National Outcomes Measurement System (NOMS): 2003

National Center for Treatment
Effectiveness in Communication Disorders
Rockville, Maryland

Since 1998, speech-language pathologists (SLPs) have had a tool to help them document the real-life impact of their interventions. This tool, the National Outcomes Measurement System, or NOMS, was developed by ASHA to help its members meet the need for outcomes data which they could use with a variety of clinical and non-clinical audiences.

In the early-to-mid 1990s, SLPs increasingly found themselves called upon to provide evidence of the impact made by their treatment efforts. Third-party payors in particular were demanding such evidence. ASHA responded by establishing a task force to develop a clearinghouse within ASHA for the aggregation and dissemination of outcomes data. The task force determined that no existing outcome measurement systems adequately captured the impact of SLP intervention. Some systems were too clinically-oriented to be understood by third-party payors, non-SLP administrators, and other non-clinical audiences. Previously existing tools had poor reliability and/or validity while others seemed inappropriate as communication and swallowing issues were only minimally addressed amid a morass of often marginally-related measures.

In 1997, ASHA created the National Center for Treatment Effectiveness in Communication Disorders (NCTECD), a staff unit charged with developing sources of data that ASHA members could use to address questions regarding the impact of their services. NCTECD's charge is to develop data sources for all ASHA members, not just SLPs. The recognition of unmet needs for outcomes data has been much more strongly felt among SLPs than audiologists. Although this is slowly changing, the result has been that virtually all the work done at NCTECD, to date, has focused on speech-language pathology.

Most of the tools developed by the NCTECD fall under the heading of NOMS. NOMS is the umbrella term for three separate, but related, nationwide data collection systems.

The first data collection system to be developed and launched was the Adult component of NOMS, as it was the arena of adult health care in which SLPs most acutely recognized an unmet need for outcomes data, Data collection for the Adult component began in late 1998. The database currently contains data on over 70,000 patient-stays.

Although the initial impetus for the development of NOMS was the need for data to satisfy health insurance corporations, school-based SLPs soon recognized this approach could be applied to the school setting.

In the spring of 1999, the second component was launched, called the Pre-Kindergarten component. This component tracks outcomes for children ages three to five years who receive SLP services in health care or school settings. This database contains data on approximately 6,000 interactions.

The third component, called the "K-6" component, was launched at the beginning of the 1999-2000 school year. The goal of this component is to measure the impact of SLP intervention upon the students' ability to fully participate in classroom activities.

All three NOMS components have similar structure. Upon patient or client admission to SLP services, the SLP submits (via the Internet or a "scannable" paper form) an Admission form which captures basic demographic and diagnostic data about the individual receiving services. The SLP scores the patient on one or more of a series of seven-point scales to measure the patient's level of functional communication. These scales, referred to as the Functional Communication Measures (FCMs) are disorder-specific. The SLP scores the patient on whichever FCM corresponds to the patient's treatment plan.

When the patient/client is discharged from SLP services, whether because of discharge from the facility, completion of treatment goals, or for whatever reason, the SLP completes a Discharge form. This form is used to record data about the amount and type of services provided and to record discharge scores on the same FCMs previously gathered via the Admission form.

Movement along the FCM scales from admission to discharge is used as the outcome measure, and it is compared to the patient characteristics and service delivery variables to get a sense of which factors influence outcomes.

Participating sites have access to an on-line database from which they can generate reports of their data and compare with national benchmarks. Pre-formatted reports can be created and printed with a single mouse click, while the more adventurous can do their own customized queries of the data to examine issues not covered in the standard reports.

Application of the data:

NOMS participants use the data in four major ways.

I. Advocacy:

Advocacy with third-party payors can range from using data to support continued treatment of and reimbursement for a specific patient to development of evidence-based guidelines for reimbursement. Advocacy can also be directed to health care or school administrators to make the case for staffing levels, additional training needs, critical pathways, etc. Finally, the data can be used for advocacy with policymakers. In 2001, for example, ASHA members and staff used NOMS data in testimony before the Virginia Board of Education in a successful effort to limit SLP caseload sizes in the public schools.

II. Accreditation:

NOMS is the only SLP-specific outcomes system approved by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO's standards have evolved in recent years from recommending the collection of outcomes data to requiring it to most recently requiring that data be collected with a JCAHO-approved outcomes measurement system.

III. Quality Assurance:

An important feature of NOMS is that participants have the ability to compare the outcomes seen in their patients with national data on similar patients and treatment settings. This provides context for the interpretation of a site's data and helps identify programmatic strengths and needs.

IV. Patient Education:

One of the benefits of the relatively easy to understand terminology used in the Functional Communication Measures is FCMs can be used as a vehicle for dialogue between the clinician and the patient. Clinicians can review the data to help give the patient or caregiver a sense of the typical outcomes seen in similar patients with various amounts of treatment.

Strengths and Limitations:

The strengths of NOMS include the large number of patients on whom the data are based, the demonstrated reliability and validity of the Functional Communication Measures, and the focus on outcomes of real-world clinical practice, rather than on highly-controlled protocols that may or may not be replicable in practice. Additionally, the national benchmark data and the on-line query tool for data analysis provides powerful tools for analyzing and interpreting the data.

The most significant drawback to NOMS lies in the methodological approach.

Ethically, clinicians cannot withhold treatment from patients in need of SLP intervention. As a result, there are no control groups. The result of that, in turn, means that NOMS data cannot establish causality. The data show what patients are able to do upon the completion of SLP intervention, but cannot conclusively show, in the absence of patient controls, that the level of functionality was due to SLP intervention.

What about Audiology?

As mentioned at the beginning, NCTECD did not set out to focus exclusively on speech-language pathology. In 1999, and again in 2000, NCTECD and ASHA's Professional Practices in Audiology staff established and worked with committees of ASHA audiologists to begin development of NOMS-like data collection in audiology.

Specific attention was paid to cochlear implants, newborn hearing screening, and hearing aids.

Unfortunately, no consensus was reached regarding how to define the outcomes associated with audiologic intervention. This failure, coupled with the perception of many audiologists that outcomes measurement was not, at that time, a critical need for the profession, led to the tabling of these efforts.

Perhaps as a result of the successes achieved by SLPs using NOMS outcomes data, the time is right to once again explore how audiologists could work together to make use of data on audiology treatment outcomes?

The URL for additional information about NOMS is https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/OutcomeMeasures.html