A CHIPRA-mandated $55-million Pediatric Quality Measures Program (PQMP) has been supporting seven Centers of Excellence in an effort to refine existing measures in both primary and specialty care and develop new ones that are more evidence based. "[Finally], there has been substantial federal investment for the design of pediatric measures to be used nationally," said Dr. Mark Schuster, who is William Berenberg professor of pediatrics at Harvard Medical School and the principal investigator for CHIPRA’s Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital.
Thus far, it "has been hard to learn from each other ... To get a sense of what and how well your peer groups are doing," he said. "We want to be able to go to a hospital that’s consistently doing better on a certain measure and ask, ‘How are you doing this? Can you help us?’ "
Experts in quality measurement say that interest and efforts are increasingly focused on measures that address more than the structure and process of care, as well as on measures that address behavioral and mental health. The national Children’s Core Set includes three measures relating to mental and behavioral health.
NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measures – which comprise a large portion of the Children’s Core Set – have "provided a basic floor of measures" for various stakeholders in the health care system by looking at factors such as immunization status and whether or not children receive well-child visits, for instance, "but they don’t say anything about what happens when the child is there or" how the child fares afterwards, said Dr. Charles Homer, chief executive officer of the National Initiative for Children’s Healthcare Quality in Boston, which assists practices, hospitals, and others in using data and measurements to improve.
"You can do very well on the HEDIS measures and still not deliver the kind of care you or I would want our children to get," he said. "As part of our efforts to improve quality, we need data-driven, higher-bar measures. ... I don\'t think we’re very far from adding some of these kinds of metrics."
NCQA’s Dr. Scholle doesn’t disagree. Like Dr. Schuster, she also is serving as a principal investigator for the PQMP. One of her main areas of focus has been the development of measures on adolescent depression care. "We need to see whether adolescents [who receive depression care] are actually improving, with a reduction in symptoms over time," she said.
Also of growing importance in pediatric quality measurement is what experts call the patient or family "experiences of care." Dr. Scholle, for one, can attest to the value of such input when it comes to measuring the quality of depression care. NCQA has been incorporating measurement of the patient/ family experience in some of its HEDIS measures, and Dr. Schuster and his colleagues in Boston have been testing a family experience of care measure in pediatric hospitals across the country.
"We’re not talking about patient satisfaction – we’re talking about the experience of care and the outcomes," said Christina Bethell, Ph.D., M.B.A., M.P.H., professor of pediatrics at the Oregon Health & Science University, Portland, and founding director of the Child and Adolescent Health Measurement Initiative, which focuses on developing patient- and family-centered measures of quality.
"We can’t ask patients about what kinds of lab tests they had, but we can ask them about their behaviors and their functioning and their outcome," she said. "Is the child going to school, for instance? Sleeping well?"
Growing use of electronic medical records and other technologies – as well as financial incentives – may help support the collection of such information. And, Dr. Bethell maintains, there is a wealth of information to tap into from national surveys like the National Survey of Children’s Health that can be used to support state and regional-level measurement and quality improvement.
Overall, "we have a lot of what we need right now to" better measure the quality of children’s health and health care. "We just have to use it better," she said, adding that the main supportive pillars of good quality measurement – policy, culture, technology, and financial incentives – "are coming together." That, she said, "is what’s really changing."