and efficiency for a better coordinated
health and healthcare through the use of health information technology.
Foster innovation and diffusion in healthcare quality improvement and
facilitate rapid adoption within and across organizations and communities.
Invest in people to prepare the next generation of health care professionals,
and support life long learning for providers.
The NQS website includes more information on this national effort,
including reports from federal agencies on how they are using these
levers within these organizations to improve quality and outcomes.
The NQS sets a framework for the nation to follow and
encourages alignment of existing quality improvement strategies.
For example, the existing quality improvement organization or QIO program.
Has become an integral part of the NQS by seeking to improve the quality of
care provided to Medicare beneficiaries.
Ensuring that Medicare pays only for reasonable and
necessary services and by addressing individual patient complaints.
QIOs are comprised of a group of health and quality experts.
In addition to ensuring alignment with existing systems, the NQS provides a road
map for delivery system reports that support improvement in quality of care.
This includes the development of new payment models that are designed to
improve quality and reduce cost.
The NQS also encourages the development and use of reliable and
valid quality measures in order to track quality improvement activities.
The US Department of Health and Human Services coordinates this process.
And in 2015, convened a measurement policy council to evaluate current measures,
create a consensus around the core group of measures for
high priority areas, and foster future measurement development.
In its 2015 report to Congress, the US Department of Health and Human Services
reported that the measurement council had reviewed nine topics so far.
Including some common and/or serious conditions,
such as hypertension control, obesity BMI,
smoking secession, depression screening, and HIV/AIDS.
They also addressed care processes such as hospital acquired conditions and
patient's safety, as well as perinatal care.
Finally, they advocated the use of the survey known as HCAHPS,
Hospital Consumer Assessment of Healthcare Providers and Systems.
This concludes Lecture a of Regulatory Environment.
By the beginning of the turn of the century, there was strong recognition that
current ways in which the delivery system was organized were not sustainable.
In this lecture, we provided an overview of the quality,
cost and access issues associated with US health care,
and noted that care can be sub-optimal and unsafe.
Healthcare access can be unreliable, costs are high, and
consuming a significant proportion of the GDP.
And the delivery system is fragmented, information technology and
the use of electronic health records can help reduce fragmentation.
However, the country is just beginning to capitalize on this potential.
We also described three frameworks or road maps for
solving some of the problems facing US health care.
The three frameworks are very similar and emphasize providing better care for
individuals and populations while paying more attention to the cost of care.
The National Quality Strategy, or NQS provides a guide for the nation's
quality improvement activities both in the public and private sectors.
