# American Health Information Community

# Quality Workgroup

# [DRAFT]{.mark}

# Summary of the 2nd Web Conference of this Workgroup

# Wednesday, January 9, 2007

## PURPOSE OF MEETING 

The principle purpose of this Quality Workgroup (QWG) meeting is to
review and discuss the Areas for Recommendations to the American Health
Information Community (AHIC), as designated in the March 6 draft of the
letter to the Secretary.

## KEY TOPICS 

### 1. Meeting Opening

AHIC Director Judy Sparrow opened the meeting by reminding participants
that the AHIC Workgroup (WG) meetings are conducted publicly.
Consequently, they are designed to meet the requirements of the Federal
Advisory Committee Act and therefore are broadcast over the Internet as
well as recorded and transcribed for later access via the publicly
available AHIC Web site.

Carolyn Clancy, Co-chair, announced that discussion would focus on the
recommendations to Secretary Michael O. Leavitt and the American Health
Information Community (AHIC). She noted that the deadline had been
changed to March 6 because of a scheduling requirement, and as a result,
they would have more time.

The QWG Meeting Summary for November 1, 2006, was approved without
changes.

### 2. Description of the Use Case Process

Kelly Cronin, U.S. Department of Health and Human Services, Office of
the National Coordinator (ONC), began a presentation on Use Case Process
by noting that many people are beginning to understand the process as
one that:

-   Articulates the needs of many systems or stakeholders

-   Provides context for certification, criteria, and processes

-   Gives context for policy discussions.

As a group, they have been trying to identify priorities. Ms. Cronin
explained that there will be discussion at the next meeting about
considerations for six or seven subcommittees. She explained that the
goal over the next six weeks is to take the larger set of priorities and
make it smaller and more manageable. In order to accomplish this, she is
seeking input from AHIC regarding which priorities are most critical.
Ms. Cronin shared her expectation that she will be getting direction
from the Community, which will shape the drafting process.

Ms. Cronin explained that ultimately, the current descriptions will
become a narrative description for use at a high level. Finally, the
more detailed version will be offered for public feedback.

### 

###### Comments/Questions/Discussion

Nancy Foster, American Hospital Association (AHA), noted that some
organizations already employ Use Case Process for quality improvement
and others are moving into that framework. She suggested that it might
be beneficial to consult with these organizations in order to glean
insights on how to improve documents.

Ms. Cronin agreed that this would be a good approach, but cautioned
against a "one-size fits all" mentality. While one approach may work for
one organization, it might not work for others. Consequently, she said
that it is necessary to balance the insight of individual organizations
against the larger context, as what happens in one institution or system
might not have external validity.

### 3. Discussion of Areas for Recommendations to the AHIC

###### A. The Addition of a Preamble

Ms. Clancy began the discussion of the Areas for Recommendations to the
AHIC by sharing the feedback and comments from Rick Stephens and Pam
French, who recommended adding a preamble or introduction at the
beginning of the letter. This would make the letter more accessible to a
reader unfamiliar with the WG.

Additionally, Ms. Clancy summarized Mr. Stephens and Ms. French's other
recommendations as follows:

-   Emphasize the critical importance of integration and alignment.

-   Speak to the use of information, both to inform consumers and to
    provide providers with feedback.

-   Revise language so that it will make sense to an outside reader who
    has little or no experience with the subject (Ms. Clancy noted that
    the preamble would help in accomplishing this).

Ms. French added that there were many people working on this, and that
it would need to be an iterative process that builds on the baseline.
She encouraged the WG to think about scalability. Additionally, she
noted that the document should be consumer friendly so that the
information can be disseminated to foster good discussions and smart
decisions about health care.

Ms. Clancy added that this letter becomes important in the public domain
because it synthesizes what the AHIC WG has accomplished and what they
aim to accomplish.

###### Comments/Questions/Discussion

There was some discussion of how the letter should emphasize consumer
choice and quality improvement. Margaret van Amringe, Joint Commission
on Accreditation of Healthcare Organizations, suggested that it might be
helpful to explain the WG's goals and directions in the preamble and
explain how these goals will benefit patients. She noted that the group
is working to do more than improve consumer choice; rather, they are
working toward quality improvement, which benefits even those consumers
who lack the freedom to choose among providers. For those areas where
performance data will not be as robust, the data will still benefit
clinicians, which in turn will benefit all patients. She urged that the
preamble equally emphasize both issues -- consumer choice and quality
improvement.

Ms. Clancy asked the group whether a national agenda is about consumer
choice, quality improvement, or combination or the two. She also asked
the group whether it was necessary to articulate their stance on the
subject in the letter.

Phyllis Torda, National Committee for Quality Assurance (NCQA), noted
that there was also an evolutionary aspect to their goals, and as people
adopt different technologies, the needs for information will change and
evolve.

Ms. Foster suggested that the letter articulate in a couple of sentences
that this effort is one of many meant to stimulate quality improvement
both by improving consumer choice and boosting quality. As such, it
plays an important role in the context of broader efforts.

Helen Burstin, National Quality Forum (NQF), suggested that the letter
provide concrete examples to help the reader better understand the
letter.

Jane Metzger, Rhode Island Hospital, suggested that the preamble allude
to one of the themes in the matrix -- the need for a unified national
agenda and a clear agreed-upon set of metrics for judging progress
against the agenda.

The group discussed the role of determining performance measures for
different specialties. One participant suggested that the letter
recognize the need to create different sets of metrics for different
specialties, rather than a one-size-fits-all approach. Ms. Metzger
answered that despite the need for specialization, the letter should be
very clear about the direction in which everyone should be headed on
general hospital performance. She noted that they would need a process
for generating a set of metrics that works for different specialties. Ms
Burstin agreed.

Ms. Clancy informed the group that the Centers for Medicare & Medicaid
Services (CMS) will be pushing a lot of the activity by virtue of
legislation, which offers an incentive to consider that option. She also
mentioned that they were working on adding a four- or five-page summary
to the visioning matrix, which attempts to tell a coherent story. She
asked the group to monitor their e-mails for an upcoming draft of the
summary.

> **Action Item #1:** ONC staff will circulate a draft summary of the
> Visioning Matrix via e-mail.

###### B. Highlighted Key Needs

Text: The WG's deliberations to date have highlighted a number of key
needs that must be addressed in the near term to meet the group's
specific charge, including the following:

1.  Automate data capture and reporting to support core sets of AQA
    clinician-focused and Hospital Quality Alliance (HQA) inpatient
    quality measures.

2.  Provide feedback to providers in real or near-real time.

3.  Enable data aggregation to allow public reporting of quality
    measures based on comprehensive clinical data that are pooled across
    providers and merged, as appropriate, with other data sources.

4.  Align performance measurement with the capabilities and limitations
    of health IT.

### 

###### Comments/Questions/Discussion

Ms. Clancy noted that of all the issues, #4 may end up being the most
challenging, because many groups that are developing measures,
especially from the physician community, are not thinking about data
needs when they are developing measures. On the other hand, she noted
that they may have an opportunity in working with them to encourage that
kind of synergy in the future. However, she pointed out to the group
that change would take time and that it would be an evolutionary
process.

Reed Tuckson, UnitedHealth Group, noted that the document should be
geared toward an average reader better and recommended adding background
about the issue.

Ms. Burstin asked if it would be possible to explain that aggregated
data are not always available, although they exist.

Ms. Clancy noted in response that this area of restricted data was
getting the most attention. She concurred that they need to allude to
the challenges in aggregating data from multiple sources. She also noted
that the Secretary has heard clearly that there is a need for access to
Medicaid data and that continued progress has been made.

Ms. Torda asked if the group wanted to make reference to CPT II codes,
or code sets that are a short-term solution designed to support quality
reporting.

Ms. Clancy questioned whether that would go into a preamble. She noted
that it would be helpful to a code reader, and said that she was open to
including CPT II codes.

###### C. Background and Discussion Section

###### Comments/Questions/Discussion

Ms. Clancy asked for comments on the background and discussion section
of the letter.

Ms. van Amringe noted that in the fifth item listed under identified
critical barriers and enablers, the letter uses the term "patient
identification system." She expressed her concern that this phrase might
be a red flag. She suggested that the letter be clarified to make it
clear that they are balancing patient identification against public
trust. Ms. Torda additionally noted that the list does not include
provider identification.

Ms. Foster asked if this was only intended for providers, or if it was
also intended to bring clarity to those groups who are developing
electronic health measures.

Ms. Clancy said that they would need to be explicit to the extent that
this functionality becomes part of the certification.

Jonathan Teich, Brigham and Women's Hospital, suggested adding a
paragraph that discusses key opportunities for AHIC.

###### D. Recommendation 1

Ms. Clancy began the discussion of the first recommendation by noting
that the letter quickly focuses on the purpose of the expert panel, as
well as who will serve on it. She noted that the WG should create an
expert panel to get extremely specific about analyzing data standards
and workflow changes. She suggested a target date near the end of July,
adding that they could not take any aspect of it lightly.

###### Comments/Questions/Discussion

Ms. Cronin expressed her concern that there was a risk of volunteer
burnout. She noted that if the expert panel is asked to do a lot of
work, it would be necessary to pay the members of the expert panel.

Ms. Burstin recommended that they make the dates and deadlines specific,
because people respond to deadlines.

Ms. van Amringe recommended that the group consider prioritizing a list
of data elements and specifying what data go with those elements.

Mr. Williams noted that he has been working with 66 hospitals to get
very specific data elements out of the hospital systems. In his
experience, the more specific the data are, the easier they are to
collect. He noted that even today, they have to bring data in-house and
clean them. At present, they do not have the infrastructure necessary
outside of the primary hospitals. Unless a hospital is affiliated,
getting data out is a major issue.

Ms. Metzger noted that she had expected that both the developers and
users of electronic health records (EHRs) would comment on any
implications down the road. She asked whether providers would be willing
to provide this information and what challenges EHRs might pose.

Mr. Williams asked if they would want to hard code the data into
electronic records, or specify where the data originate.

Ms. Cronin noted that they may be obligated to finish before July 21 in
order to begin the certification process. She said that they would
figure out internally what the latest possible date would be.

Mr. Rapp recommended that they clarify "EHR," as "automate the data
capture" implies that they may be referring to electronic health records
or something else.

Ms. Cronin noted that as Web-based methods of aggregating and capturing
data are adopted, it will be necessary to make sure criteria are
developed for EHRs. She recognized the need for a hybrid approach that
combined EHRs and health information networks.

Mr. Rapp asked if they would be using claims data supplemented by the
provider or going to the provider.

Ms. van Amringe asked if there were any issues with this area in
providing data in real or near-real time.

Ms. Cronin noted that confidentiality is important and that even in a
system, real time is difficult.

Ms. Cronin also asked how they would link across providers. They noted
that while patient identification within a setting is not a problem, it
becomes a problem when those data are being measured across providers.

###### E. Recommendation 2

Ms. Cronin opened the discussion of the second recommendation by
recognizing that there had been some discussion about privacy issues.
She asked if there are any other questions about how to link across
providers.

###### Comments/Questions/Discussion

Ms. Cronin noted that when it comes to CMS, there needs to be a clearer
legal framework for using their data outside of research and
demonstrations.

Mr. Teich suggested clarifying somewhere in the expert panel that they
are working to create something that does the best for each provider.

Ms. Foster suggested adding a bullet that discusses how capturing data
has to be integrated into decision support so that the clinician gets
the right support at the right time.

Ms. Metzger noted that it might better to use "assistance" rather than
"feedback" to avoid the negative connotation that "feedback" has. She
explained that feedback sounds retrospective, whereas the goal is to
provide decision support.

Jerry Osheroff, Thomson Healthcare, noted that most of the
recommendation deals with the issue of "who" rather than "when." He
asked if there should be a recommendation to tease out the "when."

Mr. Teich added that the recommendation did not seem to match up to the
explanatory paragraph. He suggested adding another recommendation in
order to get at the multiplicity of both aggregate data and decision
support.

There was a brief discussion of how to influence cultural change. Ms.
Cronin noted that competition has driven toward real-time data capture.
Meanwhile, physicians are more limited by claims. She asked if there was
a role for AHA to educate members. One participant noted that cultural
change cannot be mandated. Consequently, if the group wants providers to
implement EHRs and code concurrently, it would be necessary to influence
that to allow data capture. However, whether or not someone chooses to
fill it in would be difficult. Ms. Cronin suggested implementing a guide
book to facilitate this education.

Mr. Williams noted that several quality improvement organizations have
developed guidebooks in the past. He added that the real challenge was
getting people to use the information, and in order to facilitate this,
he recommended providing it in a more succinct fashion.

###### F. Recommendation 3

Ms. van Amringe began the discussion of Recommendation 3 by noting that
they may want to reword the statement immediately following the
recommendation, which reads:

> "There is wide agreement that there should be only one quality score
> per clinician or hospital for each measure in a time period. In other
> words, neither clinicians nor patients should receive mixed signals
> about an individual clinician or hospital's performance. Data
> aggregation is required to support the uniform measure of quality
> across providers."

She noted that they may need to pool and merge data for accurate
readings on particular measures. Otherwise, if they cannot link data,
then they will have different measures and will not gain a true picture
of performance.

###### Comments/Questions/Discussion

There was some discussion of how these measures might affect preferred
provider status. Ms. Burstin responded that she understood that there
was a mismatch to the bullet. She added that her group has employers who
have employees all over the country. Many of these employees worry that
measures may lead some providers to be preferred who do not seem
preferred. Ms. Cronin noted that in both the proceeding paragraph and
the recommendation, it is important to make sure that they are not
assigning a quality score for the purpose of stratifying preferred
providers.

Ms. Cronin also asked if there was anything else that they would need to
specify, and if there should be a recommendation to make sure that
information is available to consumers via Web-based servers. She noted
that there needs to be a combination of sources to ensure that data are
reliable.

Ms. Burstin mentioned that they will be judged both by consumers and
providers of care. She mentioned that it would be important to build in
and recognize the work of other organizations, like NCQA, who have been
working with researchers on how to communicate more effectively and how
to design social marketing that leads behavioral change. She added that
it also would be worthwhile to develop along parallel paths with these
other organizations.

Mr. Teich noted that if the group sets up "providing cogent feedback to
consumers" as a goal, they need to acknowledge that they do not know how
to do this yet. He suggested recognizing in the letter that there is a
desire to provide feedback to consumers. Several participants commented
on this point. Ms. Cronin summarized the commentary by suggesting that
they expand Recommendation 3.1 to recognize the importance of consumer
needs in gaining meaningful output, as well as the fact that it is still
to early to specify how to do that in terms of the needed technology and
aggregation methods.

John Loonsk expressed his concern that, from an architecture standpoint
relevant to data aggregation, Recommendation 2 specifically identifies
data aggregation, and Recommendation 3.1 suggests that data aggregation
needs should be fully teased out. He questioned whether or not this is a
good ordering. He also suggested that they clarify whether
Recommendation 3.1 poses articulation as a functional need or a
conclusion.

Ms. Cronin noted that they need to work on the wording. However, she
added that there is no intention of trying to create goals that cannot
be implemented in the next year. There is an opportunity to start
figuring out how to demonstrate how some data (namely, meds and labs)
could be integrated with claims. She added that it could be a
complementary process that CMS would be involved with.

Ms. Cronin noted that one of the core questions here is whether or not
exchange and aggregation should be combined. While quality measurement
and reporting require aggregation, there are many other functions that
are supported by data exchange that do not. She noted that if a patient
identification process occurs, it should be leveraged across both
efforts to prevent the duplication of efforts. Ms. Cronin suggested
refining the language around the Nationwide Health Information Network
(NHIN) process, as well as the nomenclature.

In 2008, there will be a process started to identify criteria for
certifying what will become the NHIN service providers. As a result,
network providers that are enabling exchange will have to go through the
same process for ambulatory and inpatient procedures. The idea is that
all of these systems are going to connect with each other if they have
to go through a certification process.

###### G. Recommendation 4

Ms. Cronin introduced the fourth section by explaining that it is a
high-level recommendation and as a result, it needs to be more specific.
She asked for input on how to refine the recommendation to make it
meaningful so that it will result in tangible coordination among various
organizations. This coordination is critical to making both quality
measurement and health IT interoperability possible.

###### Comments/Questions/Discussion

Mr. Osheroff explained that initially, there were questions about which
place was the best for measure developers to intersect with data needs.
As a result, in the first version, they were very specific in the
testing process. However, some people felt that this was too specific.
As a result, there were questions about how to advance this dialogue.

[]{.mark}

Ms. van Amringe mentioned that there is a cadre of core data element
surrounding this issue. She added that they should encourage measure
developers to use those elements without creating new ones.

One participant asked the best place for data needs to intersect with
measures. He noted that at a higher level, there are some questions
about the most logical places to think about data.

Ms. Foster noted that Janet already has started down the path with the
NQF and has reached out to measure developers to begin to talk about the
elements that ought to be commonly used. This should make many aspects
of automation more practical.

Ms. Clancy commented that the Agency for Healthcare Research and Quality
(AHRQ) would be comfortable taking on the role of convener. She
explained that the real challenge is figuring out where they are in the
process, who needs to be involved, and who has been funding some of the
measure developments. Convening and offering feedback is a critical part
of that process.

Ms. Torda noted that sometimes measures are used as statistics rather
than for granular reporting. She expressed her concern that some
providers might use the measures to judge whether everybody passes them
or not. She added that implementation details can affect specifications
or measures, and this makes it difficult to determine whether a specific
measure should be used for all purposes and all settings.

One participant asked if a measure has to specify which data sources
should be used. There are a number of characteristics that need to be
specified in order for something to be useful as a measure. Ms. Cronin
asked whether the specification should be flexible, given the
environment in which it might be implemented (e.g., when electronic data
are more readily available, can they follow different specifications
than when claims data are more available?).

Ms. van Amringe noted that if they are successful with the first set of
recommendations, then they will have fodder to provide measure
developers as they look at and try to align their work. She said that
ideally, when NQF provides guidance and criteria, the changes to data
can be automated.

A participant noted that right now, measure developers have the luxury
of not worrying about whether things are easily coded and captured
electronically. If they want to move to an electronic data capture
state, some of the richness of quality measures disappears.

Ms. Clancy responded that entrepreneurs will figure out how to solve
this problem. However, she did not know whether the entrepreneurs would
figure out how to solve it in a way that reflects the interest of
multiple stakeholders and that comes up with a transparent methodology.
One option suggested was to make a general statement that NQF was
working to address the problem.

One participant clarified that they had previously discussed using the
expert panel to try to accomplish Recommendation 4 and become more
specific in Recommendation 4. In Recommendation 1, they could go back
and look at current measures and identify the information necessary to
make data electronic. They could use funding to encourage measure
developers to follow this.

Ms. Clancy asked what the output would be. She expressed her concern
that there might be multiple trails. She also noted that this was an
opportunity for shared leadership. She added that the WG would need the
support of professional groups to gain legitimacy.

Following Ms. Clancy's discussion of legitimacy, there was a discussion
of the usefulness of a template. One participant suggested that output
might serve as a template for what needs to accompany a measure in order
to accomplish the purpose of each step. It would help narrow the scope
to offer a template for a measure that could be automated. The template
could be sensitive to different environments. Ms. Clancy noted that this
template would be reasonable not only at the back end, but also at the
front end. A template would help them to recognize when they are using
an element that has no standard. Another participant noted that a
template fits in with how this is going to be redesigned.

A second discussion arose regarding who should weigh in on the template.
Ms. Clancy noted that the legitimacy issue becomes very important and a
lack of guidelines can be a real problem. Another participant noted that
all of the previous measures that the WG had considered required
substantive clinical literature to support the impact on quality. In the
absence of a guideline, a tangible clinical consensus from an expert
panel is required.

### 4. Recap of action items from today's meeting 

Ms. Clancy announced that they will be sending out a summary of the
Visioneering Matrix electronically. She asked the WG for comments either
embedded in the documents or simply as text in e-mail.

### 5. Public Comments

There were no public comments.

### 6. Adjourn

Ms. Clancy thanked the group for their comments and discussions. She
told the group it was good that not all of the issues were settled.

**SUMMARY OF ACTION ITEMS**

> **Action Item #1:** ONC staff will circulate a draft summary of the
> Visioning Matrix via e-mail.

**MEETING MATERIALS**

Agenda

Draft Recommendation Letter for AHIC

Draft Visioning Matrix

Overview of Public-Private Measure Automation Efforts

Draft Recommendation to AHIC - Slides

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

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

*Co-chairs*

Carolyn Clancy AHRQ

Pam French (for Richard Stephens) The Boeing Company

*Staff Co-chair*

Kelly Cronin ONC

Helen Burstin NQF

Anne Easton Office of Personnel Management

Nancy Foster AHA

Michael Kaszynski Office of Personnel Management

John Loonsk ONC

Jane Metzger Rhode Island Hospital

Jerry Osheroff Thomson Healthcare

Carol Ostrowski NQF

Michael Rapp CMS

Susan Postal Hospital Corporation of America

Sunil Sinha CMS

Jonathan Teich Brigham and Women's Hospital

Phyllis Torda NCQA

Reed Tuckson UnitedHealth Group

Margaret van Amringe Joint Commission on Accreditation of Healthcare
Organizations

Josie Williams RCHI

#  

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conferences do not necessarily reflect the official policies of the
DHHS; nor does mention of trade names, commercial practices, or
organizations imply endorsement by the U.S. Government.*