Putting the value framework to work.

10.1056/nejmp1013111 nejm.org 1 zations, including my own, now describe enhancement of value for patients as a fundamental goal and are using concepts developed by Michael Porter (see 10.1056/ NEJMp1011024, and the framework papers in Supplementary Appendixes 1 and 2 of that article) to shape their strategies. What has changed? And what are these organizations actually doing? Practical motivations lie behind the interest in the value framework. Rising costs and a stagnant economy pose problems with no easy solution. Budgets cannot be planned responsibly by hoping for growth in volume. As all players try to protect their incomes, nerves are fraying. Physicians are pitted against hospitals, specialists against primary care physicians, academics against the community. In this fractious context, value is emerging as a concept — perhaps the only concept — that all stakeholders in health care embrace. Providers, patients, payers, and policymakers all support the goal of improving outcomes and doing so as efficiently as possible. No one can oppose this goal and expect long-term success, just as no one in a for-profit company can resist decisions likely to enhance long-term shareholder value. The value framework thus offers a unifying orientation for provider organizations that might otherwise be paralyzed by constituents’ fighting for bigger pieces of a shrinking pie. So how is the concept of value being translated into reality? As is often true in medicine itself, the critical first step is measurement. Provider organizations need to capture data on the outcomes that matter to patients, as well as the costs for a patient over meaningful episodes of care. These data are essential for assessing whether value is improving. This work is not easy, because the collection of such data has not been encouraged by the feefor-service system and is hindered by the silos in the current organizational structure of medicine. Current information systems are designed to support clinicians in performing individual services for individual patients and to collect their reimbursement. Outcomes as important as death are not routinely recorded; functional-status outcomes (e.g., whether a patient with headand-neck cancer can swallow or talk) are buried in free text and are not captured in analyzable Putting the Value Framework to Work