Published 6/1/2007
Kenneth L. Moore, MD

Clinical performance measures depend on physician input

AAOS brings expertise in measure development to Physician Consortium for Performance Improvement

Ever since the Institute of Medicine (IOM) published its landmark book To Err is Human: Building a Safer Healthcare System, awareness and development of clinical quality measures in medicine have increased. As Harvey Fineberg, MD, PhD, MPH—then the IOM’s president—said, “The only way to know whether the quality of care is improving is to measure performance.” And to accurately measure performance in medicine, we need clinical performance measures.

Keeping physicians in charge
The question of who will develop these performance measures is crucial. Organized medicine is being pushed to develop clinical performance measures, and both the AAOS and individual orthopaedic specialty societies are currently working to develop rigorous, scientific performance measurement standards.

In addition, the Academy is sharing its experience in developing clinical performance measurement standards with outside organizations that are developing comprehensive performance measure sets in all areas of medicine. The American Medical Association’s Physician Consortium for Performance Improvement® is one such organization.

As its name implies, the Physician Consortium for Performance Improvement is physician-led and physician-focused. Its mission is to become the primary source for evidence-based clinical performance measures and reporting, and to involve representatives from the entire medical profession in the ongoing development of those measures.

Robert H. Haralson III, MD, MBA, AAOS director of medical affairs, and I represent the Academy at the Consortium. Dr. Haralson has also been elected to fill the “at-large organizational member seat” on the Consortium’s executive committee. In addition, several other AAOS fellows currently serve as representatives to the Consortium, including David R. Mauerhan, MD (representing the American Association of Hip and Knee Surgeons); David A. Wong, MD (representing the North American Spine Society); Michael A. Wayslik, MD (representing the Florida Medical Association); and Andrew Gurman, MD (representing the Pennsylvania Medical Society).

The Consortium, which is formally convened and governed by the American Medical Association, comprises more than 100 national medical societies and state medical societies in nearly all recognized medical specialties. Other major participants at the Consortium include the Council of Medical Specialty Societies; the American Board of Medical Specialties and its member-boards; and experts in methodology and data collection. In addition, federal government agencies such as the Agency for Healthcare Research and Quality (AHRQ); and the Centers for Medicare and Medicaid Services (CMS) directly participate in the development of performance measures at the Consortium.

CMS subsequently implements the finished measures in its ongoing pay-for-performance initiatives, such as the Physician Quality Reporting Initiative (PQRI). Currently a voluntary program, the PQRI will eventually require participating physicians to report data on specific performance measures to qualify for incentive payments.

How are performance measures used?
Evidence-based clinical performance measures can foster provider accountability and enhance the quality of care, thus improving patient health and safety. As performance measures are developed, the Consortium helps promote and facilitate their implementation by the wider medical and payer communities.

Performance measures may be used in a variety of ways. They can serve as forums for medical organizations, as the basis for developing demonstration projects, or as examples to educate physicians on measures usage. Performance measures can be integrated with health information technology, as well as with advocacy efforts to increase funding and base health policy decisions on improving patient care and patient and physician relationships. Ultimately, the process of developing and implementing performance measures will advance the science of performance measurement itself.

How are measures developed?
Performance measure development focuses on clinically relevant topics that occur frequently and/or result in a high cost of care. After a thorough literature search and review, the best available research evidence is used to develop the measure criteria.

The actual work of developing new performance measures is assigned, by topic, to various work groups formed within the Consortium. During 2006, 20 work groups participated in developing various measures. The exact number of new measures to be developed in 2007 will be determined by the Consortium’s elected executive committee, which includes Dr. Haralson.

Once the measures have been finalized at the Consortium level, they are posted for a 1-month public comment period. After the work group considers and address the public comments, the measures are brought before the entire Consortium for final approval (a majority vote is required). The approved measure is then forwarded to the National Quality Forum for national, multi-stakeholder approval before it is implemented by both public and private payors.

To date, the Consortium has developed performance measures for a broad range of medical conditions and specialties, including primary care, pediatrics, cardiology, orthopaedics, and geriatrics. As of March 2006, it had developed a total of 178 performance measures, which had been or were in the final process of being formally approved for implementation.

PQRI orthopaedic measures
Of the 74 performance measures included in the PQRI program, nine are targeted for orthopaedic surgeons. They include the timing and administration of antibiotics, deep venous thrombosis prophylaxis, and osteoporosis. Detailed information on these performance measures can be found on the CMS Web site at

Kenneth L. Moore, MD, is a member of the AAOS Guidelines Oversight Committee and serves as the AAOS volunteer liaison to the AMA Physician Consortium for Performance Improvement.