2005 National Consensus Meeting on EMS Clinical Performance Indicators
Executive Summary
In June, 2005, the North Central EMS Institute and its partners, the National Rural Health Resource Center, the Rural EMS & Trauma Technical Assistance Center, the National EMS Management Association and the American Ambulance Association hosted a one-day session to form the EMS industry’s pilot set of clinical performance indicators.
There is a lot of federal activity in the health arena surrounding performance improvement, quality improvement, benchmarking and indicator development. There is also some activity within EMS in these arenas with development of the National EMS Information System (NEMSIS), the Open Source EMS Initiative’s Performance Indicator Development Project, and the National EMS Performance Measures Project. However, EMS is behind the curve in relationship to other sectors of the healthcare community.
In March 2005, the Medicare Payment Advisory Commission (MedPAC) advised Congress that it needs to adopt “pay for performance” programs for hospitals and other specified care providers, stating “Medicare payment systems are neutral and sometimes negative toward quality.” It advises Congress to support methods that measure quality-enhancing activities that are supported by information technology.
It is a good thing MedPAC did not include the EMS industry within the list of providers to move to pay for performance, because EMS isn’t ready. As organizations representing the major facets of the EMS industry, we need to lead this process ourselves in a pro-active manner rather than have it developed in haste under a future mandate that affects our federal funding and reimbursement.
The 2005 meeting focused on identifying a limited set of performance measures for the EMS industry. A pilot set of indicators that can be derived from the data elements included in the NEMSIS data set was established. We encourage the National EMS Performance Measures Project, the Open Source EMS Initiative and other similar efforts continue to develop EMS industry consensus on additional clinical and operational performance indicators.
June 2005 National Consensus Meeting on EMS Clinical Performance Indicators Participants
Federal Partners:
HHS - HRSA Office of Rural Health Policy
HHS - HRSA Trauma National Resource Center
HHS - HRSA EMS-C National Resource Center
DOT - National Highway Traffic Safety Administration – EMS Division
Organizations:
American Ambulance Association, Association of Air Medical Services, Coalition of Advanced Emergency Medical Systems, National Ambulance Coalition, National Association of EMS Educators, National Association of EMS Physicians, National Association of State EMS Directors, National EMS Management Association, National Organization of State Offices of Rural Health, National Registry of Emergency Medical Technicians, the National Rural Health Association, the North Central EMS Institute, the Rural EMS & Trauma Technical Assistance Center, the Rural Health Resource Center, Stratis Health QIO and the University of Minnesota Rural Health Research Center.
Software Vendors:
Med-Media, Medtronic, Ortivus North America, and Zoll.
Background
There are a wide variety of public reporting methods on health care quality. Public quality reporting for some health sectors has recently been demanded by payers, purchasers and the government. Medicare has required public quality reporting by health plans since 1998, end-stage renal dialysis facilities since 2001, nursing homes since 2002, and home health agencies since 2003. Hospitals began public reporting of quality data this year and reporting for clinics is in the planning stages.
There are good reasons for payers (including state and federal governments) and purchasers to demand quality reporting. Informed consumers can be participants in their health care. As the cost of health care skyrockets, government can force acceleration of the pace of improvement, leading to transformational changes in the way health care is delivered, to slow the pace of inflation. High performing providers should be rewarded for exceptional performance – for their part in leading the transformational changes that are necessary.
In the past, either transformational changes have led to payment policy changes, or payment policy changes have forced transformational changes. A couple decades ago, Congress began experimenting with cost control measures on the payment side. Fee schedules and prospective payment systems began replacing fee-for-service as the dominant payment mechanism. Those payment policy changes, which in the case of hospitals favored outpatient care, led to dramatic shifts in how care was delivered. Eventually, Congress required a completely unprepared EMS industry to shift from fee-for-service to a fee schedule.
The next wave of change has already begun. The EMS industry cannot afford to wait. It must engage in the process to have a seat at the table. It must have a seat at the table to assure the next payment overhaul accounts for its unique characteristics.
Quality – Variations on a Theme
Quality Assurance involves measuring to assure adherence to processes or controls to meet performance standards. Significant efforts toward Quality Assurance (QA) began strongly in the 1970s and 1980s. During that time, Medicare established Peer Review Organizations (PROs) which are now known as Quality Improvement Organizations (QIOs) under a regulatory model to identify outliers in care in the hospital and physician health care sectors. Often these efforts served as punitive tools.
In the 1990s, the focus of quality was on the Quality Improvement (QI) model. PROs were focused on offering and supporting focused QI projects in hospitals. Inside the health care world, the reason for early QI efforts were finances; measuring encounters and procedures, with an expected outcome of reducing internal costs. It is anticipated that QI will continue to be a focus for the foreseeable future.
In this third phase of quality, however the emphasis is shifting from the internal to external world. External forces will dictate QI activities and reporting. There will be statewide quality improvement efforts across the continuum of care, including public reporting of quality measures.
The shift to an external focus is breeding new terminology which is currently concerning to health care providers. This year MedPAC advised Congress that it needs to take the next Medicare payment shift to more uncharted territory, Pay for Performance (P4P). There are a number of health care experiments already underway, purporting to use P4P. In reality, P4P is still undefined, but there are enough experiments occurring that some standard consensus will emerge yet this decade.
“Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Institute of Medicine, 1990
What’s Happening Today
Those parts of healthcare (physicians and hospitals) that were early targets of Medicare are going through another shift. There are major public reporting activities emerging. Congress has tied the full hospital annual payment updates (APU) for 2005-2007 to a requirement that hospitals submit data for 10 quality measures. Medicare is publishing data from these hospitals that are receiving the full APU.
Medicare is again modifying the focus and charge of QIOs. The QIO 8th Scope of Work began August 1, 2005. Its new emphasis is on improving healthcare quality culture and increasing information technology. For the first time, it also includes a specific rural component.
The National Rural Health Association (NRHA) and the Medicare Hospital Flexibility Grant Program (FLEX) program are embracing the focus on rural health quality. The Technical Assistance Center for the FLEX program has been leading efforts for rural hospitals to increase their activity and capacity for quality reporting, primarily by promoting the balanced scorecard approach. The NRHA has fully embraced the quality mandate, sending messages that not only can rural healthcare providers fit into a quality system; they can lead the transformational change for all of healthcare.
There are some important distinctions between urban and rural healthcare providers. The measures Medicare put in place for its early efforts in quality reporting were structured around high volume inpatient care. Consequently, most rural hospitals do not fit into the system, because they don’t achieve enough volume and because rural hospitals treat in their emergency rooms and transfer to larger tertiary hospitals, particularly with chest pain patients. The current measures do not include emergency room care, thus rural hospitals are usually not able to report on the care they provide chest pain patients. In the mean time, the Office of Rural Health Policy has convened a Rural Quality Advisory Panel that will draw on an interdisciplinary knowledge base to develop measures and improvement strategies across the rural continuum of care.
Current Hospital Public Reporting
There is a number of voluntary and mandatory quality reporting systems already in place for hospitals. Many of these are available to the public, although no one is sure the tools are yet public-friendly, nor if the public at large actually accesses them. While some are highlighted here, others also exist.
- The Joint Commission on the Accreditation of Healthcare Organizations (www.jcaho.org) – JCAHO features a “Quality Check” program that reports data on hospitals, nursing homes and other healthcare settings
- HealthGrades (www.healthgrades.com) – Uses Medicare and state survey data to calculate a 5-star rating system of hospitals and nursing homes
- Leapfrog (www.leapfroggroup.org) – Promotes and rates hospitals on 4 patient safety “leaps” – computerized physician order entry, use of intensivists, volume, and 27 safe practices
- Healthcare Facts (www.bluecrossmn.com) – Blue Cross of Minnesota reports care given and safety information in nutrition label format for large hospitals
- Hospital Compare (www.hospitalcompare.hhs.gov) – Provides public data on the hospital measures collected by Medicare
- Hospital Quality Alliance (www.aha.org) – a voluntary program sponsored by the American Hospital Association that includes a 10 measure starter set and 13 optional measures, with more than 3,600 participating hospitals
- Minnesota Health Information (www.minnesotahealthinformation.org) – Information about the cost and quality of health care in Minnesota
- Adverse Event Reporting (www.health.state.mn.us/patientsafety/) – State mandated reporting of 27 “Never Events”
The public tools referenced above and others like them are powerful tools to direct the attention of health care providers toward quality improvement. While providers are paying attention, consumers are not yet, but may begin to with education. The sponsors of the tools are also beginning to learn which work and which don’t, and will use this information to refine their processes.
What’s Happening in EMS
There are a number of benchmarking and performance measure projects underway in the US. All of these programs are worthwhile and should be encouraged to continue. The existing programs, however, are geared toward system and business performance, or they are stuck in the quality assurance phase of the previous decade. To date, there is no known organization sponsoring measures that would integrate with the current public reporting tools used in other parts of the healthcare industry.
The EMS Division of the National Highway Traffic Safety Administration has financed a forum on EMS performance measures. The National Association of State EMS Directors and the National Association of EMS Physicians are coordinating the project under contract with NHTSA. The project has brought the various agencies working on performance measures together to share their ideas and to attempt to achieve consensus on one standard set of measures. Information about this project is available at www.measureems.org. A host of organizations are participating in the program, which is now in Phase II. 138 measures have been identified and the steering committee is refining the list to 25.
The advantage to NHTSA’s project is that all of the major organizations interested in EMS performance measures are seeking common ground. One disadvantage to the project is that the various players are developing measures for their own various reasons and to meet their individual goals. There has been no project oriented directly at inserting EMS into the healthcare quality measures discussion. NHTSA and the EMS Performance Measures project participated in our national consensus meeting. The EMS Performance Measures project will include the consensus of the meeting in its continuing work to gain a national consensus.
In addition to sponsoring work to bring the divergent organizations together on EMS Performance Measures, NTHSA (in cooperation with other federal partners) has been busy updating the standardized National EMS Information System (NEMSIS) data set. This is also a consensus driven project, but is geared toward global EMS data. One distinct advantage to this project is that instead of just focusing on the data needs at a US level, this second EMS data set has data items that will provide useful information at the local, regional, state and national level. The original federal EMS data set contained only 83 items, the new set will have standardized definitions on over xxx. The program is also being structured so that it will be Information Technology ready, reducing the burden for ambulance services to participate. Congress is supportive of this approach and has earmarked funds to continue its development.
The National Consensus Meeting’s Pilot Set of EMS Measures
While all of the individual programs and the EMS Performance Measures project are worthwhile and should continue their work, our goal was to create consensus on an initial “pilot set” of EMS quality measures – measures that will fit within the framework in use by private and public payers.
At our national consensus meeting we wanted to meet the following objectives:
- Simple: consider this the “EMS Starter Kit”
- For Everyone: target the least common denominator
- Ease: consider those that can be measured from NEMSIS
- Useful: for the local, regional, state and national level
The participants identified measures from the clinical, operational and educational arenas. Of these, the agreed upon starter set would include measures in these categories:
- Time
- System issue: time of symptom onset to 911 access
- Benchmark issue: time of dispatch to arrival at patient’s location
- Respiratory
- The percentage of patients who require respiratory support that receive it
- How long did it take to provide respiratory support?
- Accuracy
- Accuracy score of PCR
- ALS Subset: the percentage of patients whose condition indicated ALS that actually received it
- BLS Subset: time to defibrillation
A workgroup of the consensus meeting will meet to assure these measures can be identified in the NEMSIS data set and to write the indicator formatting. NHTSA is considering a special project within NEMSIS to begin analyzing data from these indicators.
Where We Go From Here
P4P is coming to healthcare, both in the public and private sectors. The evidence for this is clear and unmistakable with MedPAC pushing Congress and Medicare restructuring QIO focus. The last major changes in health care payment centered on prospective payment and fee schedules. During that wave, the ambulance industry was absent in the discussion and was caught off guard when Congress announced the establishment of the Medicare ambulance fee schedule in 1997.
Ambulance services cannot afford to sit back and watch how P4P rolls out. In order to survive, regardless of size or location, ambulance services must get engaged in the process that will determine our future for 2010 and beyond. Performance improvement must start at the local level with changes in attitude and with leadership commitment.
There are a number of things ambulance services can do now to help secure their future.
- Develop internal quality improvement projects in your agency. There is almost an infinite amount of information available on the internet on how to start QI projects.
- Develop participative management practices in your agency. The EMTs and paramedics must be an integral part of the efforts to improve your operation. Get them started thinking quality and reporting, and spend extra effort on patient documentation
- Find out if there are any interdisciplinary care teams already functioning in your area, and where appropriate, insist on participating. EMS must be at the table for every discussion
- Embrace and engage in the evolution of the National EMS Information System and state EMS data collection efforts
- Develop or participate in collaborative projects in your healthcare community, make them truly interdisciplinary, by including the discipline of EMS
- Find out if it is possible to work with your QIO. While ambulance services are not currently in the QIO scope of work, two Congressional bills, if passed, would require CMS to change the scope. In the mean time, learn what the QIO is doing with the segments of healthcare they are working with to see what you can learn about what your future might look like
- Think beyond the ambulance. What can your EMS agency do, what expertise can you share, that can contribute to continuous care in addition to episodic care.
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