file:///6%3A22%3A99/Temporary%20Items/nscomm40/tmp/tmp1/edt1.html[AMA]
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JAMA REPORTS
ELECTRONIC INFORMATION FRAMEWORK ESSENTIAL
TO MEASURE CLINICAL PERFORMANCE
National panel stresses need for timely
access to detailed and accurate data
CHICAGO An integrated health information
framework is needed to meet the critical
challenge of measuring the quality of U.S.
health care delivery, according to an
article in the September 22/29 issue of The
Journal of the American Medical Association
(JAMA), which summarizes key findings from
a National Committee for Quality Assurance
(NCQA) report.
Eric C. Schneider, M.D., M.Sc., of the
Harvard School of Public Health in Boston,
and colleagues state that "the increasing
effectiveness of medical treatments,
unexplained variations in their use, and
cost-containment pressures have created an
urgent need for accountability. Comparing
performance and publicizing that
information will drive clinicians to
improve clinical care and should counter
financial incentives to restrict
appropriate care."
The authors assert that tracking clinical
performance will require not only clinical
data stored in information systems, but
also an integrated health information
framework. "An information framework
includes local information systems
(hardware, software and data), but also
specifies and standardizes data elements
and protocols for linking records across
information systems," they write. "A
single, comprehensive functional health
information framework does not yet exist."
"As we progress toward an information
framework, we will learn through
measurement (rather than speculation) which
clinicians and plans offer the highest
quality of care," the authors write. "We
will also create the tools to deliver
high-quality care more effectively and
consistently, to learn which interventions
are most successful, and to pass on these
effective practices to succeeding
generations of clinicians."
The authors suggest the framework must have
these characteristics:
* It specifies data elements, such as
the patient's date of birth, medical
history and medications
* It establishes linkage capability
among data elements and records
* It standardizes the element
definitions, including the structure
and content of medical records, and
codes for symptoms, diagnoses and
other terms
* It is automated to the greatest
possible extent
* It specifies procedures for
continually assessing data quality
* It maintains strict controls for
protecting security and
confidentiality of data
* It specifies protocols for sharing
data among appropriate institutions
The authors offer these recommendations:
* Expand and improve the capture and use
of currently available data
* Create an environment that rewards the
automation of data
* Improve the quality of currently
automated data
* Implement national standards
* Improve clinical data management
practices, including using the most
precise International Classification
of Diseases (ICD) code to describe the
patient's condition
* Establish a clear commitment to
protecting the confidentiality of
enrollee information
* Begin capital planning to incorporate
the cost of expanding, upgrading or
replacing hardware, software and
communications technology
The authors believe many positive
developments will help meet the challenge.
"The hardware, software, and communications
technology for entering, managing,
retrieving and transferring text, numeric
and graphical data have become highly
sophisticated," they write. "The Internet
promises to drive down infrastructure
costs. ... Research continues to
demonstrate the value of automated clinical
information systems for health care
management at all levels Ñ as error
monitoring systems, as reminder systems for
preventive care, and as decision support
tools for clinicians."
(JAMA. 1999; 282:1184-1190)
Editorial: NCQA Chooses Its Quality
Measures Wisely
In an accompanying editorial, Clement J.
McDonald, M.D., of the Indiana University
School of Medicine and the Regenstrief
Institute for Health Care in Indianapolis,
comments on the recommendations offered in
the NCQA report. "For the most part, these
are good recommendations that will benefit
practitioners by enabling more computer
automation of their practice and at the
same time deliver more comprehensive
quality measures," he writes.
However, Dr. McDonald disagrees with the
recommendation that clinical information be
coded at the most detailed level of the
ICD-9 system. "In many circumstances,
coding at full ICD-9 details is
ridiculously excessive, clinically off
target, and adverse to efficient electronic
medical record keeping," he writes. "The
needed electronic systems will be more
appropriate, useful, and acceptable if they
are not constrained by absolute adherence
to the peculiarities of ICD-9 coding," he
concludes.
(JAMA. 1999; 282:1181-1182)
Note: The Schneider et al work was
supported by a grant from the Robert Wood
Johnson Foundation, Princeton, N.J.
© 1995-1999 American Medical Association.