JAMA Commentary: Benefits of a Patient-Centered Performance Management System
All too often, the U.S. healthcare system fails patients on two levels: some patients fail to receive care that would clearly help them, while other patients receive care that will not benefit them (and may even be harmful). The current focus on "one size fits all" guidelines and performance measures may even promote unnecessary and harmful treatment. But now healthcare systems have a rare opportunity to implement patient-centered approaches that will drive appropriate decisions for individual patients, rather than across-the-board adjustments that decrease utilization more or less arbitrarily. A "Patient-Centered Performance Management System" would help clinicians and patients make individualized decisions about optimal care for common clinical situations, would explicitly incorporate patient preferences, and would reinforce such decisions through patient-centered performance measures. For example, a 48-year-old non-smoker, with treated hypertension and hyperlipidemia, but no known cardiovascular disease presents to a clinic with a systolic BP of 144/82 mmHg. How should the clinician decide whether this patient needs his BP medications adjusted (based on the "one size fits all" recommendation of BP <140/90)? In a patient-centered performance management system, the electronic health record (EHR) would automatically calculate this patient's 10-year risk for cardiovascular disease (about 5%). Then the system could present the cardiovascular risk reduction (benefit) and adverse effects of medications or other treatments in a way that both the clinician and the patient could understand. The essential element in this system is its commitment to directly considering the net benefit of care at the individual patient level (not using population averages), while also eliciting and capturing individual patient preferences for care.
Distinguishing between high- and low-value healthcare requires a level of sophistication that is within the reach of clinicians, but involves several steps. First, decision tools are needed for common and costly clinical scenarios, such as the prevention and treatment of cardiovascular conditions, which use individual patient characteristics to determine whether a medical service is appropriate for an individual in a given situation. Second, these tools must integrate with the EHR environment in order to automatically populate fields with patient-specific information. Third, the tools need to present information to patients and clinicians in a way that promotes informed decision-making and that captures the outcomes of these discussions. All this information can then be incorporated into personalized performance measures that encourage the provision of high-value care, motivate shared decision-making for preference-sensitive care, and discourage the provision of low- or negative-value care. In this way, the vision of decreasing unnecessary and potentially harmful care and its attendant costs can be realized, along with improving appropriateness and personalization of care for all patients.
This work was partly supported through VA/HSR&D's Quality Enhancement Research Initiative (QUERI). Dr. Kerr is Director of Diabetes-QUERI and also is Director of HSR&D's Center for Clinical Management Research in Ann Arbor, MI, where Dr. Hayward is an investigator.
Kerr E and Hayward R. Patient-Centered Performance Management: Enhancing Value for Patients and Healthcare Systems. JAMA Commentary July 10, 2013;310(2):137.