The National Quality Forum (NQF) commissioned two background papers to inform its work on patient-reported outcome performance measures (PRO-PMs). The second paper considers how reliable and valid PRO-PMs that provider groups, regulatory agencies, payers and insurers, and others could be developed for use for accountability and quality-improvement activities. These considerations include selecting the PRO items or instruments, defining the appropriate target population, and establishing exclusion and inclusion criteria that ensure adequate samples can be found in the individual provider organization. Further, the approaches for calculating performance scores and using risk-adjustment techniques to adjust for differences in population case mix must also be considered. The authors are from RTI International and the Brookings Institution.

Organizational performance measures are numeric quantifications of healthcare quality for a designated accountable healthcare entity (i.e., provider), such as a hospital, health plan, nursing home, or clinician.  The calculation of performance scores based on PRO-PMs must be both valid and reliable for that accountable healthcare entity.  Some specific challenges to the validity of PRO-PMs are patient preferences (e.g. declining pain medication, which would result in higher pain levels), and the need to use proxies (such as family members and caregivers) for patients who do not want to, or are unable to, report their outcomes themselves.  While some measures can be validly reported by proxies (functional status such as how far someone walked that day), other more subjective measures (such as measures about pain or depression) are more challenging to report validly solely by proxies.

Before PRO-PMs can be used for accountability, quality improvement, or even payment, there must be considerations of patient risk adjustment. It would not be fair to compare one provider with many Medicare patients (who are more likely to be older and less mobile), with another provider with primarily Medicaid patients (who are more likely to be younger and more mobile).  The paper discusses several factors to be considered in any risk adjustment.

Finally, the paper discusses the opportunities and challenges in collecting and analyzing PRO-PMs through “eMeasures”, leveraging electronic health record (EHR) systems.  While there are advantages to having such data documented and retrievable from the EHR, there are concerns about authentication (ensuring the data is in fact reported by the patient or proxy), and about privacy (some data about patient experience of care should only be shared with the provider in aggregate, not linked to that patient’s EHR).

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