In April 2015, the Institute of Medicine (IOM) released Vital Signs, a consensus committee report which identifies 15 core measures for assessing the nation’s health. The streamlined core measure set is a critical tool for mitigating measurement burden, sharpening focus on priorities that matter most, and aligning measurement activities around shared goals for health and health care. The application of the core measure set, standardized and harmonized at every level, holds the potential not only to substantially improve performance in the multiple systems in play, but to yield data of the reliability and comparability necessary to accelerate the continuous production of new knowledge on what works best.
Still, the utility of the set depends on widespread adoption and demands strong leadership at every level of the health care system — beginning with the Secretary of Health and Human Services (HHS), and extending to standards organizations, provider groups, hospitals, state and municipal departments, payers and purchasers, among others.
At the report’s release event held earlier this year at the National Press Club in Washington, DC, a panel of key national leaders, each with important stake in the effectiveness of health and health care, discussed what Vital Signs means for their respective organizations, and identified opportunities where each can contribute to ensuring the adoption and use of the IOM’s recommendations.
The following blog post offers perspectives from the CEOs of five health care organizations who sat on this panel — the American Public Health Association, the National Governors Association, the Association of State and Territorial Health Officials, the American Medical Association, and the American Hospital Association. These organizations are critical to the progress envisioned, and their collective pledge of support represents an important step toward the use of Vital Signs as a roadmap to achieve better health at lower cost.
Georges C. Benjamin, Executive Director, American Public Health Association
The release of Vital Signs reflects a growing national awareness of the importance of population health, and in the relationship between health and health care. The 15 measures presented by the IOM are critically important for thinking through what population health means, with particular emphasis on the social determinants of health.
One proposed measure is “healthy communities,” and is conceptualized as an index of various social and environmental factors in the community that influence health (e.g., education, housing, income, neighborhood walkability). Other measures, such as “overweight and obesity,” “well-being,” “unintended pregnancy,” and “addictive behavior” are inextricably linked to social determinants.
Progress in these domains will require involvement from key leaders outside the health sector, including schools, employers, city agencies, and others. Having an integrated health system requires rewarding providers, hospitals, and others for taking action to keep communities healthy, as well as collaborative action that extends beyond the health system and involves actors not directly involved in health or health care.
Embedding the community perspective into health care requires new and different approaches to measurement, as well as meaningful engagement with individuals and communities. The identification of community engagement as a distinct domain for measurement is a critical contribution of this report, as it emphasizes the role of communities in readiness for health.
During my time as a health officer in Maryland, the state required a small set of measures for all Medicaid managed care plans. The data from this work showed improvement over time in performance on the specific measures, but more importantly, fostered a culture of health within those systems, and a reordering of priorities for accountability and improvement.
This is the potential that the Vital Signs report offers. By drawing attention to the health measures that matter most, and promoting shared accountability for improvement, Vital Signs can act as a tool for ensuring that our system keeps its focus not only on the health of individuals, but on the opportunities and needs of the whole population.
Dan Crippen, Former Executive Director, National Governors Association
This report provides an important road map for aligning the measures that we use with the population- and systems-based approaches that characterize the health care system today. States have particular opportunity for leveraging the results of this report, as almost every aspect of health care involves state decision making in some way — from payment and contracting to medical education and staffing. I believe that states will be able to use this report to good ends.
Part of what makes this report powerful is its emphasis on parsimony and on comparability in measurement. These factors are particularly important for benchmarking and goal setting among states, where high-quality measures are needed to chart progress, and readily comparable data are needed to enable comparisons among states and communities.
The 15 measures identified in Vital Signs also reflect the complexity of the health system, and by focusing at the system level, can act as a tool for focusing attention on what is most important. If I am a physician with a patient who is depressed and diabetic, I know that treating their depression will most likely lead them to take better care of themselves. Physicians know, intuitively, that these interactions matter even if there is not a randomized controlled trial to prove it. By focusing on outcomes and population health, Vital Signs can create opportunities and incentives for these approaches to care, through an emphasis on shared accountability.
Looking ahead, the National Governors Association will work together with stakeholder groups, starting with HHS, and I would propose an initial focus on Medicaid as a subset population for considering implementation. While efforts have been made in the past to achieve standardization and alignment at the state level, we now have an opportunity to restart this effort with appropriate leadership and incentives.
As Daniel Patrick Moynihan used to say: if you want to solve a problem, you first have to measure it appropriately. If we can’t measure our health care system, its most meaningful inputs and outputs, and its true performance, we will not get to a solution. Vital Signs is a giant step forward toward achieving this goal.
Paul E. Jarris, Former Executive Director, Association of State and Territorial Health Officials
Vital Signs represents an important aspirational piece of work. A significant step in the right direction, there is nonetheless much work left to do if its vision is to become a reality.
One important conceptual element of the report is its emphasis on health and health care as two different, if closely related concepts. This calls attention to the significance of elements outside of the care system—from social determinants, to education and the environment—in determining the health and wellbeing of a community and the nation.
Equally critical is the report’s notion of having the HHS Secretary set national goals and create a system of metrics, such that local, regional, and national performance can be aggregated and disaggregated, and that contributions can be collected horizontally across stakeholder groups, building shared accountability into our approach to performance measurement.
Making the core metrics actionable will also depend on the quality of data, and our ability to shorten the timeline between data collection and reporting, so that stakeholders can have continuous feedback about their population of interest. This includes not only the clinical indicators that are often emphasized in health care settings, but also measures of social determinants of health, and community features and actions that contribute to improving health.
Disparities represent an important cross-domain priority embedded in the report — and an area where particular focus will be needed to ensure that the report’s recommendations are carried through in implementation. I think we may also need an aggregate, larger measure on health equity to ensure focused attention on the extent to which all citizens and patients are able to achieve their best health.
Looking to next steps, the Association of State and Territorial Health Officials supports the Vital Signs report, and we are willing to join those at the state health agency level, in first achieving finalized, standardized measure specifications, and then working toward implementation at different levels and in different settings. This work is surprisingly complicated and difficult, and we will all need to join in to make it a success.
James L. Madara, CEO, American Medical Association
The release of Vital Signs is both critical and opportune for the American Medical Association (AMA). We all want a strong health care system, but when we think of the aspirational goal of better health at lower cost, it is almost too broad to be actionable.
What has been missing is a framework or roadmap that would create linkages between this goal and the everyday measurement activities that assess the details of care and quality. The 15 core measures presented in Vital Signs give us this roadmap, creating an opportunity to bring the tools we use to assess quality and performance—measures—in alignment with the overarching goals of the health care system.
Vital Signs reflects, in important ways, what the AMA has found in its collaborative studies with RAND that analyzed how physicians are impacted by changing payment and delivery systems. What we found was that there are too many measures in use, and that practices were ill-equipped to manage the data gathering and reporting requirements.
In some cases, leaders would resort to shielding their colleagues from this measurement tsunami and we then saw that physician groups would spontaneously identify evidence-based measures and use those that were related to their patient population. This supports the well-known notion that when physicians believe, they act. This is a powerful incentive. This can be leveraged in the implementation of Vital Signs.
The AMA is already working in alignment with key stakeholder groups — not only care and measurement entities like the National Quality Forum (NQF) and the Centers for Disease Control and Prevention (CDC), but also important community stakeholders like the YMCA. We feel strongly about the need for multi-stakeholder collaboration and accountability in the care system and were pleased to see this perspective reflected in the Vital Signs report. For example, implementation of measurement approaches depends heavily on electronic health record (EHR) vendors and the extent to which their products enable timely and actionable access to information for providers and patients.
This report comes at just the right moment: as we’re still spending excessively without getting the outcomes we want. There is growing awareness that measurement itself is too costly, and doesn’t promote the mission of shared accountability represented by population- and community-based approaches to reforming health care.
We at the AMA also believe that this is everyone’s business because everyone in the health system touches these measures. We feel Vital Signs represents an important step forward, and are committed to working with the Secretary of HHS to bring this report to life. It will be a long and hard fight because achieving parsimony and alignment requires compromise from all corners. But it represents a critical transformation in how we think about the health system.
Richard Umbdenstock, Former President & CEO, American Hospital Association
I am pleased to lend the fullest support of the American Hospital Association (AHA) toward Vital Signs and its implementation through the office of the Secretary. It is terrific work that comes at a critical time, and we should work together to start using it — today.
Hospitals have had extensive experience with measures, and experience directly the burden created by continuous proliferation, particularly through the creation of slight variations of similar measures tailored to the needs of different payers or groups. The AHA has been asking for core metrics for years, and are pleased with the product that the IOM delivers in Vital Signs — a promising roadmap for developing a more rational measurement system.
Measurement is critically important to our ability to improve the nation’s health. It helps us get better faster on behalf of patients, while also unlocking the power of information for patients to take action in improving their own health and the health of their communities. We’ve seen benefits of standardized, focused measures, most recently in the Hospital Engagement Network undertaken across the country. This work shows what can happen when we’re on the same page with a broad range of stakeholder groups, and demonstrates the transformative potential of the core metrics approach.
I am ready to pledge the AHA’s support to this project, and propose as a first step that HHS work with stakeholder groups to integrate and align the recommendations of this IOM report with key elements of the National Quality Strategy. Let’s not have different variations on a theme in the policy world, as we do in the measurement world.
We also pledge to do our part in contributing to the development of hospital-specific measures, as well as to broader measures where hospitals can play a role. The key is for the range of stakeholders in health to get on the same page regarding what are our shared goals, what we are accountable for collectively, and what we should measure to ensure that everyday incentives are aligned with our overarching mission as a nation. This report is the start of that. Let’s start using it today.
Note 1
As reflected in their bios, Dan Crippen, Paul E. Jerris, and Richard Umbdenstock have left their positions since contributing to this post.
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