Outcome management: new name for old idea.

The concept is deceptively simple, even if its final implementation promises to be the result of an enormously complicated process. Outcomes management proposes that the final arbiter of the quality of health care should be the patient. An appropriate evaluation of the quality of health care, Dr. Ellwood says, has to account for positive health outcomes for patients. There is a good deal more to the concept than that, but, reduced to its essentials, outcomes management suggests that the key measurement of quality will be an assessment of the impact of health care interventions on the quality of patients' lives. Equally important, the patient will have a key role in assessing those outcomes.

The concept is not new. The term is a fresh and concise label for notions that have been around for some time. Paul Ellwood, MD, Chairman of InterStudy, a health care think tank in Excelsior, Minn., who has coined the term "outcomes management,"in much the same way that he earlier coined the term "health maintenance organization," admits that the words are new from him but that he is building with old material. "I hope that outcomes management will enjoy the same spread that HMOs have seen. So far, acceptance has been much greater. HMOs were viewed with distrust and sometimes alarm. Many found the concept threatening. My feedback so far on outcomes management is that the medical profession is more than ready for its implementation. Many see it as the first useful answer to the relentless debate over quality of care. It is something that providers can work with."

So what exactly is outcomes manaement, and why should physician executives be interested in its future.

As designed by Dr. Ellwood, outcomes management would draw on four already existing techniques for its implementaiiom

* It would establish guidelines for physicians to use in collecting clinical and follow-up information on patients.

* It would routinely and systematically measure the functioning and weU-being of patients, as well as disease-specific clinical outcomes, at appropriate time intervals.

* It would pool clinical and outcome data on a national basis.

* It would analyze and disseminate results of this data collection to health care decision makers.

For Dr. Ellwood, the emphasis in outcomes management is on health. He believes that physician executives are uniquely positioned to serve as leaders in implementing such a patient-oriented approach to quality determinations. "I feel that medical organizations are going to become accountable for producing health and that we are going to be focusing increasingly on what really works in medical care--what helps patients. The experts on that should be physician executives. They are accountable for the ability of their organizations to produce a better quality of life for patients. They have the greatest possible understanding of how the organization actually influences health outcomes." It is the physician executive's unique blend of clinical and managerial expertise that comes to bear on the health organization's performance, according to Dr. Ellwood. "While individual doctors know how they are going to personally influence somebody's health, the physician executive understands both the clinical involvement for a particular patient and how that and other cases come to represent the overall institution, with all its doctors, nurses, and other professionals, on performance and quality."

Another way of describing the unique viewpoint of the physician executive is to call medical management "practicing medicine epidemiologically." In this view, Dr. Ellwood says, the medical organization is an epidemiological phenomenon. "The physician executive deals with groups of physicians and groups of patients over time. There is no question that physician executives need to know about finance, personnel, and other aspects of general management, but it is the physician executive's understanding of the complete environment in which health care services are provided that makes him or her the best guardian of quality issues," Dr. Ellwood says.

Dr. Ellwood says that quality has tended to be defined in terms of pathology rather than quality of life outcomes. He just doesn't think that makes sense. "Quality, in my view, is a positive influence on people's quality of life and on their ability to function as complete human beings. Quality is their feeling good and being able to do the things that people like to do. Quality is not just lowering people's blood pressure or getting their blood sugar normal. Physicians have fallen into the trap of thinking that when they've lowered patients' blood sugar, they've helped the patients. They've only helped them if the patients are going to be able to live fuller lives or are going to live longer."

Comparisons of results and the development of a national database on the outcomes of specific interventions are the backbone of outcomes management. If physician executives are to be able to make any correlations between diagnoses, interventions, and outcomes, they will need an experiential database on a diagnosisby-diagnosis basis. Dr. Ellwood is not daunted by either the need or the size of the undertaking. "I think that quality of life can be measured objectively. It's not an abstraction. It's just like any other laboratory test. Medical care organizations, both individually and as a group, will presumably follow people over time to find out just what has happened to the quality of their lives."

What will be required to start up the outcomes system that Dr. Ellwood envisions is, in its simplest terms, systematic follow-up on all or nearly all chronically ill patients, putting that information into a computerized database, analyzing it, and determining which outcomes point to significant and useful interventions. "In a final outcimes system," Dr. Ellwood says, "this evaluation would be fed back to patients so that they can decide on the care they want. By the same token, doctors would decide what care they should give and physician executives would determine how the organization should function to produce both the care and the expected outcomes. That's all there really is to outcomes management."

As was mentioned earlier, this is the second major health care concept championed by Dr. Ellwood. His earlier prosyletization on behalf of HMOs, PPOs, and competition was more difficult, he says. "We are not running into the kind of skepticism and opposition that the HMO concept faced. People are saying, 'Here is an idea that makes sense, that maybe will help us out of this dilemma that we're in of just being concerned about cost and not about what we're really doing for people.' In the past, we've defined quality too abstractly. Everybody is for quality, but nobody knows what it is. Outcomes management says that quality in health care is really a better quality of life. That seems to be a rather acceptable concept." While outcomes management is proving to be more acceptable to health care professionals, Dr. Ellwood says it is in some ways a much more difficult idea to implement. "It's not the kind of thing that Congress can embrace or that the President is going to base a health message on. It is a concept that has to be spread within and generally adopted by the health care field itself. It is unlikely to be imposed from above."

Dr. Ellwood does not mean to suggest that outcomes management is without opposition. Quality has already become nearly a subindustry in the health care field, and there are vested interests for many of the approaches and programs that are now sold to measure and monitor it. So no new entry on the scene can expect to be accepted immediately and totally, he says. And he admits that there are legitimate concerns about outcomes management that will have to be addressed. "In a time of accelerated litigation in the practice of medicine, outcomes management would make the actions of providers even more public. It would also compare actions against outcomes and perceived norms. Being part of a big database accentuates the risk of being discovered, of making a

mistake."

Some opposition comes from doctors and organizations who feel that outcomes management violates their autonomy. They believe that outcomes management interferes with the doctor- patient relationship. On this, Dr. Ellwood is adamant. "As a prospective patient, I would just as soon know who gets good results," Dr. Ellwood says. "I think doctors increasingly acknowledge that quality isn't a secret between them and patients. These things should be available to people to help them make choices among providers."

Of course, consumers are not yet totally comfortable with shopping for their health care needs. HMOs and managed care, and the application of consumerism in health care, have seen a break in consumer reticence in this regard, but the reluctance is still there. Dr. Ellwood believes that outcomes management overcomes that reluctance. 'The assumption is that consumers can't understand health and medical care. That's another advantage of using quality of life as the measuring tool. The questions asked of the consumer are in the consumer's vernacular."

Who has signed on the outcomes management bandwagon? Dr. EUwood says that there has been some play in the public press, but the biggest "sold" group for now is insurers. "We've heard from big purchasers--Blue Cross, Medicare, United HealthCare, the large insurance companies. They recognize that they have to have better criteria for selecting providers for their clients. They are groping toward high measured value in the health care services they pay for, and they are looking for systems that assure them that they're getting it."

One of the items for implementation in the outcomes management system is a national database of diagnoses, interventions, and quality assessments. Dr. Ellwood believes that one of the reasons for the attractiveness of outcomes management at the moment is the technological ability, through computers, to build such a system. "We've got the computer power to do it. It's feasible in ways that it just wasn't before. We've also got more computer literacy among physicians. Outcomes management is really applying a clinical trial approach to everyday medical care, but on an order that requires extensive access to computers."

And that, says Dr. Ellwood, is where physician executives enter. "Physicians will have to be persuaded that outcomes management is inevitable and that there's a reasonably practical system for its implementation. On top of that, as doctors get into outcomes management they will have to learn some new things about large databases, about how decisions are made, and about epidemiology. The role I see the American College of Physician Executives playing is in preparing physician executives for a new way of managing. Outcomes management means that the College has to think of medical management as a clinical science that's related to management. The College's goal will be to help its members become proficient in that science."

The core of what physician executives know, Dr. Ellwood says, is how health care organizations influence the health of people, as opposed to individual physicians knowing how they affect the health of their patients. "Much of medical care really involves interaction among physicians. Physician executives understand that interaction and how it affects people's health."

What physicians have to understand, Dr. Ellwood says, is that virtually anyone can measure the quality of life. "The scale that we have developed is going to be in the public domain. If a firm wants to administer the questionnaire to its employees and then compare how different providers are doing as far as quality of life is concerned, they will know as much as the providers know."

Dr. Ellwood believes that the quality of life element, the idea of learning directly from patients about how medical care has affected them, is the key to the outcomes management approach. "The catalytic element, in my view, is measurement of the quality of life and making information about the impact of the health care organizations on the quality of life available to the public. Once that happens, outcomes management will take off. At first, we are going to be showing that people have changed, but we're not going to be sure what changed them. Doctors will demand more and more sophisticated information, and outcomes management will grow from there. The place and period of observation of the patient will be extended beyond the health system out into their everyday lives instead of collecting the information only while the patient is in the hospital or the doctor's office. This quality of life information could be collected every six months for as long as the patient lives."

In all this, Dr. Ellwood says, physician executives will decide what has to be changed about the provision of health care services by organizations in order to bring quality up to snuff and to make sure that the organization gets the best possible results. "If somebody gets better results up the street, it's going to be very clear who's responsible--the physician executive."

Dr. Ellwood is not alone in believing that the ultimate disposition of the quality debate will rest on successful implementation of some kind of outcome management system. The Joint Commission on Accreditation of Healthcare Organizations has been working on such a system for about two years now. The area in common for the various approaches to outcomes management that are now being considered, says Dr. Ellwood, is the database. "It's extraordinarily important for everyone who is working on this idea of following patients over time and making comparisons to all be using the same database. We do what we can to coordinate our activities with those of the Joint Commission. But JCAHO and Dennis [Dennis O'Leary, MD, FACPE, President of the Joint Commission] have another very strong belief. If this information isn't used, if it doesn't effect the behavior of organizations, there is no point in collecting it. They feel, as I do, that there has to be some physician executive in place who understands outcomes management and has the authority to command the resources of the organization to deliver the level of quality that the outcomes management system dictates."

Dr. Ellwood believes that quality is a legitimate point of competition among providers and that outcomes management will make the competition more open and public. "It's inevitable that the public will have access to the quality information, That's not even a subject for discussion. Organizations, if they get good resudts, are going to make it available to the public in order to compete."

Hospitals should be especially attracted to the concept of outcomes management, according to Dr. Ellwood. "I think that the idea of being judged on the basis of producing health is appealing to hospitals. People are increasingly specifying the hospital for their care. If a hospital can say, "We get better results; our hospital improves patients' health," it will see that as a competitive advantage.

Dr. Ellwood thinks that quality and quality assurance need better public relations. "We ought to think of quality assurance in a positive way. It's improvement of health we're looking for, not a failure to do the right thing. Quality assurance has gotten stigmatized because much of it concentrated on finding doctors who are doing the wrong things. By measuring and continually feeding back the positive effects of interventions on health, you reward doctors who are doing a good job. In the future, quality assurance is going to continually improve the performance of the organization, not just singling out those who are making mistakes." At the bottom line, Dr. Ellwood places proponents of outcomes management in the "unafraid of competition category." Those organizations and people that feel that they practice good medicine or offer a good service aren't afraid of outcomes management at all, he says. Those that are uncertain or reluctant to see change tend to reject the concept. But there is a danger in this, he says. "With most new products, you can wait and see whether you like a change before you adopt it. You can let somebody else try the change first. Because this database looks at patients over time, if you're late getting in, you don't have prior experience with patients. So the number of patients you have in your database and the number of years of observation that have been made are fewer. Therefore, the organization or the individual is behind those who started earlier."

Dr. Ellwood contends that the power and the authority of physician executives can only change if they have some new knowledge, some new basis for authority. "They have to be uniquely useful to physicians and they have to have some knowledge of how the organization functions that is not currently available to the existing chief executive officer if they are going to become chief executive officers or reposition themselves in the organization. They need to deserve some new responsibility, and there have to be some new expectations from the organization."

Dr. Ellwood's theory is that the new expectations are that organizations will measure their ability to produce health and that physician executives are the ones who understand how that is done. "They will get their power and authority from their unique clinical and organizational insights. Even physicians who are CEOs can enhance their utility and power in the organization by understanding more about how the organization influences the health of people. However it is accomplished, there needs to be a physician executive in charge of ensuring that the organization produces health."

But, Dr.ENwood insists, one way or another outcomes management will be the next wave. He believes that the College and the medical management profession have a vested interest in assuming responsibility for implementation of this new system. Just as important, he says, physician executives are already positioned for this new role. "If the College, or some national provider group, "does not pick up on this, somebody will. It makes too much sense. If physician executives within traditional medical care organizations don't gain knowledge and control of the provision of health care, purchaser organizations will."

Further Reading

The followingadditionalsources of information on outcomes management were obtained through a computerized search of databases. Copies of the articles cited are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/ 287-2000.

"Outcomes Management: The next Step Beyond Quality Assurance." Hospital Strategy Report 1 (5) :1, 5-7, March 1989.

"What Is Outcomes Management? How Does It Work?" Hospital Strategy Report 1 (5) :8, March 1989.

Barell, V., and others"Evaluating Improvements in Multistaged Health Care: The RiskCare-Outcome Cycle." ORB 12(11):404-7, Nov. 1986.

Berwick, D. "Toward an Applied Technology for Quality Measurement in Health Care. Medical Decision Making 8(4) :253-8, Oct.-Dec. 1988.

Cleary, P., and McNeil, B"Patient Satisfaction as an Indicator of Quality Care." Inquiry 25(l):25-36, Spring 1988.

Couch, J. "Assessing Medical Care on the Basis of Its Value." Physician Executive 13(4):7-10, July-Aug. 1987.

Donabedian,A. "Quality Assessment and Assurance: Unity of Purpose, Diversity of Means." Inquiry 25 (1) :173- 92, Spring 1988.

Ellwood, P. "Shattuck Lecture--Outcomes Management. A Technology of Patient Experience."New England Journal of Medicine 318(23):1549-56, June 9, 1988.

Friedman, E. "The JCAH Quality Initiative: What Can Hospitals and Physicians Expect?" Physician Executive 13(4):2-6, July-Aug. 1987.

Hughes, R., and others. "Hospital Volume and Patient Outcomes. The Case of Hip Fracture Patients." Medical Care 26(11):1057-67, Nov. 1988.

Larkin, H. "Quality and Outcome Are '88 Research Focus." Hospitals 62(2) :68, Jan. 20, 1988.

Lohr, K. "Outcome Measurement: Concepts and Questions." Inquiry 25(l):37-50, Spring 1988.

McDonald, R., and Blizard, R. "Quality Assurance of Outcome in Mental Health Care: A Model for Routine Use in Clinical Settings." Health Trends 20(4):111-4, Nov. 1988.

Robinson, M. "Sneak Preview: JCAHO's Quality Indicators." Hospitals 62(13):38-43, July 5, 1988.

Robinson, M. "Progress on Quantifying Quality." Trustee 41 (9) :12-3, Sept. 1988.

Robinson, M. "CT Hospitals Use Outcome Data To Measure Quality." Hospitals 62(17) :29, Sept. 5, 1988.

Smith, G. "Using a State-of-the-Art Approach, Evaluating Hospital Quality Means Comparing Patient Outcomes by Various Methods." Business and Health 5(11):20, 22-3, Sept. 1988.

Stevenson, J., and others. "An Outcome Monitoring System for Psychiatric Inpatient Care." QRB 14(11):326-31, Nov. 1988.

Madeek, B. "Quality Assurance through External Controls." Inquiry 25(1) :100-7, Spring 1988.

Wennberg, J. "Improving the Medical Decision-Making Process." Health Affairs 7(1):99-106, Spring 1988.