# American Health Information Community

# Quality Workgroup

# Summary of the Eighth Web Conference of This Workgroup

# Thursday, May 3, 2007

## KEY TOPICS

### 1. Call to Order

The Web conference was called to order at 12:39 p.m. Participants were
reminded that this Quality Workgroup (QWG) meeting, like all American
Health Information Community (AHIC) Workgroup meetings, is designed to
meet the requirements of the Federal Advisory Committee Act.

### 2. Welcome/Opening Remarks/Acceptance of Meeting Summary

QWG Co-chairs Carolyn Clancy and Rick Stephens welcomed participants.
Dr. Clancy noted that the QWG is transitioning to work on its Broad
Charge and that this meeting's presentations will provide context for
the QWG's next steps, which Mr. Stephens will address after the
presentations. The March 27, 2007, QWG meeting summary was accepted
without changes.

### 3. Update on AHIC Ad Hoc Subgroup on Clinical Decision Support (CDS)

Kelly Cronin noted that the QWG's Broad Charge addresses advancing CDS.
Also working on aspects of CDS are the Personalized Healthcare,
Population Health and Clinical Care Connections, and Electronic Health
Records (EHR) Workgroups. To help organize these efforts, the Subgroup
has been asked to think through key focus areas for each Workgroup
building on related work by the Department of Health and Human Services
(HHS) Agency for Healthcare Research and Quality (AHRQ), the HHS Office
of the National Coordinator (ONC), the American Medical Informatics
Association (AMIA), and other members of the health information
technology (HIT) community.

The CDS Subgroup will meet May 4, 2007, to discuss next steps. We will
provide updates to QWG members on the CDS Subgroup's work. The QWG then
may be given the opportunity to present to AHIC its plans over the next
year for advancing the translation of quality measures and data to CDS
and patient empowerment in conjunction with these other groups' efforts.

### 4. Testimony on Data Infrastructure Requirements -- Data Aggregation

###### A. Provider Perspective

###### B. Payer Perspective

###### C. Regional Collaborative Perspective

*A. 1.* Ron Paulus, Chief Technology and Innovation Officer, Geisinger
Health System, gave a slide presentation titled "Data Infrastructure
Requirements: From 'Data' to Clinical Transformation" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/paulus.ppt>).

*Summary:* Geisinger Health System's goal is to use HIT to re-engineer
the traditional clinical decision hierarchy by altering traditional
clinical workflows and helping patients and their families make many of
the decisions made today by physicians. At present, data are generated
from some three million fully integrated EHRs, claims data, and relevant
operations data and sent to a Clinical Decision Intelligence System,
which aggregates and standardizes the information for performance
measurement and analysis among other uses. From there, relevant
information can be sent to "effector arms," such as alerts, prompts,
order sets, and automated care plans, through a decision support engine
still under development. Reporting and feedback loops help incentivize
best practices. Examples of quality improvement successes in diabetes
care, vaccinations, and coronary artery bypass surgery were given.

*A. 2.* J. Michael Kramer, Chief Medical Information Officer, Trinity
Health, gave a presentation titled "Clinical Decision Support to Assist
Clinician Delivery of Evidence- Based Care: Experience from the Nation's
Leading Electronic Medical Record (EMR) Implementation at Trinity
Health" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/kramer.ppt>).

*Summary:* Trinity Health currently has a primary EMR for more than 4
million patients, 50 percent of patients registered in Trinity's system.
Inputs into the current data warehouse include financial,
administrative, and clinical data. At present, quality data collection
on about 30 measures is largely retrospective and manual. Turning
retrospective quality data collection and review into real-time care
faces many challenges, including identification of patient clinical
conditions. Trinity has found surrogates useful, however, and is working
on incentives for improved physician reporting. Standardized terminology
such as SNOMED is needed to help provide clear, recognizable quality
definitions that can be made discrete in the EMR; physicians need
incentives to provide in a more usable form a large percentage of the
data required to assess inpatient care quality; quality definitions need
to be less complex for ease of abstraction from the EMR; and underserved
communities will need assistance to benefit from HIT systems capable of
handling collection of multi-source data.

###### Provider Perspective Comments and Questions

Responding to questions, Dr. Paulus noted that productivity, efficiency,
and quality gains lie at the heart of what Geisinger is trying to
achieve by leveraging technology for clinical transformation; that
Geisinger is actively trying to share its approach with other practices
and hospitals in its region; and that while having an electronic
infrastructure measure, monitor, and help enable quality care is a
fundamental business decision for large or medium-sized organizations,
smaller organizations and physician practices will need help such as
turnkey services from vendors and incentives.

Dr. Paulus also noted that enablers of the Geisinger system have
included leadership from within the company, the group practice model,
and community trust building; that barriers have included lack of
broadband connectivity in rural areas; and that the system's largest
data deficit lies in histories and dictated text data. Specific methods
of capturing the most important data with the least amount of effort are
currently under review.

There was discussion of barriers to translating evidence into practice,
including the possible need to re-engineer quality measures as well as
to address traditional clinical work flows. Responses to Michael Rapp's
query about hospital-physician cooperation in reporting measures
included a theory that as more physicians see the value of electronic
reporting, they may be more willing to use hospital information systems
to help them report.

Responding to questions about the percentage of data elements needed for
quality measures resides in EMRs, Dr. Kramer noted that at Trinity, the
percentage is probably higher than for most organizations because
nursing documentation, medication orders and medication administration,
and intake assessment process are all discrete and electronic data.

Discussion about provider interest in using regional data aggregation
led to the conclusion that standardized data sharing agreements for
quality measures might stimulate more use of Regional Health Information
Organizations.

*B. 1.* Shirley Lady, Vice President, Business Informatics, Blue Health
Intelligence (BHI), gave a slide presentation titled "Blue Health
Intelligence: Better Knowledge for Healthier Lives" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/lady.ppt>).

*Summary:* The BHI health data warehouse may become the largest in the
health care world, with 79 million patient representations expected by
mid-2008. It was built and co-funded by Blue Cross Blue Shield (BCBS)
plans across the country (with more plans expected to join, including,
possibly, smaller plans) as a result of demand, including by employer
groups. The warehouse currently collects only de-identified patient data
for the purpose of reporting back to plans and developing benchmarks to
support local and national accounts aggregated at different statistical
levels. Data can be adjusted by a number of codes, including Standard
Industrial Classification codes. Data are not sold at present. Rules for
research access will be considered in the future. The warehouse
currently contains medical claims, enrollment, and some provider data,
with a pharmacy and quality indicators data phase scheduled for
completion in the near future. Standardization of data through common
definitions and common data elements is deemed essential. Goals include
improving customer reporting, understanding the relative performance of
providers, strengthening pay for performance programs, and developing
more effective care management interventions. Challenges include size,
funding, complexity, and an aggressive time line.

*B. 2.* Carol Wilhoit, Medical Director, Quality Improvement, BCBS of
Illinois (BCBSIL), gave a slide presentation titled "Data Infrastructure
for Quality Improvement" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/wilhoit.ppt>).

*Summary:* BCBSIL quality improvement data are organized around three
focus areas: health maintenance organization medical groups and IPAs,
physicians in the preferred provider organization (PPO) and BlueChoice
networks, and hospitals. Quality improvement initiatives, data needs and
infrastructure, and reporting challenges differ for each focus area.
Claims data, the richest source of data, are used to look at a variety
of quality indicators, as are pharmacy data. These data are aggregated
in an Electronic Data Warehouse (EDW). Other data sources include IPA
encounter data and Medicare data aggregated with claims data for
assessment of hospital-specific complication rates using AHRQ
indicators. Data aggregation supports business functions such as
provider feedback, quality improvement, and public and Health Plan
Employer Data and Information Set (HEDIS) reporting. Hybrid reporting is
used for a variety of purposes. A Web-based application to allow PPO
physicians to supplement claims data with medical record data is
planned. Barriers include limited ability to add new data elements to
the EDW, difficulty in obtaining complete encounter data and compiling
them into a consistent format, possible difficulty in achieving accurate
provider data entry into medical records, and significant reporting
challenges for physicians providing recommended preventative care.

*B. 3.* Michael Rapp, Director, Quality Measurement and Health
Assessment Group, Office of Clinical Standards and Quality, HHS Centers
for Medicare and Medicaid Services (CMS), gave a slide presentation
titled "2007 Physician Quality Reporting Initiative (PQRI): Module 2 --
Preparation and Participation Strategy for Successful Reporting" (see
also <http://www.hhs.gov/healthit/ahic/materials/05_07/qual/rapp.ppt>).

*Summary:* PQRI focuses on quality of care through use of evidence-based
measures and financial incentives for Medicare physician (and other
clinician) reporting starting in 2007. Participation benefits include
confidential feedback, bonus earning potential, and preparation for the
eventuality of pay-for-performance and public reporting. The list of 74
quality measures used can be viewed at
[www.cms.hhs.gov/PQRI](http://www.cms.hhs.gov/PQRI). The reporting
system is primarily claims-based, using CPT Category II codes for
quality, with potential for eventual use by the private sector.
Reporting thresholds and bonus payment calculations are set by statute.
Proposed quality measures for 2008 will be published by August 15, 2007.
By statute, they must be endorsed or adopted by consensus; include
measures submitted by specialty; and address structural aspects, such as
use of EHRs. CMS initiatives for 2008 include possible use of registries
to reduce reporting burden.

###### Payer Perspective Questions and Comments 

Responding to questions, Ms. Lady clarified that "de-identified" data in
the BHI warehouse means that encounters, including dates, are encrypted
and while they can be identified as a unique encounter, they do not
include the individual patient's name. Data can be re-identified for use
by health plans and providers for patient management purposes. She
confirmed that identifiers in the warehouse dataset permit linking of
different episodes of care but that the information is encrypted. She
also confirmed that the project will have geographic variations analysis
capability in the future.

Responding to questions, Dr. Wilhoit noted that BCBSIL is close to
making a decision not to include preventive care in evaluations of
costs; that physicians are not providing additional data from medical
records quite yet, in part because data received from the IPAs is of
high quality; and that the vendor-built database BCBSIL has for MEDPAR
and Blue Cross data works well for providing valid complication rates
for most hospitals across the State.

Responding to questions, Dr. Rapp noted that PQRI 2007 data will be
collected from July 1, 2007, through the end of February 2008 and that
CMS will ensure that requirements, such as reporting 80 percent of
cases, are followed.

*C. 1.* Micky Tripathi, President and Chief Executive Officer,
Massachusetts eHealth Collaborative (MAeHC), gave a slide presentation
titled "Massachusetts eHealth Collaborative" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/tripathi.ppt>).

*Summary:* MAeHC, an independent nonprofit launched with \$50 million
from BCBS and assistance from the American College of Physicians, has
wired three Massachusetts communities for health care delivery pilots
involving some 500 physicians and 500,000 patients. The project's first
phase, of clinical IT and implementation support (involving EHRs,
systems integration, workflow redesign, and decision support), is
underway, with stand-alone information exchanges in each community to
connect physicians and hospitals in real time scheduled next and quality
measurement to follow. Vital information from EHRs will reside in each
exchange only with patient permission. Limited datasets with random
unique identifiers will be extracted from the exchanges for a Quality
Data Warehouse (QDW) to provide outcome analysis and benchmarking of
data for physicians using the AQA Alliance starter set of measures.

*C. 2.* Betsy Clough, Director of Operations, Wisconsin Collaborative
for Healthcare Quality (WCHQ), gave a slide presentation titled
"Wisconsin Collaborative for Healthcare Quality" (see also
<http://www.hhs.gov/healthit/ahic/materials/05_07/qual/clough.ppt>).

*Summary:* The WCHQ is a voluntary consortium of health care
organizations representing 40 percent of all physicians in the State
dedicated to building a set of ambulatory measures to enable medical
groups and health systems to collect and report quality care data using
medical group data on all patients (even absent EHRs). A three-question
model was developed from which denominators can be derived completely
electronically from existing administrative data. Six measures are being
publicly reported at present at the physician group level via the Web
(for diabetes; high blood sugar; breast, cervical, and colorectal cancer
screening; and postpartum follow-up). Moving forward, other measures
will be added and registry-based submission of denominators will be
possible. Lessons learned include that measures must be easy to
interpret in practical ways to improve health care designs.

###### Regional Collaborative Perspective Questions and Comments

Responding to questions, Dr. Tripathi noted that the percentage of
patients who have given permission given for their data to be accessed
has been very high, that MAeHC does not know yet if data from EHRs and
the information exchanges will be complete enough for quality
improvement purposes, that building a program for integrating claims
data at the QDW level is part of a long-term vision, and that MAeHC
plans to contract out outcomes analysis and public reporting. He agreed
to provide information in the future on what MAeHC learns about the
common data elements across its quality measures.

Responding to questions, Ms. Clough noted that the WCHQ represents all
the large and most of the medium-sized practices in the State and is
conducting a pilot with smaller practices to understand their needs;
that physicians pay WCHQ to participate; and that one effect that the
WCHQ system seems to be having is the encouragement practices to band
together to request data on their patients from external vendors, such
as from external labs or PBMs.

### 5. Workgroup Discussion of a Systematic Process for Realizing the End-State Vision

Mr. Stephens began the discussion by noting that the QWG leadership is
interested in developing a process for realizing the QWG's end-state
vision that takes into account stakeholders' disparate motivations in
improving health care quality and what various stakeholders, such as
those present today, already have in place and plan for the future.

Key steps to consider moving forward are as follows:

1.  Conduct an environmental scan of, for example, data infrastructure
    requirements and the needs of various stakeholders.

2.  Look at various concepts and drivers that already exist.

3.  Develop an approach for collecting and analyzing data.

4.  Link key requirements together based on priority needs.

5.  Craft a systemic process.

Mr. Stephens indicated that the co-chairs would provide updates as the
process was further developed so that QWG members would have the
opportunity to provide input and feedback.

### 6. Recap of Testimony and Workgroup Discussion on Common Themes for Addressing Data Infrastructure Requirements (Emphasis: Barriers, Enablers, and Lessons Learned for Methods for Data Aggregation; Workflow Issues; and Episodes of Care)

Mr. Stephens asked QWG members to discuss key points and critical areas
from today's testimony, particularly issues, such as barriers.

Responses included the following:

-   Pay close attention to barriers and lessons learned from today's
    presentations.

-   Standard terminology and data elements are critical to move towards
    HIT-enabled quality reporting

-   Look at what data streams are electronically available for quality
    measures and reporting (including, but not limited to, EHRs).

-   Look at data collected in typical EHRs and how those data elements
    could be used to drive quality reporting.

-   Look at data elements as required input into the measure development
    process.

-   Look at workflows in the translation of quality measures to improved
    health care.

-   Recognize the potential outcomes of QWG recommendations already
    advanced to AHIC.

-   Specifically acknowledge the Quality Alliance Steering Committee's
    current task of identifying common data elements in a core set of
    measures and the follow-up processes of the HIT Standards Panel's
    establishment of interoperability standards for those data elements
    and of Certification Commission for HIT development of concomitant
    certification criteria. (It was noted that the Committee is also
    expected at some point to address workflow issues.)

-   Take hybrid data systems into consideration for an interim period,
    in general, driven in part by the possible need for a variety of
    demographics data sources.

-   Attain some type of open and broadly achieved national consensus on
    the process to be followed for improving health care quality through
    HIT across the country.

### 

### 7. Public Comments

Angela Jeansonne, American Osteopathic Association, commented that the
meeting reflected a "real understanding" of smaller practices; the
issues they face in terms of cost, burden, and interoperability; and
their need for outreach.

## Adjourn

Mr. Stephens noted that the next QWG meeting will take place June 22,
2007, at 1:00--4:00 p.m., and he adjourned today's meeting at 4:30 p.m.

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

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

*Co-chairs*

Carolyn Clancy AHRQ

Richard (Rick) Stephens The Boeing Company

*ONC Director*

Kelly Cronin

*Members and Alternates*

Janet Corrigan, Helen Burstin, and National Quality Forum

Carol Ostrowski

Helen Darling National Business Group on Health

Anne Easton and Michael Kaszynski U.S. Office of Personnel Management

Nancy Foster American Hospital Association

Jane Metzger First Consulting Group

Susan Postal Hospital Corporation of America

Jonathan Teich Brigham & Women's Hospital

William Tierney Regenstrief Institute, Inc.

Phyllis Torda National Committee for Quality Assurance

Reed Tuckson UnitedHealth Group

Charlene Underwood Siemens Medical Solutions and Healthcare Information
and Management Systems Society EHR Vendors Association

Margaret Van Amringe Joint Commission

*Senior Advisors*

Theresa Cullen Indian Health Service

Jerry Osheroff Thomson Healthcare

*Presenters*

Betsy Clough Wisconsin Collaborative for Healthcare

Quality

J. Michael Kramer Trinity Health

Shirley Lady Blue Health Initiative

Ronald A. Paulus Geisinger Health System

Michael Rapp CMS

Micky Tripathi Massachusetts eHealth Collaborative

Carol Wilhoit BCBS of Illinois

**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 HHS; nor does
mention of trade names, commercial practices, or organizations imply
endorsement by the U.S. Government.*