Outcomes Reporting Systems: What Matters?
The right system for collecting and reporting outcomes will have several features, one of which is reporting.
By Al Amato, PT, MBA*
August 2018
The value of patient-reported outcomes (PROs) permeates health care. Patient-centered care demands that the patient’s perception be placed at the center of health care decision making.
A common target of PRO measurement is the patient’s perception of his or her functional status or change in function. The Centers for Medicare & Medicaid Services (CMS) consistently encourage PROs of function in quality and payment initiatives such as Functional Limitation Reporting (FLR), the Physician Quality Reporting System (PQRS), and the Merit-based Incentive Program (MIPS). Many other payers across the nation require functional outcomes reporting. Collecting, scoring, risk adjusting, aggregating, and using outcomes in any meaningful way can be laborious and costly. To assist in this data collection and reporting process, there are several outcomes measurement system options available to minimize those burdens. Clinicians need to be aware of the various components within outcomes system options to make the best clinical and business decision possible.
The right system for collecting and reporting outcomes will have several features, one of which is reporting. Reporting should add to the clinical understanding of the patient, assist the clinician in designing a treatment plan, inform/engage the patient, and predict improvement at the end of care. When comparing the available reports, ask yourself: (1) How useful will they be for clinicians in managing each patient?, (2) How will the data facilitate management of staff?, and (3) What is the potential to improve the effectiveness of marketing efforts?
Consider that such report features are not available when using static paper-and-pencil functional measures; all you get is a score. Business processes no longer support paper measures due to the time and effort involved with collecting, scoring, recording, storing, aggregating, and analyzing the data. It is not enough to just get a score. True outcomes systems combine functional scores with other data to help the clinician manage the patient and the owner manage the practice.
Most automated/software-based systems appear to offer the same features, creating the illusion that they are the same. For instance, an electronic medical record (EMR) may have the option to collect functional outcomes. The EMR service appears to have exactly what is desired: information housed in a single solution and the use of functional measures that are familiar. Although this sounds like the easiest and best choice, it is important to consider what you get and what you don’t get with such options.
The savvy business owner needs to be familiar with the science of each PRO when weighing options. Do the functional outcomes measurement assessments used provide for the most accurate and efficient data collection? For instance, consider the Oswestry Disability Index (ODI), a well-recognized and widely used measure for low back pain. Despite its popularity, the ODI has been shown to do poorly in assessing higher functioning patients, with floor effects reported ranging from 30 to 44 percent.1,2 The Neck Disability Index (NDI), similar in content and recognition to the ODI, demonstrated similar floor effect problems at 36 percent.3 Additionally, both the ODI and NDI have been shown to lack unidimensionality, rendering score interpretation problematic.1,3,4
Many of the static PRO functional measures in use today, such as the ODI and NDI, were developed decades ago. While they represented state-of-the-art science at the time, modern scientific approaches produce measures that may be more reliable to address the formidable measurement needs of today’s health care quality and payment initiatives. The older PRO tools are being replaced with psychometrically sound newer measures that are more efficient and accurate. Payment for service will be based on quality expressed as demonstrating patient improvement. You will have a risk of unfairly lower payments due to using measures based on inferior science.
Another feature that various outcomes system vendors may offer is risk adjustment. Risk adjustment is critically important for comparative reporting. Without risk adjustment, it is impossible to achieve fair and accurate comparisons between providers. Consider two features of risk adjustment when shopping around:
- Are advanced scientific methods being employed to separately determine how each patient trait might affect the outcomes, or are patients placed into “buckets” of general traits?
- How many separate concepts and variables are accounted for? In our experience, clinicians prefer as many patient variables as possible to be considered. It is no longer acceptable to practicing clinicians to only account for a small number of factors like age, gender, chronicity, or payment type. Consider whether the outcomes system takes into account many other factors such as condition type, surgical history, current postoperative status, specific medical comorbidities, sociodemographic features like educational level, exercise history, use of medication, and history of previous treatment for the same condition. Clinicians and business owners should demand comparisons that are as close to “apples to apples” as possible. Even better: a Jonathan apples to Jonathan apples comparison!
Measurement data collection and reporting tools require high accuracy and responsiveness to capture the amount of perceived change in function. A strong risk adjustment process increases the accuracy of benchmarked reports and more fair comparison of quality of service. An outcomes system requires both the best measurement tools and a strong risk adjustment process to financially protect your business in quality payment models. Being familiar with the science of outcomes measurement and reporting strengthens your ability to make sound business decisions when deciding on which outcomes system to use.
References
1Brodke DS, Goz V, Voss MW, et al. PROMIS PF CAT outperforms the ODI and SF-36 physical function domain in spine patients. Spine. 2017;42(12):921-929.
2Brodke DS, Gos V, Voss MW, et al. Oswestry Disability Index: a psychometric analysis with 1610 patients. Spine. 2017;17(3):321-327.
3Hung M, Cheng C, Hon SD, Franklin JD, Lawrence BD, Neese A, Grover CB, Brodke DS. Challenging the norm: further psychometric investigation of the Neck Disability Index. Spine. 2015;15(11):2440-2445.
4Van der Velde G, Beaton D, Hogg-Johnston S, Hurwitz E, Tennant A. Rasch analysis provides new insights into the measurement properties of the Neck Disability Index. Arthritis Rheum. 2009;61(4):544-551.
Al Amato, PT, MBA, is president and co-owner of FOTO in Knoxville, Tennessee. He has more than 40 years of experience as a Physical therapist. He can be reached at Alamato@fotoinc.com.
* The author has a vested interest in this subject.