While the goal remains clear—improve patient health outcomes with a lower price tag—the path has been anything but simple or proven. According to a recent Kaiser Family Foundation/Commonwealth Fund survey, half of primary care physicians say the proliferation of quality rules to assess performance has had a negative effect on quality of care. From the point of view of managed care executives, 36% cite compliance with government mandates as their biggest challenge. While perhaps surprising findings, they highlight the complex quality management challenge that physicians, health systems, and health plans are up against. For healthcare and health plan executives and providers alike, the enormous and complex regulatory reporting demands are both overwhelming and at odds with contractual and organizational demands.
More reporting rules have yielded more complexity—more data sources and types, more analytics tools, more integration needs. Yet, clinical quality reporting for many—even hospitals and health plans – is still done manually behind the scenes. Spreadsheets run complex formulas to calculate compliance along with a skilled team of quality and technical staff. Spreadsheets require manual maintenance and are plagued with issues of consistency, version control, errors and traceability. Not surprisingly, it’s extremely time intensive. For example, importing and exporting large volumes of clinical quality data in spreadsheets can take days. What’s more, there is little room for proactive management to improve productivity or reduce costs.
Something must change. Healthcare technology organizations are now racing to offer ways for quality, regulatory, contractual and organizational rules to be met, changed and updated faster, and without such heavy reliance on technical and clinical expertise. The need for tools that provide an easy-to-use, do-it-yourself interface for rules management is in great demand. Business users must be equipped to bend the rules and easily configure, audit and operationalize clinical quality measures (CQMs), cohorts, clinical alerts and other rules without dependency on IT and without manual intervention. A critical success factor will rely heavily on this ability within the complex technical landscape of health systems.
To achieve this, organizations need to put a robust rules management solution in place that allows them to manage all measures centrally and create their own roadmap for regulatory, contractual and organizational performance. They will need to not only build and manage rule definitions for larger initiatives such as HEDIS and MIPS/MACRA, but also easily scale up to include Hierarchical Condition Category (HCC), CMS Star, and vast libraries of custom measures.
Success will rely on five critical capabilities:
- An extensive rules library with a wide array for pre-built measures and key performance indicators (KPIs) covering the vast set of known CQMs and KPIs for Meaningful Use, PQRS, HEDIS, PCMH, etc.
- A strong ability to create different types of rules for CQMs, alerts, cohorts, bundles and more.
- An ability to extensively test new rules before they are deployed. Ideally, test scenarios and data should be centrally managed with complete traceability of test cases.
- Management of the entire rule life cycle, from configuration to testing, with control over each rule’s progression across environments from development through to production.
- Ability for implementation teams and quality management professionals to view summaries and detailed information, such as go-live status, configuration to-do lists, rules review, etc. These teams must be able to access rules data and analytics through highly visual and interactive dashboards.
Implementing a strong rules management solution delivers immediate productivity gains and cost reductions. Our experience with healthcare organizations has shown that adopting a rules management solution can reduce the time spent in configuring complex measures by as much as 30%. Process and efficiency gains around quality measure management are also routinely higher. There are fewer process steps, and teams are better able to manage measure deployment stages, such as under review, in testing and deployed. Complex rules can be created and configured in a few hours. Importing and exporting large value sets can be done in a matter of minutes, something which usually took one to two days manually.
In addition, putting a robust solution in place opens the door to driving real and significant value from an organization’s quality initiatives. With central management of all measures—regulatory, contractual and organizational performance measures—organizations can better operationalize improving patient health outcomes while reducing costs. For example, with collaboration among all stakeholders, including patients, and centralized rules management, organizations can operationalize population health initiatives that improve patient compliance, such as for diabetes management.
Bending the rules in a way that makes them work for organizations rather than against them is key as we embark on the next part of the healthcare journey. With a centralized solution to manage regulatory, contractual and operational rules according to five critical capabilities, organizations can reduce overall risk around measure management and delivery. They can also drive the business intelligence needed to fill the gap between meeting regulatory requirements and optimizing contractual and organizational performance – and make quality indicators work for them, rather than the other way around.
Kristi Jones is the director of product management at CitiusTech.