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Federal Health Care Programs Need Coordination, IOM Says

Donna Young

The federal government—the most influential regulator and the largest purchaser of health care services, spending over $512 billion annually—should take the lead to address serious quality-of-care and safety concerns confronting the nation, the Institute of Medicine (IOM) said in a report released Wednesday.

Congress, IOM suggested, should direct the secretaries of the departments of Health and Human Services (HHS), Defense (DoD), and Veterans Affairs (VA) to work together to establish standardized performance measures and public reporting requirements for clinicians, institutions, and health plans participating in the government's health care programs.

Data collected by federal health care programs should be used to create reports comparing the quality of care among providers and, said IOM, those reports should be made readily available to the public—something that federal agencies have failed to make a firm commitment to in the past.

"The federal government should take full advantage of its influential position to set the quality standard for the entire health care sector," said Gilbert Omenn, a professor of internal medicine at the University of Michigan and chairman of the panel that prepared the report.

Omenn spoke at a public briefing at the National Academies in Washington, D.C., on Oct. 30.

About one third of Americans receive health services through Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), DoD Tricare programs, the Veterans Health Administration, or the Indian Health Service, according to IOM’s report.

"The federal government should assume a strong leadership position in driving the health care sector to improve the safety and quality of health care services provided to the approximately 100 million beneficiaries of the six major government health care programs," the report said. "Given the leverage of the federal government, this leadership will result in improvements in the safety and quality of health care provided to all Americans."

But IOM suggested that government agencies are not coordinated in their efforts to improve the health care system and should work together to develop common ways to measure performance.

The IOM report, Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, is the third in a series requested by Congress.

The first report, To Err Is Human: Building a Safer Health System, released in 1999, raised public awareness about the large-scale occurrence of serious medical errors.

Crossing the Quality Chasm: A New Health System for the 21st Century, a report released last year, suggested that the U.S. health care system is in need of major reform.

In its latest report, IOM suggested that the Quality Interagency Coordination (QuIC) task force—created in 1998 by the Clinton administration to coordinate public health care quality-improvement efforts—or some other interdepartmental structure, should play a pivotal role in implementing the six-year research agenda outlined in the report.

The interdepartmental team should declare standardized sets of performance measures for 15 leading health conditions by 2004, Omenn said, adding that federal health care programs should begin pilot testing some of those measures as soon as possible.

IOM proposed that health care providers wishing to do business with federal health care programs should be required by 2007 to submit audited patient-level data necessary for the performance measurements.

Federal health care programs, IOM said, should use higher-than-normal reimbursements or other incentives to recognize providers who adopt "best practices."

In addition, the report noted, the government must strongly support the development of computerized clinical records, which providers and regulators need so they can adequately measure and improve the quality of care.

Congress, IOM also said, should consider options, including tax credits, subsidized loans, and grants, to facilitate the rapid development of a national health information infrastructure.

The lack of computer-based clinical data for some federal programs, most notably Medicare, Medicaid, and SCHIP, Omenn said, "is a major impediment" to improving the quality of health care.

"This is the 21st century. Our quality-enhancement processes should not need to rely on culling information from paper medical records or claims forms to assess quality," he said.

IOM commended VA and DoD for their efforts to establish computer-based records and decision-support systems and said these departments should make software and intellectual property available in the public domain so others can benefit.

However, the General Accounting Office (GAO), in a September report to Congress, said that patients who receive medications from both VA and DoD health services, a group known as shared patients, face an increased risk for medication errors because of the departments' separate and uncoordinated information and formulary systems.

VA and DoD providers and pharmacists generally do not have access to shared patients’ complete health information to aid in making medication decisions, GAO said, because "information in one agency’s electronic health record system is generally not accessible by the other agency."

GAO also noted that clinicians in one government department generally are unable to use computerized prescriber order entry to order medications that are to be dispensed by the other department’s pharmacy.

Automatic checks for drug allergies and interactions are not complete for shared patients because the checks do not cross over to the other department's database, the Congressional investigative agency found.

DoD and VA, responding to GAO, said that a joint initiative, known as the Federal Health Information Exchange (FHIE), would be a long-term solution to many of the departments’ information-sharing problems.

FHIE, formerly known as the Government Computer-Based Patient Record (GCPR), was started in 1998 as a program intended to provide for the sharing of clinical patient data among VA, DoD, and the Indian Health Service.

GAO scolded the agencies in April 2001 because the project was years late and several million dollars over budget. But FHIE finally got under way in July.

HHS Secretary Tommy G. Thompson, in a statement responding to IOM’s report, said that his agency has a number of initiatives under way to increase the quality of health care.

Thompson pledged to provide national leadership, working with public- and private-sector partners, to promote the rapid development of the technology necessary for an electronic health record and the infrastructure needed for use by the health care system.

American Hospital Association (AHA) President Dick Davidson, in a statement, said hospitals welcome greater coordination of federal standards and regulations.

AHA, he said, hopes that federal agencies "choose valid and useful measures on which there is already broad, voluntary consensus."

"Hospitals want the public to know about the quality [of] care they receive," he said. "But patients and families must have information that is reliable and easy to understand."

To often, he said, there is confusion about what constitutes quality and what information can be trusted.

"Various organizations provide inconsistent and invalid data in an attempt to grade hospitals," he said. "That data is often difficult to comprehend and only shows a part of the picture. We need a shared national strategy for quality measures that includes the active leadership of the hospital community in concert with government initiatives to provide the public not just with data but with helpful information about the quality of care."