HCFA HEALTH-CARE QUALITY IMPROVEMENT PROGRAM - THE MEDICAL INFORMATICS CHALLENGE

The peer-review organizations (PROs) were created by Congress in 1984 to monitor the cost and quality of care received by Medicare beneficia ries. In order to do this, the Health Care Financing Administration (H CFA) contracted with the PROs through a series of contracts referred t o as ''Scopes of Work.'' Under the Fourth Scope of Work, the HCFA init iated the Health Care Quality Improvement Program (HCQIP) in 1990, as an application of the principles of continuous quality improvement. Si nce then, the PROs have participated with health care providers in coo perative projects to improve the quality of primarily inpatient care p rovided to Medicare beneficiaries. Through HCFA-supplied administrativ e data and clinical data abstracted from patient records, the PROs hav e been able to identify opportunities for improvements in patient care . In May 1995, the HCFA proposed a new Fifth Scope of Work, which will shift the focus of HCQIP from inpatient care projects to projects in outpatient and managed care settings. This article describes the HCQIP process, the types of data used by the PROs to conduct cooperative pr ojects with health care providers, and the informatics challenges in i mproving the quality of care received by Medicare beneficiaries.