Many predicted benefits are associated with the widespread adoption of interoperable electronic medical record (EMR) systems. Automation and cost-effective operation of clinical quality performance measures in large health care delivery systems are often mentioned and perhaps the most important benefits.

However, many experts seem to believe that we will not have low-cost, automated performance measurement until EMR systems are widely deployed. That is not necessarily true.

It is troubling that this misconception is prompting some policy-makers and thought leaders to advocate that Medicaid managed care organizations participate in electronic health exchanges. If it were to become a mandate, that approach would incur huge costs that would sap the already limited resources available for direct care. 

For example, in Wisconsin's Medicaid program, nearly all health plans are sponsored by mixed or group model plans that do not own any of the clinics or hospitals with which they contract. 

Consequently, health maintenance organizations have virtually no power to dictate when or even if their network providers implement EMR systems or which systems they use.

However, states can use existing electronic data interchange and Medicaid Management Information Systems to accurately measure performance. 

Wisconsin created the Medicaid Encounter Data Driven Improvement Core Measure Set for use in the Family Medicaid program, the State Children's Health Insurance Program, and a managed care delivery system for older people and individuals with disabilities who are eligible for Supplemental Security Income.

Wisconsin's approach differs substantially from typical provider-level measures in a number of key ways.

• Performance measurement data is generated routinely from normal operations. Costly, slow and intrusive reviews of paper medical records for data extraction have been eliminated at the provider level, avoiding privacy issues, duplicative paperwork costs and administrative inefficiency. Routine edits and data-validity audits track data quality and completeness.
• Encounter data can be merged with other electronic data streams to improve accuracy and completeness. That is not possible with provider or health plan-reported systems and probably won't be possible on a routine basis even after broad EMR adoption.
• Health plans and providers do not calculate or report their own results. That approach prevents duplicative costs while eliminating inaccuracies caused by variations in interpretations of measure specifications or provider data systems. 
• Because the measures are user-defined, they can be added to or modified quickly as program needs dictate and include topics of high importance to Medicaid programs not included in other measure sets, such as federally mandated blood lead testing and Early Periodic Screening, Diagnosis and Treatment Program. 

System-level measures are broad in nature and relatively low in cost but capable of providing critically important insight into problem areas and what to do about them.

Provider-level measures are narrow in focus and generally more costly, but they are essential for conducting a detailed analysis of problems and a focused response for improvement.

Ilminen is a nurse consultant at Wisconsin's Department of Health and Family Services.