**Problem Statement for the AHIC QWG Requirements Analysis**

**Problem Statement**

*What health information technology requirements, competencies, and
skill sets are needed to collect, aggregate and analyze longitudinal
measures that look at patient care quality across entire episodes of
care?*

**Potential Solution**

Current quality measurement efforts are based on measures, such as those
developed by the HQA and AQA, that are focused on evaluating the
delivery of care in one setting (i.e., inpatient, physician office,
etc.). These measures look at quality of care using a lens focused on an
individual ailment within an isolated encounter. As recognized in the
Quality Work Group (QWG) Vision, the health care community recognizes
the need to shift measurement from this siloed viewpoint to one that
will help assess quality of care across the spectrum of care settings
assesses quality from a longitudinal / episodic perspective.

**Proposal for Guiding QWG Efforts**

We propose that the QWG focus their efforts for the next six months on
identifying how health information technology can support longitudinal
measurement. This involves identifying how data could be collected,
aggregated, and analyzed in the future. This approach will help focus
QWG efforts to collect and analyze testimony and develop targeted
recommendations to the Secretary of HHS to ensure that health
information technology supports longitudinal measurement. More
importantly, it will help to inform public and private sector dialogue
about the alternative approaches for using technology to advance the QWG
vision.

One aspect of the quality measurement and improvement infrastructure
that can be addressed by looking at longitudinal measurement is the
integration of multiple data sources to inform measures. Currently, most
longitudinal quality measurement use claims data as a primary data
source. There are severe limitations with this approach as measures that
use claims data are limited in their clinical perspective and measure
results can only be applied retrospectively to achieve improvements in
care delivered in the future. As the industry increases its use of EHRs
and explores methods to integrate other data sources such as pharmacy
dispensing information, lab data, and data across organizations, there
will be a transition from predominantly sole-source measurement to
multi-source measurement. By focusing on longitudinal measurement, QWG
efforts can help define the critical path towards making this transition
from primarily sole-sourced to multi-source measurement. Our focus is on
defining the intermediate and long term states and identifying the
enablers and barriers to achieving this vision.

**Proposed Approach**

The scope of the requirements includes all diseases, however to guide
the initial stages of the requirements analysis we believe it will be
useful to choose sample conditions to make the conversations concrete.
We propose that the QWG select one acute and one chronic illness to
develop general business and high-level system requirements for each of
these two major categories of illness. These requirements will detail
how HIT can be used to help answer questions such as:

-   What methods could be used to identify patients that are included in
    populations under study for quality?

-   What methods could be used to collect information to inform
    longitudinal analysis? How should the numerator and denominator for
    longitudinal measures be defined? What role will claims data play in
    the future? Where is it most important to have clinical data from
    EHRs?

-   What methods could be used to aggregate this data? What types of
    competencies will be required? Could those competencies reasonably
    be found in the multiple communities?

-   What methods could be used to analyze it?

-   How can concurrent feedback be achieved? Episode construction is
    currently done through a retrospective analysis of claims data. In
    the future, could prospective and/or concurrent episode construction
    be possible due to more widespread use and functionality of EHRs?
    Could a feedback loop reasonably be used to create health system
    alerts to improve care before episodes are complete?

If QWG determines this approach is feasible, it can be further fleshed
out and used as a construct or framework that can guide and focus QWG
activities both in the immediate future and the longer-term.

Immediate efforts will focus on gathering enough requirements through an
environmental scan, interviews, and testimony to inform the
recommendations due to the Secretary of HHS in Fall 2007 and will be the
focus area for our first requirements analysis cycle. Subsequent
requirements analysis cycles will continue focusing on the topics
outlined above, looking at them through the lens of longitudinal
measures, but will focus on specific areas in more detail as dictated by
the QWG and by the amount of investigation required to develop sound
recommendations.

The longer-term analysis, i.e., the simulation or "what if" analysis,
will look at the quality measurement and improvement infrastructure and
help assess and recommend paths to achieve the envisioned future state
by looking at the use of varying options for the infrastructure.

**Appendix A: Example** **Scenario for Consideration -- Diabetes**

Longitudinal measurement is particularly important when considering
chronic illnesses, though there are also many cases where longitudinal
measurement is needed for acute care as well. Diabetes is an example of
a chronic illness where quality measurement from a longitudinal
perspective would significantly increase the ability to manage the
patient's treatment and ensure high quality care is being delivered.
Diabetes treatment is often provided by multiple physicians through
multiple visits, and in both inpatient and outpatient care settings. The
patient may have separate physicians for related eye exams, foot exams,
for monitoring blood levels, such as HbA1c. Additionally, the patient
may have been hospitalized due to diabetes-related complications such as
heart disease, stroke, kidney failure, blindness and/or circulation
problems.

Current diabetes care measurement only looks at treatment from a single
lens, either inpatient or outpatient, and focuses on only one aspect of
the full spectrum of treatment a diabetes patient may require. For
example, measurement of HbA1c control for an individual visit is useful,
but in order to really assess diabetes control, looking at HbA1c levels
over the course of the year can provide valuable information regarding
how well the patient is managing their illness and will help the
physician determine what course of actions to take to help control the
diabetes.