Vital Signs Core Metrics for Health and Health Care Progress

Thousands of measures are in use today to assess health and health care in the United States. Although many of these measures provide useful information, their sheer number, as well as their lack of focus, consistency, and organization, limits their overall effectiveness in improving performance of the health system. To achieve better health at lower cost, all stakeholders—including health professionals, payers, policy makers, and members of the public—must be alert to which measures matter most. What are the core measures that will yield the clearest understanding and focus on better health and well-being for Americans? With support from the Blue Shield of California Foundation, the California Healthcare Foundation, and the Robert Wood Johnson Foundation, the Institute of Medicine (IOM) convened a committee to identify core measures for health and health care. In Vital Signs: Core Metrics for Health and Health Care Progress, the committee uses a four-domain framework—healthy people, care quality, lower cost, and engaged people—to propose a streamlined set of 15 standardized measures, with recommendations for their application at every level and across sectors. Ultimately, the committee concludes that this streamlined set of measures could provide consistent benchmarks for health progress across the nation and improve system performance in the highest-priority areas.


The Measurement Landscape
Health measurements are requested or required by many organizations for many purposes, including efforts to track population, community, and individual health; assessments of health care quality and patient experience; transparency monitoring; public reporting and benchmarking; system or professional performance requirements; and funder reporting. Many of these measures are very similar, with only slight variations in terminology and methodology. However, their differences are often signifi cant enough to prevent direct comparisons across states, institutions, and individuals. In addition, many measures focus on narrow or technical aspects of health care processes, rather than on overall health system perfor-

REPORT BRIEF APRIL 2015
mance and health outcomes. According to the committee, the growing number of clinical measures, even those that provide valuable information, draws attention to narrow, specifi c elements and away from system capacity and effectiveness.
The necessity to collect, analyze, and store data for such a large number of measures also imposes a signifi cant burden on providers, organizations, and the health care system as a whole. Preliminary research commissioned by the committee fi nds that the growth in measurement and reporting activities results in considerable expense and requires substantial time commitments-without a matching return on investment. The establishment of a core set of measures could improve effi ciency and ensure a focus on the most important health outcomes.

The Core Measure Set
To select a core measure set, the committee fi rst considers each candidate measure's importance for health, likelihood to contribute to progress, understandability, technical integrity, potential to have broader system impact, and utility at multiple levels. Next, in considering how the measures should operate as a set, the committee selects 15 measures that together have systemic reach, are outcomesoriented, are meaningful at the personal level, are representative of concerns facing the U.S. health system, and have use at many levels. The core measures proposed by the committee are as follows: 1. Life expectancy: Life expectancy is a validated, readily available, and easily understandable measure for a critical health concept. Because life expectancy depends on a full range of individual and community infl uences on health-from cancer to homicide-it represents an inclusive, high-level measure for health.

Well-being:
Well-being captures the subjective dimensions of health related to quality of life. Furthermore, levels of well-being often predict utilization of and satisfaction with health care. Selfreported well-being is a reliable indicator.

Overweight and obesity:
More than two-thirds of Americans are overweight or obese, a fact that has causes and consequences that extend beyond the health system-including socioeconomic, cultural, political, and lifestyle factors. 11. Care match with patient goals: Systematically assessing each patient's individual goals and perspectives ensures that the health care system is focusing on the aspects of care that matter most to patients.

Personal spending burden:
Care that is too expensive can limit access to care, lead people to avoid care, or prevent them from spending money in other areas of value to them-with far-reaching economic impacts.

Population spending burden:
Health care spending consumes a large portion of the U.S. gross domestic product, dwarfi ng the health care spending of other nations. This burden can be measured at national, state, local, and institutional levels.
14. Individual engagement: Given the effects of personal choices on health, as well as the increasing use of personal health devices, it is critical for individuals to be aware of their options and responsibilities in caring for their own health and that of their families and communities.

Community engagement:
Across the United States, communities have and utilize different levels of resources to support efforts to maintain and improve individual and family health-for example, addiction treatment programs, emergency medical facilities, and opportunities for social engagement.
The committee recognizes that these 15 measures will not be suffi cient to meet every interest for each organization, nor are there established methods for measurement in each area. To begin to accommodate these challenges, the committee identifi es 39 additional priority measures that can act as surrogates while refi nement is under way (see Box).
The necessity to collect, analyze, and store data for such a large number of measures imposes a signifi cant burden on providers, organizations, and the health care system as a whole.

Addictive behavior:
Addiction, including to nicotine, alcohol, and other drugs, is prevalent in the United States, representing a complex challenge for the health system, communities, and families. Every year, substance abuse and addiction cost the country more than $500 billion.

Unintended pregnancy:
Unintended pregnancy, a signifi cant challenge for both individual and community health, is a measure that aggregates a variety of social, behavioral, cultural, and health factorsparticularly women's knowledge about and access to tools for family planning.

Healthy communities:
Individual health is a function of a wide range of socioeconomic and community factors, from infrastructure to social connections. Community health includes critical elements of health that fall outside the care system, such as housing, employment, and environmental factors.

Preventive services:
Preventive services (for example, screening for hearing loss or counseling for tobacco cessation) present a valuable opportunity for both improving health and reducing costs.

Care access:
A person's ability to access care when needed is a critical precondition for a highquality health system. Factors that could hamper access to care include lack of health insurance, clinician shortages, lack of transportation, cultural and linguistic barriers, and physical limitations.

Patient safety:
Avoiding harm is among the principal responsibilities of the health care system, yet adverse outcomes are common. Ensuring patient safety will require a culture that prioritizes and assesses safety through a reliable index of organizational results.
10. Evidence-based care: Ensuring that patients receive care supported by scientifi c evidence for appropriateness and effectiveness is a central challenge for the health care system. Currently, an estimated one-third of U.S. health care expenditures Refi nement of the measures and methodology will require leadership from stakeholders across sectors.

Implementation of the Core Measures
Successful implementation of the core measures will depend on their relevance, reliability, and utility to stakeholders. Implementation challenges include multiple competing priorities for stakeholders, the sizable degree of change proposed, and the slow pace of change overall in the health system. Progress can be accelerated by ensuring that the core measurement set is applied by, and adds value to, existing measurement activities. The committee stresses that leadership will be required at nearly every level of the health system. CEOs of health care organizations, payers and employers, standards organizations, and public health agencies will have important roles in the uptake, use, and maintenance of the core measures as practical tools. The committee recommends that the Secretary of the Department of Health and Human Services, with support from the Executive Offi ce of the President, lead the effort to refi ne, standardize, and implement core measures throughout the nation.

Conclusion
The set of core measures proposed by the committee is a tool for enhancing the effi ciency and effectiveness of measurement. Ultimately, widespread application of a limited set of standardized measures could not only reduce the burden of unnecessary measurement but also align the incentives and actions of multiple organizations at multiple levels. Vital Signs lays the groundwork for the adoption of core measures that, if systematically applied, could yield better health at lower cost for all Americans. f