**4. Quadruple aim-based outcome measures**

A formal pilot to assess technology is essential before a full launch. Measures of outcomes need to be created to determine how well the solution performed, especially regarding helping solve the problem for a specific case use. From the author's Digital Health vision to help achieve the Quadruple Aim, let us see how we might use this to formulate our outcome measures. Dr. Don Berwick and his colleagues introduced the Triple Aim to improve the patient's care experience and populations' health and reduce costs to improve the US Healthcare System [9]. This evolved into the Quadruple Aim as the importance of caring for the provider was acknowledged. Many health care organizations have adopted the four aims as their overarching goals. There has never been an impetus to rank them. However, without patients, the health care system would have no reason to exist. Even if quality and patient satisfaction are outstanding, cost-prohibitive care and a lack of clinicians or staff due to low engagement will lead to a model that could not be sustained. The prevailing priority is to improve the patient and clinician experience, hopefully leading to better clinical quality and cost control.

Concerning patient satisfaction, surveys are the means to collect data. Overall, questions are not specific enough, so we need more directed ones that tie back to case uses. Patients are now also customers and consumers. They want to interact with the health care system as they see fit, not just by the traditional telephone call and in-person visit, which involves a process that is not easy to use. They want to engage using virtual tools like audiovisual connections, texting, and e-mailing. They want to be able to self-schedule. They want to get referrals, tests, results, and prescriptions quickly. Price transparency is essential too. Finding tools that can achieve these wishes is our mandate.

#### *Emerging from Smoke and Mirrors DOI: http://dx.doi.org/10.5772/intechopen.96212*

Physician Engagement starts with ways to improve the EMR so that there are fewer clicks, less need for brain power and time, and better workflows. Frustration over the EMR has directly contributed to the burn out of providers and staff who are less caring and less careful, directly impacting the patient experience and clinical care quality. There is less attrition of patients, physicians, and staff when they are satisfied and engaged. Human capital groups agree that it costs nearly \$1 M to replace a physician throughout the healthcare system. We do not know the effect of turnover on patient satisfaction and quality of care, but both are likely reduced.

Quality in Medicine has always been about clinical criteria- the quality of life, reduced morbidity, and reduced mortality. The Quadruple Aim's focus, however, is on the overall health of the population. Historically, this was under the purview of Public Health and Preventive Medicine but has morphed into its own Population Health discipline. Measures created by government agencies in collaboration with payers, provider groups, and academic institutions are geared towards payment and are only indirect measures of quality of life, morbidity, and mortality.

Cost considerations have evolved over the years, going from dollars adjusted for inflation to Cost-Effectiveness to Return on Investment to Medical Waste calculations. Value-based care, coupled with Evidence-Based Medicine as a core component of decision-making, has gained enormous popularity since it is a useful cost control model. The hope is that this approach will significantly impact the estimated 1/3 of all medical costs being spent unnecessarily in the USA.

For any of the four Quadruple Aim goals, investigators can create specific outcome measures for a pilot. Financial Analysts must choose newer and more innovative ways to factor in non-monetary benefits. For example, engagement leads to better care, less morbidity and mortality, less attrition of patients and providers and staff, more retained, and new patients. A surrogate measure might be non-productive patient time for travel, waiting, and going to the pharmacy. Alternatively, for a physician, measure time to chart in the EMR, lost productivity due to missed appointments from no-shows, and face-to-face time with a patient.
