A GOVERNMENT WEB SITE devotes about a million bytes to the subject of outcomes measurement, but the bottom-line definition boils down to one simple word: results.

Those who foot the bill want to know what they get for their money. That's why an accreditation agency for the first time is mandating outcomes measures from providers of home medical equipment and services, while managed care organizations have begun to request outcomes as part of the contract negotiating process.

"Anecdotal evidence is nice, but a medical director once told me, 'In God we trust; all others must bring data,' " says Greg Solecki, vice president of health care at Henry Ford Home Health Care in Detroit. "The warm and fuzzy aspects of home care are more powerful when attached to data that demonstrate results."

WHAT THE DATA SHOW FOR OUTCOMES TO BE USEFUL, according to Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, an evaluation framework must be set up that relates sound processes to good patient outcomes and reduces risk in the delivery of care.

The performance measurement systems must be cost-effective and user-friendly, O'Leary says. To ensure quality of care to the public, the measurement systems must be able to be evaluated on all levels. And, he says, there must be a consensus among evaluators on which tools to use for the assessment to be valid.

Why bother?

"Do it to save money and to make money," says Bob Ferry, director of research and development for Emeraldcare, Gastonia, N.C. "Otherwise, there's no reason to do it."

Put into practice, results can help an HME provider pinpoint areas to improve, services to promote, and even help sway a managed care decision-maker to put real dollars into one provider's pocket over another's. For example, an asthma nebulizer is delivered without proper instructions and the patient winds up in the emergency room, which increases the payer's costs.

"The insurance company wants to know which provider's patient doesn't end up in the emergency room," says Jeffrey Souza of Healthcare Quality Management, a Yuba City, Calif.-based data management firm. "The people who pay the money want to see that they get what they pay for."

Ferry says the measurements for HME providers should address quality control of equipment, customer satisfaction and proper patient instruction.

"How can you tell if you're improving if you didn't know where you were before?" he asks. "This is a new science for health care, but it's something we should do."

For all of the compelling reasons to embrace the concept, however, the HME industry hasn't. HME providers generally don't respond to new ways of doing business, Souza says, until staring down the barrel of a gun.

"Providers understand it might be good," he says, "but they don't need it, so they don't do it. It's like exercise. It's good for me, but I don't do it. If I had a heart attack, then I'd do it."

Souza insists a provider willing to pay his company's $1,500 annual service fee will more than earn it back because the outcomes will lead to greater efficiency and the documentation will lead to more business.

"We've found that, once the providers get started collecting data, they use the information to address issues within the company,' he says. "They see they can do something with it. We know it's valuable, but we can't force people to try it or browbeat them. It's not worth the time."

Maureen Yadgood, a North Andover, Mass.-based consultant, is another advocate of voluntary outcomes measurements and benchmarking (the comparison of one provider's results with those of others). "It's cost-effective to know your strengths and weaknesses," Yadgood says. "How can you tell unless you measure it?"

Because a provider's ability to prove it can deliver as promised could lead to a sale or a contract, the reality for the HME industry, some providers say, is that widespread implementation of outcomes measures is not so much a question of if, but when.

"A lot of insurance companies, big HMOs, when you come in to negotiate a contract, they're apt to ask if you have performance improvement programs and what they look like and what you do [with them]," says Carol Lyonnais, community relations coordinator of Cape Medical Supply, Sandwich, Mass. "It's already happening."

Solecki agrees.

"When you are dealing with an integrated delivery system, dealing with employer groups like automakers, you need to demonstrate not only being cost-competitive, but also that you can have an impact on community health," he says. "The data tell the story for you."

Lyonnais says Cape Medical put a quality improvement program in place before the JCAHO mandate and it helped streamline the intake and delivery processes.

"It also helped every employee understand how each job impacts every other job," she says. "It helped eliminate repetition and redundancy, and it helped morale. It was a tremendous benefit."

THE ACCREDITATION-OUTCOMES CONNECTIONS CAPE MEDICAL SUPPLY IS ONE of the approximately 3,000 accredited providers required to begin implementing outcomes measurements as part of JCAHO's Oryx initiative.

Billed by JCAHO as "the next evolution in accreditation," Oryx is designed to link accreditation and outcomes of care. To remain accredited, providers will gather data to support their claims of quality, identify areas of excellence, receive warnings of potential problems, verify corrective actions and compare performance with competitors.

Consultants say the HME industry should assume that the Health Care Financing Administration will eventually mandate outcomes measurements for HME providers, since it has imposed OASIS (Outcomes and Assessment Information Systems) on home health agencies beginning this year. They speculate that HCFA could piggyback on JCAHO's Oryx initiative by simply requiring accreditation for Medicare HME reimbursement. A HCFA spokesman says there currently are no plans for that.

Skeptics are concerned that outcomes measurements could lead to a disproportionate share of responsibility landing on the HME provider.

"It's going to be very difficult for the equipment supplier to be held responsible for patient outcomes independent of the skilled nurse, the case manager and other providers," says Paulette Nardi, director of special projects for Homecare Solutions, a South Hackensack, N.J., support surfaces manufacturer.

JCAHO claims that Oryx will make the accreditation process more credible, objective, consistent and useful.

Providers hearing this for the first time-well, you've already missed the first deadline: As of December 31, 1998, you were required to select a performance measurement system capable of transmitting data to JCAHO, and at least two outcomes measures that relate to at least 20 percent of the company's patient population.

The program will be implemented in phases, so the next deadline is January 1, 2000 (a date recently moved back from July 1, 1999), when collection of data must begin. After that, no system changes will be allowed for one year, so JCAHO recommends submitting data in advance to work out potential bugs. By July 31, 2000, data collected from the first quarter of 2000 must be transmitted to JCAHO.

JCAHO's stated long-range goal for its Oryx initiative is to establish a data-driven continuous survey and accreditation process to complement the current standards-based assessment. This could be especially valuable for those who are choosing providers, because it would offer objective evidence regarding quality of care and price, industry players say. Over time, performance measurement data are expected to be made available to the public.

OUTCOMES TERMS DEFINED JCAHO PROVIDES A GLOSSARY of Oryx initiative terms that can make your head spin, but a few definitions are worth noting:

"Clinical measures" evaluate the processes or outcomes of care associated with the delivery of clinical services. They allow for comparisons within and across health care organizations. For HME companies, measures that assess the selection, delivery, setup and maintenance of equipment are clinical.

"Patient perception of care measures" focus on the delivery of clinical care from the patient, family or caregiver's perspective. For example, to what extent did the patients feel their needs were met by the provider?

The number of measures and the proportion of the patient population they address will be increased each year. By December 31, 1998, providers must have selected two additional measures pertaining to at least 25 percent of the patient population. The following year, two more measures and 30 percent; the year after that, two more measures and 35 percent. At some point, patient satisfaction and functional health status will be required.

If you have a couple of months with nothing to do, you could visit JCAHO's Web site and read page after page about the Oryx initiative. If you'd prefer telephonic interaction with a machine, the Oryx information line number is 630/792-5085. Otherwise, you can just keep reading.

The $10,000 ANSWER THE OBVIOUS FIRST QUESTION for providers, of course, is how much will it cost?

The answer: plenty.

JCAHO will charge each software system vendor a $5,000 annual participation fee, plus transmission fees of $10 per measure per organization per quarter, costs that inevitably are passed on to customers, the HME provider. JCAHO surveys indicate a system then will cost HME providers about $10,000 annually to maintain plusa full-time employee, although systems providers say that is inflated.

"There's a fury over the costs," Yadgood says. "The industry got caught off-guard and it's real frustrating. The concept is great, but having it pushed down our throats is not so great."

Theoretically, JCAHO claims performance measurement will lead to significant-and potentially cost-saving-improvements in care, as well as eventually allowing the public to guide care decisions based on the information generated.

As unlikely as this might sound, let's say you got caught up in holiday shopping and the bowl games and forgot to select a system, earning a special Type I recommendation. A written progress report explaining a plan of correction is required within 30 days, and if the requirements are not met in the prescribed manner, violators face loss of accreditation.

For assistance, the Joint Commission provides information about each contracted system and, with appropriate study, providers can sort through it to determine the system best suited for their business.

Speaking theoretically again, the software system vendor sends raw data to the measurement system (most likely monthly), which summarizes it in a specified format and sends it to JCAHO quarterly. For JCAHO to compare data of multiple organizations using the same measures, data must be sent by the system provider and not directly to JCAHO by the HME provider.

The Joint Commission claims on its Web site that its primary interest in Oryx results will be "how the organization uses the data to improve and, ultimately, in the results of the improvement activity." Trends in the submitted data, according to the Web site, may signal possible noncompliance with certain Joint Commission standards. Automated analysis will identify organizations warranting contact, with continuing poor results drawing escalating levels of response.

"I have a challenge for JCAHO," says Yadgood. "Let's see JCAHO measure its outcomes and let the public see how it's doing. The airlines publish their results. Why not the accreditation commission?"

IT TAKES CAPITAL to generate outcomes and for many providers, that can be a major stumbling block. But investing in a software system that can produce outcomes can reap many benefits, experts say. Generating outcomes, they say, can help a provider to:

1. Save money and make money.

2. Pinpoint areas for improvement.

3. Target services to promote.

4. Land managed care contracts.

5. Become more efficient.

6. Educate employees on the interrelationship of different departments.

7. Reduce risk in the delivery of care.

8. Address quality control of equipment.

9. Spotlight customer service concerns.

10. Monitor proper patient instruction.