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Information System Concepts for Quality MeasurementAuthor(s): Brent JamesSource:

Medical Care,

Vol. 41, No. 1, Supplement: The Strategic Framework Board's Design fora National Quality Measurement and Reporting System (Jan., 2003), pp. I71-I79Published by: Lippincott Williams & WilkinsStable URL:

http://www.jstor.org/stable/3767730

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MEDICAL AREVolume1,Number1,Supplement,pI-71-I-7902003LippincottWilliams&Wilkins,nc.

InformationystemConceptsforQualityMeasurement

BRENTJAMES,

MD,

MSTAT

BACKGROUND.ealth care informationsys-temsinusetoday frequentlyfallshortofwhatisneeded tomeet thedemandsfordata andreportingonperformance. Manyobserversbe-lieve substantialimprovementsin informationsystemswillbenecessaryifthepotentialofanationalqualitymeasurementandreportingsystem(NQMRS)is to be realized.A sharedvisionwillfacilitateprogressinimprovinginformationsystems.

OBJECTIVES.

TOarticulate a set ofguidingprinciplesandoperational stepsfor the devel-opmentof functionalinformationsystemsinhealth care.RESEARCH ESIGN.Experienceinbuildingsuchsystemsfor one health caredeliverysys-tem was used todevelopanapproach.Thiswas discussed withStrategicFrameworkBoard members andintegratedwithother con-siderationsforgoingfrom a localsystemtoone that couldaccumulate information forna-Health care isinherentlyaninformation sci-ence. Health careinformation includesformalknowledgeofdisease and diseasetreatment,aswellashistoryandphysicalexaminationfindings,laboratoryandimagingresults,patientpreferencesandvalues,andoutcomesofhealth careinterven-tions. The betterinformation ahealth careprofes-sionalhas,thebetterheorshecandiagnoseillness,identifyhealthimprovementopportunities,discusstreatmentoptionswithpatients,imple-mentinterventions,and achievedesiredout-comes.Similarly,nformationisnecessaryforpa-tients tomake choicesconsistent withtheir valuesandpreferences.Information isalsokeyforplan-ning,managing,andimprovingthehealth care

FromIntermountainHealthCare,SaltLakeCity,Utah.Addresscorrespondenceandreprint requeststo:

tionalpurposes.

FINDINGS.

Thekeyelementsof afunctionalinformationsystemincludeprovisionsthat(1)data shouldbe collectedonce,(2)aggregationof data forhigher-levelreportsshould bean-ticipated,(3)issuesrelated toprivacyandcon-fidentialitymustbeaddressed,and(4)mea-surementsystemsshould includeanauditstandard.Aseven-step processfordevelopingafunctionalinformationsystemisoutlined.

CONCLUSIONS.

A shared national measure-ment framework is essential because the datasystemsthat health caredelivery organizationsusearenot static.Along-termvision canguidethegrowthofadatasystemovertime. AnNQMRScan bethevehicle thatprovidestheneeded vision.Keywords:Datacollection;functional infor-mationsystem;nationalqualitymeasurementandreportingsystem; StrategicFrameworkBoard.(MedCare2003;41:I-71-I-79)delivery system.Data andinformation lieatthecore ofanyquality management system.1Insummarizingprinciplesfor datacollectionandmanagement,we looked towell-establishedmodelsfromoutside healthcare,suchas bank-ingandtransportationsafety.Insuchmodels,acentralagencyreleasesspecificationsforreport-able data. Thedataaregeneratedbybusinessesaspartofroutineoperations,thenindepen-dentlyreviewed toestablishcompleteness,ac-curacy,andreliability.Auditors examinethestructure andfunctionofthereportingsystemused within abusiness.Theydonot evaluatetheresults,butonly certifythat thenumbersgener-atedarereasonablycorrect.

BrentJames,MD,MStat,IntermountainHealthCare,36SouthStateStreet,Suite2100,Salt LakeCity,UT84111-1486. E-mail:bjames@ihc.com

1-71

MEDICALARE

Weenvisiona similarintegrateddatasystemforqualitymeasurementandreportinginhealthcaredelivery.Under such asystem,healthcaredeliverygroupswouldgenerateinformationforinternaloperations(directcaredelivery, management,andimprovement)in awaythatmakesitpossibletocombinethose data intohigh-levelreportsforaccountabilityand selection.That willrequirestandardsfordata collection andreportingand anauditsystemto ascertainthatthe datacollectedarereasonablyaccurate.Asharednationalmeasurement framework isimportantbecausethe manualandautomateddatasystemsthathealth caredelivery organiza-tions usetomanageandimprovetheir care arenotstatic.Along-termvisioncanguidethe datasystemdevelopmentover time. TheStrategicFrameworkBoard(SFB)viewedthe nationalqual-itymeasurementandreportingsystem(NQMRS)asprovidingthatvision sothatsoftware vendorsand health caredelivery groupscandevelopcom-patibleinternaldatasystemsthatsupportshareddatafor externalaccountability.Qualitymeasuresforspecificdiseasesor clinicalsupportprocessesarelikelyto arisefrom avarietyofdifferentorganizationsand sources.We thereforeproposeatheoreticframeworkunder whichitwouldbepossibleto combinemeasuresgeneratedbyarangeofgroupsandusethemeasurestogether.

KeyElementsof a FunctionalInformationSystem

For an informationsystemtobefunctional,thedatacontainedin itmust beaccurate,complete,availablein atimelymanner,anduseful formul-tiple purposes.Fewexistinginformationsystemsinhealthcarehave achievedthis levelof function-alityandthose thathavegenerallyexistwithinasingleorganization.ForanNQMRSto realizeitsfullpotential,thenationwillneed all healthcareorganizationsto havefunctionalinformationsys-tems. Somekeyelements ofthatfunctionalityarehighlightedhere.

Single-PointDataCollection

The SFBrecommendssingle-pointdata collec-tion whenpossiblebecauseredundancyandtheburden ofdata collectionareminimizedand datacollectedatthepointoforiginareusuallymoreaccurateandcompletethandatageneratedatsecondary points.Clear,standarddefinitionsen-sure thatconsistentinformation isproducedovertimeandacrossgroups, allowingforaccuratecomparisonofinputsand results.This isperhapseasiesttoenvisionin a com-pletelyelectronic informationsystemenviron-ment.Forexample,when apatientcomes in foravisitandhashis or herweightand bloodpressuremeasured,theproviderwould enter thosefiguresdirectlyinto the clinical informationsystem(witha hand-held device orperhapsa scale and bloodpressurecuff that transmit resultsdirectlytothedatabase).The informationiscollectedin awaythat allows the informationto beusedby(1)thephysicianatthat visit(bychartinghow thesevaluescompareto the last fewvaluesmeasuredforthispatient),(2)thepatientintrackinghis or herhealth statusovertime,and(3)othersto evaluatetheproportionof thephysician's,medicalgroup's,healthplan's,region's,state's,andnation'spopu-lation that isoverweightorhashighbloodpressure.

CombiningData forMultipleUses

The corework of a health caredeliverysystemoccursattheinterfacebetweenpatientsandhealthcareprofessionals.Those interactionsgen-eratelargevolumes ofdata(eg,a medicalrecord),whichinturndrive otherdatagenerationandreportingsystems supportinghealth caredeliveryoperations(eg,data forbilling,purchasingofsupplies,staffing,budgeting,orplanningforphys-icalfacilities).Single-point,source-leveldata col-lectionimpliesthat such datawill firstbe useful tomanageworkprocessesatthe front-lineinterface,but also canbe "rolledup"oraggregatedintohigh-levelreportsfor usethroughoutamanage-menthierarchy.Forexample,clinicalinformationgeneratedduringapatientencountercanbeusedfor directpatientcare aswell asforsummaryreportsat thelevelof individualclinicians,caredeliveryteams,clinics,regions,deliverysystems,orgeographicareas.Primarydataareusuallyobtainedattheindi-vidualpatientlevel.Secondaryroll-updataareusually reportedatapopulationlevel.Althoughproperlystructuredprimarydata cannearly alwaysbecombinedtocreatesecondarymeasuresandreports,dataoriginallycollectedatapopulationlevel oftencannot beusedtogenerateindividual1-72JAMES