# American Health Information Community

# Workgroup on Quality

# 

# Summary of the Web Conference 

# Held on Wednesday, October 11, 2006

# Second Meeting of This Workgroup

## PURPOSE OF MEETING 

The principal purpose of the meeting is to hear presentations relating
to critical issues raised during the Quality Workgroup's first meeting,
the "healthy" tension between the Workgroup's Specific and Broad
Charges, and two key aspects of the Workgroup's work:

-   The Business Case for Automating Quality Reporting

-   Identifying the Critical Next Steps for Automating Quality.

## KEY TOPICS 

### 1. Presentations Relating to the Business Case for Automating Quality Reporting

**A.** Francois de Brantes, National Coordinator, Bridges to Excellence,
focused his presentation entitled "AHIC Quality Workgroup" (the complete
presentation is available at
<http://www.hhs.gov/healthit/achic/materials/meeting10/qual/deBrantes.ppt>)
on subsets of performance measures determined to have impact on cost of
care, which are therefore able to serve as good predictors for the
business case for automating quality reporting.

Actuaries have validated savings per patient by physicians participating
in Bridges to Excellence diabetes and cardiac programs and measures. For
example, control of blood pressure at less than 140/90 mm Hg has been
estimated to save \$547 per patient.

Bridges to Excellence also has identified the highest value (in clinical
impact and cost savings) cardiovascular ambulatory measures from the AQA
starter set, such as blood pressure management. More detail is to come
in a study in process for publication.

Clinical data has limitations but is needed to mitigate the limitations
of claims data -- attribution (of claims to physicians), measurement,
and timeliness. Even if attribution and measurement issues are
addressed, there is a significant time lag in obtaining claims data and
using it to score performance. Appropriate health information technology
(HIT) is needed to speed up the performance feedback loop to consumers
and physicians. Clinical information derived from electronic health
records (EHRs) is critical in this regard.

*Comments/Questions/Discussion*:

The needs for automation to result in near real-time reporting and for
certified interoperable EHRs were emphasized. The projection that 50
percent of practicing physicians would have certified EHRs by 2010 was
noted, as well as the need for some continued use of claims data
potentially enriched by clinical IT elements from laboratory (lab) and
pharmacy data. The need for physicians' offices to be rewarded at a
higher level for timely reports was emphasized, in part to encourage
higher EHR adoption. A blended intermediate solution is manual chart
extraction of data as well as electronic chart extraction. A member
asked what percentage or volume of care is covered by the 50 percent
projection and observed that the Workgroup should consider strategies
needed for the near-term future.

##### Action Item #1: The Quality Workgroup will ascertain the percentage or volume of care covered by the projection that 50 percent of practicing physicians will have EHRs by 2010, in part to be able to report back to the Community on potential impacts on quality for the near-term future. 

There was discussion of the acceptance level of quantitative scoring.
Mr. de Brantes explained that the Bridges to Excellence scoring is
accepted for a number of reasons, including the measure set used and the
fact that score credit is not based on 100 percent of a given patient
population. The impact of voluntary versus nonvoluntary participation
was also discussed, as well as the value of the findings of independent
validation studies.

**B.** Phyllis Torda, Vice President for Development, National Center
for Quality Assurance (NCQA), gave a slide presentation on "Quality
Measurement Meets the Electronic Environment" (the complete presentation
is available at
<http://www.hhs.gov/healthit/ahic/materials/meeting10/qual/IT_measurement_Torda.ppt>).

The types of measures currently used for evaluation are:

-   Clinical performance on quality, utilization (related to cost,
    including administrative data and a hybrid method that samples
    members from administrative data), and resource use cost

-   Patient experience of care -- Consumer Assessment of Healthcare
    Providers and Systems

-   Systems use at the practice level, including HIT (NCQA -- Physician
    Practice Connection -- how physician practices are using electronic
    information to deliver care).

In addition to considerations of electronic data for claims and
enrollment, there is the issue of lab data. At present, 20--50 percent
of health plans get lab data electronically. This enables more quality
measurement, but most physicians do not receive the data in retrievable
form. The use of registries is emerging as a way to create a database
with retrievable information that is disease-specific and allows
management of care. Dr. Torda noted that EHRs for primary care
practitioners are not the same as EHRs for specialists because the data
elements differ. The first question to ask, across the board, is what
guidelines exist for building quality measures.

Future sources of data for quality measurement include not only
hospitals, payers, personal health records, principal physician
electronic medical records (EMRs), and lab and radiology data, but also
home monitoring and pharmacy data and data from other physicians' EMRs.
Getting data from these sources is difficult enough, but getting the
data in the right hands at the right time to improve continuity of care
is a challenge that requires strategic thinking. For example, the
Workgroup should look at not only EHR capabilities (inpatient and
ambulatory) but also the network services needed to get data from one
point to another.

While HIT can eliminate or reduce many costs, there are issues,
including:

-   Making sure not to overwhelm physicians with measurements that are
    too sensitive, such as some prescription alerts

-   Making sure that measures requiring administrative data allow for
    comparison to chart data

-   Addressing measurement bias when switching from claims to EHR data,
    as well as differential quality and cost implication issues

-   Automation costs -- initial investment versus long-term benefits,
    who pays, and who benefits

-   Technical issues -- not recording critical data in coded,
    retrievable fields; the importance for one-time data entry of
    integrating data collection needed for clinical management and data
    needed for measurement; and all aspects of interoperability

-   Privacy and legal issues, such as access to data for quality
    purposes, ownership of medical record versus other data, and
    ownership of aggregated data.

NCQA efforts include Partner Connection programs with pilots in two
locations where data can be uploaded directly from EHRs over the Web
into NCQA systems for scoring and program recognition. Dr. Torda
estimated that the number of physicians participating in the program
could double in a year or two.

Dr. Torda noted a beta test with GE Centricity in Maine of the Diabetes
Recognition Program and a higher volume test to come with 1,200
physicians from Kaiser Southern California. An important precursor is
NCQA's certification of the reporting capability from some EHRs.

Dr. Torda concluded thusly:

-   At present, NCQA is working through the issues of how to get data
    transferred from providers' EHRs to health plans for use in their
    Health Plan Employer Data and Information Set (HEDIS) reporting.

-   NCQA, the American Medical Association (AMA), and the Centers for
    Medicare and Medicaid Services are talking with vendors about what
    they want in terms of identification of standardized measure sets.

*Comments/Questions/Discussion:*

At present, the Commission for Certification of HIT (CCHIT) has not
addressed yet the functionality in EHRs for public reporting on approved
quality measures. Jane Metzger, who sits on the Commission, recommended
that:

-   The Quality Workgroup invite CCHIT to comment on that status of
    quality measures for ambulatory EHRs and the implications of EHRs
    submitting data to data intermediaries

-   AMA be asked to present on their experiments with different EHR
    vendors

-   The Workgroup analyze -- perhaps through a briefing from the
    Leapfrog Group -- the current state of prompting, alerting, and
    medication checking in the EHR industry, with the goal of improving
    that current state.

### 2. Presentations on Identifying the Critical Next Steps for Automating Quality 

**A.** Floyd Eisenberg, Managing Director, Clinical Informatics
Secondary Data Use, Siemens Medical Solution; and Co-chair, HIT
Standards Panel (HITSP) Biosurveillance Technical Committee, gave a
presentation on behalf of the Healthcare Information and Management
Systems Society (HIMSS) EHR Vendors Association entitled "Critical Next
Steps for Automating Quality Reporting" (the complete presentation is
available at
<http://www.hhs.gov/healthit/ahic/materials/meeting10/qual/Eisenberg.ppt>).

Dr. Eisenberg noted the following:

-   Customers do not currently place a high priority on quality
    improvement tools.

-   Complying with quality guidelines can lengthen the time needed to
    document care.

-   No standardized methods exist to report quality measures to payers
    or quality improvement organizations.

-   Current government efforts do not allow early EHR-adopting
    physicians to report quality data electronically.

-   Clinical performance measures need to be process specific, free of
    charge, and independent of care setting and use coordinated
    terminologies.

-   Measures should be related to more prevalent, higher-impact
    incidents.

-   Specification is needed to enable EHR vendors to integrate clinical
    performance measures into their products, but proscriptive
    methodology should be avoided.

-   Interoperability standards are needed for guidelines and clinical
    performance measures, but the industry should not be overwhelmed
    with too many measures at once, different measures should be
    aligned, and the industry should be given advance notice to allow
    time for testing and possible modification.

-   A number of organizations, including AMA and NCQA, are collaborating
    on performance measure integration into EHR systems. Two workgroups
    have formed on data capture and internal reporting and data
    extraction and external reporting.

-   HITSP will be reporting to the Office of the National Coordinator
    (ONC) at the end of October on clinical data sharing among
    physicians and between physicians and patients for consumer
    empowerment and collecting data for biosurveillance using the same
    mechanisms.

**B.** Louis Diamond of Thomson Medstat presented on "Sources of Data
for Quality Measures" by focusing on both work underway in the AQA HIT
subgroup on defining administrative data and Thomson Medstat's efforts
to create a framework for accessing and using clinical data to support
quality measures (the complete presentation is available at
<http://www.hhs.gov/healthit/ahic/materials/meeting10/qual/Diamond.ppt>).

The AQA HIT subgroup is exploring the definition of administrative data
by:

-   Describing and defining the various data elements of all
    administrative and clinical data constructs

-   Describing data flow from collection at point of care to storage,
    including manual and electronic handling

-   Mapping these two dimensions.

Dr. Diamond and his team at Thomson Medstat have looked at various uses
of clinical data, defined various elements of that data, and developed
criteria for focused access and use of clinical data elements.
Importantly, although differences between administrative and clinical
data can be fuzzy, the team is finding common language to define the
differences, particularly as it pertains to quality indicators and
quality measures. The bottom line consists of mapping exercises that
identify data elements to support quality measurement sets and permit
identification of where and how those data elements might best be
captured.

Options include enhancing administrative data and directly accessing
clinical data. In the short term, claims data access and merging could
help as well as continued exploration of extracting key data elements
from EMRs.

*Comments/Questions/Discussion:*

Both clinical and administrative data are needed for quality
measurement. Despite obstacles, claims data need to be improved for many
different purposes.

**C.** Kristine Martin Anderson, Principal, Booz Allen Hamilton,
outlined challenges in using EHRs for quality improvement in a
"Discussion Document: Automating Quality Reporting with Commercial EHRs"
(the complete presentation is available at
<http://www.hhs.gov/healthit/ahic/materials/meeting10/qual/Anderson.ppt>).

Ms. Anderson outlined a situation where a quality measure is, for
example, the percentage of acute myocardial patients receiving a beta
blocker within 24 hours of arrival at a hospital; where the hospital has
a standing order that prompts physicians to order oxygen, aspirin, a
beta blocker, and other therapeutic interventions; and where an EHR is
used to transmit the order for the beta blocker to the pharmacy, the
drug is dispensed, and a nurse administers the medication and documents
that in an electronic medication administration record.

Although it seems feasible in this situation to know which patient
received the beta blocker, difficulty lies in finding which patients are
*supposed* to receive it and which are not. Contraindications can be a
big challenge, for example, because:

-   There are many relevant medical record data sources

-   Few standards exist for clinical documentation, making analysis
    across charts difficult and across hospitals impossible

-   Often there are few linkages between ambulatory and inpatient
    records.

Ms. Anderson prepared a separate handout examining one multi-hospital
health system's consideration of automating quality reporting. The
handout included the following findings:

-   Of the data elements for quality measures evaluated, some 60 percent
    could be automated using the planned EHR system.

-   Another some 18 percent of the data elements could be partially
    automated.

-   The remaining percentage of data elements could not be automated,
    largely due to documentation requirements.

-   In the end, automating 60 percent of the data elements would result
    in automation of only four quality measures.

Ms. Anderson and her colleagues found similar problems elsewhere. In
short, there is a large gap between the adoption of EHRs and the
evolution of EHRs to support quality. She concluded by showing examples
of common barriers to automation that must be addressed to improve
quality of care and to streamline reporting.

*Comments/Questions/Discussion*:

There was discussion about designing the right kind of accountability
system and hoping the market works toward solutions, as opposed to
proscribing specific solutions. Points made included that certification
needs to ensure organizations have the basic IT tools needed to improve
on the front end and report on the back end. It was suggested that the
Workgroup explore the data elements needed for a standards-based system
focused on quality metrics.

There was further discussion of what is needed in quality measure
development and standardization processes to close the gap between EHR
adoption and EHR evolution to support quality, now and in the future. It
was pointed out that the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) has been active in this area. It was noted that
tension exists between credible, accepted quality measures and what is
feasible in terms of data.

There was further discussion of looking across data elements used in
different measurement projects to come up with data element standards,
in part to help vendors decide what to embed in EHRs that could be used
for multiple purposes. One member commented that harmonization of
measures is important, but also, and perhaps first, harmonization of
data elements needs to be addressed.

**D.** Theresa Cullen, Chief Information Officer, Indian Health Service,
focused on the Indian Health Service's (IHS) 25-year-old Resource and
Patient Management System (RPMS) in a presentation entitled "Measuring
Quality with EHRs" (the complete presentation is available at
<http://www.hhs.gov/healthit/ahic/materials/meeting10/qual/Cullen-IHSsystem.ppt>).

RPMS integrates multiple clinical systems into one database (PCC). PCC
functions as a health data repository. It has enabled electronic quality
reporting for 6 years through the Clinical Reporting System (CRS) on a
total of 350 clinical quality measures benchmarked to industry standards
(although most sites use only 30). Chart reviews have been eliminated at
a cost savings of \$57 million since 2002.

Dr. Cullen described how the CRS works, emphasizing that it uses
identical, programmed logic to ensure comparable performance data across
all IHS facilities. IHS also has developed standardized code sets that
are semantically interoperable to enable retrieval of data in a
consistent manner.

Dr. Cullen noted the following:

-   A list of IHS performance measures and a CRS fact sheet are
    available in a separate document. The performance measure list
    contains all the requirements and definitions of numerator and
    denominator, as examples.

-   The logic used for quality measures is the same logic that prompts
    health maintenance reminders for patients.

-   Improvement is tracked over time including in reports to providers.

-   Users also can run patient lists to help them, for example, to
    verify RPMS data against a patient's chart information or identify
    patients who need certain screenings and procedures.

-   Confidential patient lists also show how providers met a given
    measure over time.

-   CRS is adaptable; for example, although behavioral health datasets
    are not very standardized, IHS has developed internal codes for
    domestic violence and alcohol screening for female patients, with
    significant impact.

-   This Federal system is fairly robust, granular, and available for
    anyone to use for their own applications.

### 3. Co-chair's Summary 

Dr. Clancy summarized key themes from the presentations for the
Workgroup\'s consideration:

-   The Quality Workgroup should decide how to use the power of HIT and
    of the quality improvement community to drive progress without
    slowing down the momentum of AQA, Hospital Quality Alliance (HQA),
    and NCQA efforts.

-   In terms of standardizing data elements (Dr. Eisenberg's
    presentation), the Quality Workgroup should consider the potential
    overlaps between its charges and the work of other Workgroups, such
    as Biosurveillance. A starting point is AQA and HQA quality
    measures.

-   The Quality Workgroup should not proscribe solutions to flaws in
    current systems but, rather, focus on where the CCHIT can make a
    difference, to help reassure physicians and others making EHR
    investments that their purchases will assist quality improvement
    reporting.

-   Quality reporting is not just about accountability; it is not an end
    goal but rather a means to an end, quality ***improvement***.

-   The Quality Workgroup can build on recommendations in Ms. Anderson's
    presentation.

### 4. Next Steps

##### Action Item #2: Presentations from the Department of Veterans Affairs (VA) and possibly the Department of Defense (DOD) will be arranged. 

##### 

##### Action Item #3: Specific "Next Steps" to be pursued, including consideration of issues for CCHIT, will be communicated soon to Workgroup members. 

##### 

##### Action Item #4: The Quality Workgroup's presentation to the Secretary and to the Community at its October 31, 2006, meeting will be a progress report highlighting issues discussed in the Workgroup's first two meetings, including: 

##### Issues involving data and workflow

##### Issues involving capturing the right kind of data, including policy and/or regulatory considerations

##### Incentives for reporting electronic data

##### Data stewardship and control

##### Data storage and access.

##### 

##### Action Item #5: The ONC staff will create a framework chart of the Quality Workgroup's Specific Charge to enable tracking of gaps as they are discussed and resolved and to inform future the Workgroup\'s recommendations. 

##### 

##### Action Item #6: The Quality Workgroup's November meeting will focus on the visioning process, from ambulatory and inpatient perspectives, primarily for the mid-state (2010). 

##### 

##### Action Item #7: Dr. Clancy will report back on Agency for Healthcare Research and Quality (AHRQ) meetings next month on quality guidelines and translation into quality measures. 

### Quality Workgroup Meeting Schedule:

-   November 1, 2006, 1--4 p.m.

-   December 13, 2006, 1--4 p.m.

### 5. Public Comment 

No public comment was received.

## SUMMARY OF ACTION ITEMS: 

##### Action Item #1: The Quality Workgroup will ascertain the percentage or volume of care covered by the projection that 50 percent of practicing physicians will have EHRs by 2010, in part to be able to report back to the Community on potential impacts on quality for the near-term future. 

##### 

##### Action Item #2: Presentations from the VA and possibly the DOD will be arranged. 

##### 

##### Action Item #3: Specific "Next Steps" to be pursued, including consideration of issues for CCHIT, will be communicated soon to Workgroup members. 

##### 

##### Action Item #4: The Quality Workgroup's presentation to the Secretary and to the Community at its October 31, 2006, meeting will be a progress report highlighting issues discussed in the Workgroup's first two meetings, including: 

##### Issues involving data and workflow

##### Issues involving capturing the right kind of data, including policy and/or regulatory considerations

##### Incentives for reporting electronic data

##### Data stewardship and control

##### Data storage and access.

##### 

##### Action Item #5: The ONC staff will create a framework chart of the Quality Workgroup's Specific Charge to enable tracking of gaps as they are discussed and resolved and to inform future the Workgroup\'s recommendations. 

##### 

##### Action Item #6: The Quality Workgroup's November meeting will focus on the visioning process, from ambulatory and inpatient perspectives, primarily for the mid-state (2010). 

##### 

##### Action Item #7: Dr. Clancy will report back on AHRQ meetings next month on quality guidelines and translation into quality measures. 

##### [Quality Workgroup]{.underline}

**[Members and Designees Participating in the Web
Conference]{.underline}**

**October 11, 2006**

*Co-chairs*

Carolyn Clancy HHS/Agency for Healthcare Research and Quality (AHRQ)

Richard Stephens The Boeing Company

*ONC/OPC Director*

Kelly Cronin HHS/ONC

*Members*

Sunil Sinha (for Abby Block) HHS/Centers for Medicare and Medicaid
Services

Janet Corrigan National Quality Forum

(also Carol Ostrowski)

Helen Darling National Business Group on Health

Anne Easton Office of Personnel Management

Nancy Foster American Hospital Association

Jane Metzger First Consulting Group

Margaret O'Kane NCQA

Susan Postal Hospital Corporation of America

Gerald Shea AFL-CIO

Jonathan Teich Brigham and Women's Hospital

Reed Tuckson UnitedHealth Group

Floyd Eisenberg Siemens Medical Solutions, HIMSS EHR Vendor Association

(for Charlene Underwood)

Margaret van Amringe Joint Commission on Accreditation of Healthcare
Organizations

*Presenters*

Francois de Brantes Bridges to Excellence

Phyllis Torda NCQA

(for Greg Pawlson)

Kristine Martin Anderson Booz Allen Hamilton

Terry Cullen Indian health ServiceHS

Floyd Eisenberg Siemens Medical Solutions, HIMSS EHR Vendors Association

Louis Diamond Thomson MedStat

**Disclaimer:** *The views expressed in written conference materials or
publications and by speakers and moderators at HHS-sponsored conferences
do not necessarily reflect the official policies of the HHS; nor does
mention of trade names, commercial practices, or organizations imply
endorsement by the U.S. Government.*