# American Health Information Community

# Quality Workgroup

# 

# Summary of the Sixth Web Conference of This Workgroup

# Wednesday, February 7, 2007

## 

# PURPOSE OF MEETING

-   Update on AQA measures

-   Discussion of draft Letter of Recommendation for the March 13, 2007,
    American Health Information Community (AHIC) meeting

-   Discussion of future meeting topics

# KEY TOPICS

### 1. Meeting Opening

*Federal Advisory Committee Act (FACA)* **--** Judy Sparrow, Director of
AHIC, opened the meeting by noting that AHIC Workgroup meetings are
designed to meet the requirements of FACA. Therefore, they are open to
the public and are publicly broadcast over the Internet, as well as
recorded and transcribed for later access via the publicly available
AHIC web site.

*Opening Remarks* -- Quality Workgroup (QWG) Co-chair Dr. Carolyn Clancy
noted that the date of the next AHIC meeting has been moved to March 13,
2007. She will present the QWG's Letter of Recommendation and the QWG's
future scope of work at that time.

Dr. Clancy stated that she would need to step out of the meeting for a
while, and requested that Ms. Nancy Foster act as co-chair during that
time.

*AQA Measures Update* -- As context to her update on the AQA measures,
Dr. Clancy noted changes that have been promulgated in physician
reimbursement by Medicare. Beginning July 1, 2007, instead of a
reimbursement cut, physicians will receive a 1.5 percent increase in a
lump sum payment when they report on a subset of quality measures by
physician specialty by the end of the calendar year. This change could
affect the majority of the nation's approximately 700,000 physicians,
and it has focused new attention on quality measurement.

This development is relevant to AQA measures because, when the QWG first
began its work, discussions centered on a starter set of 26 AQA
measures. Since then, AQA has adopted a number of other measures, some
of which were already in use by, for example, the Society of Thoracic
Surgeons, and some of which were brand new. These measures are
generating interest within the physician community about what quality
measures are measuring -- competence, high performance, or a combination
thereof. These developments will inform the work of the QWG as it moves
forward by helping the QWG focus on (1) a potentially expanded subset of
AQA-supported measures, (2) building functionality to collect data to
inform these measures into Electronic Health Records (EHRs), and (3)
developing a hybrid strategy for data aggregation in the absence of
widespread availability of EHRs.

### 2. Discussion of the Draft Letter of Recommendation for the March 13, 2007, AHIC Meeting

###### **Opening Paragraphs of the Draft Letter of Recommendation**

The opening paragraphs reiterate the QWG's broad and specific charges
and then note the urgency of developing "a common framework aligned with
a variety of organizations to ensure that scalable approaches to quality
measurement and reporting are adopted."

Ms. Foster commented that the first paragraph after the specific charge
contains language, such as "scalability," that the broader community
might not understand, and she suggested some editing to make the meaning
clearer.

#### Ms. Margaret VanAmringe suggested that the paragraph opening with "Success of the Workgroup..." contain references to hospitals as well as consumers and clinicians. 

###### **Recommendations Section**

###### Discussion of Contextual Text for Recommendations 1.1, 1.2, and 1.3

Dr. Clancy noted this contextual text includes a general discussion of
automating data capture and reporting from EHRs to support a core set of
AQA clinician-focused and Hospital Quality Alliance (HQA) inpatient
quality measures. She explained that use of the word "clinician-focused"
is meant to convey the likelihood that measures for clinicians who are
not medical doctors will emerge from AQA in light of Centers for
Medicare & Medicaid Services (CMS) work on new "pay for reporting" rules
that will apply to, for example, nurse practitioners. Nurse
Practitioners have already been developing quality measures in
conjunction with the American Medical Association (AMA) Physicians
Consortium.

It was noted that HQA has promulgated outpatient as well as inpatient
quality measures and, therefore, "inpatient" should be deleted from the
contextual text and "hospital-related" substituted.

###### Discussion of Recommendation 1.1

Dr. Clancy noted that, under a National Committee for Quality Assurance
(NCQA) and AMA Physicians Consortium initiative partially supported by
CMS, work has begun on creating a map of data elements for some quality
measures. However, the QWG believes it is critical that a prioritized
set of measures be identified and that the Quality Alliance Steering
Committee is the appropriate entity to name in the recommendation, as it
has already tackled some of the issues involved.

Ms. Charlene Underwood opened a discussion about the recommendation and
the need for data elements prioritization. Ensuing discussion points
included how some of the needed data elements might cut across multiple
measures; the need for the expert panel to collaborate with CMS; the
strong possibility that because of the current National Quality Forum
(NQF) endorsement process, the AQA measures that will be deemed most
important should be known soon, including those that pose particular
data challenges; and the sense that it might be beneficial for the
expert panel to decide on a mix of measures that need to draw on many
different kinds of data.

How all of these efforts could result in improved measure development
and implementation was also discussed. Janet Corrigan noted that the NQF
is meeting monthly with major measure developers to discuss more common
approaches to or guidelines for how measures are developed and that the
next step could be to involve EHR representatives in the discussion. It
was decided that the recommendation's language be altered to reflect the
discussion.

##### **Action Item #1: QWG discussion about Recommendation 1.1 will be addressed by altering the recommendation's language to reflect the discussion.**

There was discussion of whether the new expert panel's work should
include workflow issues and health information exchange (HIE). Dr.
Clancy commented that in the near term (perhaps five years), a hybrid
strategy for data collection that includes, but does not wholly depend
upon, EHRs will likely be needed. She said she may elaborate on the
concept of a hybrid strategy for data collection in her presentation to
the AHIC on March 13, 2007.

Ms. VanAmringe suggested that when the expert panel begins to construct
a list of data elements and identify needed harmonization, it should
also make recommendations about data element standardization, including
formatting, and forward those recommendations to the Health Information
Technology Standards Panel (HITSP).

Ms. Susan Postal noted that the American Health Information Management
Association (AHIMA) is analyzing data elements by measure and also by
data gaps. Dr. Clancy indicated that Office of the National Coordinator
(ONC) staff may follow up with AHIMA to learn more.

###### Discussion of Recommendations 1.2 and 1.3

Ms. Underwood mentioned the need for data standards to be tested before
certification criteria are decided upon and issued to the EHR vendor
community. At issue, in part, is timeliness, as brand-new standards need
to be on the CCHIT's road map for 18 months. Dr. Clancy concluded that
it might be important to clarify QWG expectations, and CCHIT's process
and timelines in the presentations at the AHIC meeting on March 13,
2007.

##### Ms. Foster observed that the work emerging from the first two recommendations could inform the NQF's ongoing efforts on measures development standardization and asked if a new recommendation to this effect should be crafted. Dr. Janet Corrigan agreed that it is critically important for quality measurement data standards and certification to be closely coordinated with the work of measurement developers. She added that in Dr. Clancy's presentation to the AHIC, it also will be important to stress that such coordination on an initial core set of measures is a first step, given that other measures will come down the pipeline that pose different challenges, such as episode of care measures and composites. 

###### Discussion of Contextual Text for Recommendation 2.1

Dr. Clancy paraphrased the two paragraphs of context preceding
Recommendation 2.1, which address using evidence-based medicine to
provide assistance and feedback to providers for clinical decision
support in real or near-real time. The section notes that clinical
decision support today is hampered by the same challenge as
retrospective quality measurement; i.e., the lack of standards for data
capture, which impedes the timely identification of patients for
recommended interventions. However, there are opportunities to leverage
(1) the data capture that supports the identification of patients who
are eligible for care targeted by quality metrics and (2) the
translation of those quality metrics into clinical decision support
functionality that helps providers know what they need to do (and for
whom) to ensure the provision of quality care.

###### Discussion of Recommendation 2.1

It was proposed that an addition to Recommendation 2.1 could address the
need to leverage data that are currently being accessed and the issues
around data that are not currently being accessed. It was decided that
the recommendation needs to be broken down into distinct segments
(possibly separate recommendations) that are clear, specific,
actionable, and in parallel with the first set of recommendations. Ms.
Foster commented that one of the segments could call for the convening
of organizations that have tried to embed HQA measures into decision
support systems as a foundation for moving forward in this area.

#### Action Item #2: Per QWG discussion, Recommendation 2.1 will be broken into distinct segments (possibly separate recommendations) that are clear, specific, and actionable. Dr. Jerry Osheroff will assist, and staff will send revisions to QWG members for their review.

###### Recommendations 3.1 and 3.2 -- Contextual Text

Dr. Clancy noted that this short text speaks to "enabling data
aggregation as needed 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." She added that
Recommendation 3.1 addresses the likelihood that data will be needed
from multiple sources in the near term.

###### Discussion of Contextual Text for Recommendation 3.1 and 3.2

It was agreed that this section should refer to the need to protect
patient privacy when aggregating the data mentioned.

###### Discussion of Recommendation 3.1

There seemed to be agreement that the recommendation will be expanded:
(1) to call for the identification of the top activities that would
better facilitate obtaining integrated information; (2) to involve
multiple stakeholders in this effort; and (3) to call for subsequent
recommendations for action to be reported back to HHS, possibly directly
to the Secretary.

Ms. Kelly Cronin proposed further refinements and additions to the
recommendation: (1) that the recommendation retain the structure of HHS
working with relevant private- and public-sector leaders; (2) but then
require that the initial analysis be reported back to the QWG for
further recommendations on the specific ways to resolve large issues.
She added that the AQA pilot sites are expected to report on their
experiences in May, providing input that could assist the QWG in a
timely fashion.

##### **Action Item #3: Recommendation 3.1 will be expanded (1) to call for the identification of the top three activities that would better facilitate obtaining integrated information; (2) to involve multiple stakeholders in this effort; and (3) to call for subsequent recommendations for action to be reported back to HHS, possibly directly to the Secretary. Recommendation 3.1 will retain the structure of HHS working with relevant private and public sector leaders but be expanded to require that the initial analyses be reported back to the QWG. The revised recommendation will be shared with QWG members for their review.**

###### Discussion of Recommendation 3.2

Ms. Cronin commented that if, under the revised Recommendation 3.1, some
of the big issues can be articulated and possibly some resolved by
summer 2007, that will be timely in terms of the next round of NHIN
contracting.

###### Discussion of Contextual Text for Recommendation 4.1

The text preceding Recommendation 4.1 discusses the need to align
quality measurement with the capabilities and limitations of health
information technology (HIT), given that efficient and effective
implementation of quality measurement and reporting systems is reliant
upon the effective use of HIT. It notes further that the future burden
of data collection for quality purposes could be reduced through
increased collaboration and communication between measure developers and
HIT vendors.

###### Discussion of Recommendation 4.1

There was discussion of the need to clarify the recommendation for broad
audiences. ONC staff will make revisions to clarify that the goal of the
recommendation is to encourage better HIT alignment up front in measures
development, with data needs taken into account, so that EHRs and
network services can then be developed and certified in a way that makes
the data more readily available over time.

#### ACTION ITEM #4: Recommendation 4.1 will be revised to clarify that its goal is to encourage better HIT alignment up front in measures development, with data needs taken into account, so that EHRs and network services can then be developed and certified in a way that makes the data more readily available over time. 

Dr. Corrigan proposed that Recommendation 4.1 or a new Recommendation
4.2 go further than what is currently recommended. She suggested the
addition of a recommendation for the NQF to include criteria for measure
development that addresses a measure's ability to be incorporated into
EHRs. She also noted that the NQF would play a role in the assessment of
data needs when measures targeted for public reporting are developed.
What could also be considered is the need to develop a more standardized
approach to specifying exclusions from the denominators that could be
used across many or most measures.

Ms. Foster commented that perhaps a new recommendation in this section
could explicitly emphasize the need for organizations such as the AQA,
HQA, and others to adhere or conform to the NQF-endorsement criteria.

#### Action Item #5: The suggestions about the NQF endorsement process made by Dr. Corrigan and Ms. Foster should be considered for incorporation in the section about quality measurement alignment, possibly as one or two new recommendations. 

###### Use of the QWG's Vision in AHIC Presentation

Ms. Underwood suggested that the presentation to AHIC frame the QWG's
recommendations in a way that parallels key language used in the QWG's
Vision, such as references to "transforming key processes" in major
categories such as infrastructure and quality of healthcare delivery.

Dr. Osheroff observed that the QWG's Vision statement articulates how
the QWG hopes all the relevant quality and improvement puzzle pieces,
some of which are addressed in the recommendations, will fit together in
the end. He asked if an additional recommendation is needed calling for
the QWG to develop a future vision of how a patient and his/her
healthcare could be affected by the recommendations, once they are in
place. This illustrative example or scenario could then be used to
educate and inform involved entities, such as CCHIT, HITSP, and measure
developers.

Ms. Cronin responded that staff could draft relevant text in advance of
the AHIC meeting that builds on scenarios already drafted for other
purposes, and then vet the text with QWG members. The text could
illustrate the clinical side of the recommendations' end vision but also
paint a picture for consumers of what they could anticipate experiencing
down the road. The point could be made that while the QWG is starting
small under its specific charge, its broader charge is more about
system-level change.

Dr. Osheroff suggested that such a scenario could go on to become a
dynamic tool for engaging all the different stakeholders that will need
to work together. Ms. Cronin agreed that such a scenario could be
revised and updated as needed to assist the QWG as its deliberations
become more advanced.

Gerald Shea proposed that the text under discussion acknowledge the
current knowledge gap between the ideal state of easily available
information and the usability of that information for people so that it
is clear that the vision is essentially technological and not a new
health paradigm. Ms. Cronin responded that the QWG can take on issues
around availability and usability of data and try to more specifically
address gaps as it moves forward. She also noted that the QWG has tried
to focus on consumer perspectives and needs in its vision, and the
scenario under discussion could reflect that focus over time, without
too much concern about overlap with other workgroups, such as the
Consumer Empowerment Workgroup.

#### Action Item #6: QWG members will provide ONC staff with any useful, relevant information and/or graphics for the development of a scenario. In particular, Dr. Osheroff will further articulate his concepts for the scenario to staff.

###### Acknowledging Linkage Between the QWG and the Population Health and Clinical Care Connections (PHCCC) Workgroup 

Dr. Foster noted her recent testimony on adverse events reporting before
the PHCCC (formerly Biosurveillance) WG and proposed that linkages
between the work of the QWG and other workgroups be acknowledged in the
Letter of Recommendation. It was acknowledged that the two workgroups
share common needs, particularly in terms of data and process changes
needed for an EHR system.

##### 

###### The Business Case for Quality

There was discussion of whether a recommendation on or reference to the
business case for quality should be included in the Letter of
Recommendation. There was further discussion of the need to reference
some or all of the following points: (1) how the payment system supports
the effort to move information technology forward, (2) how improving
quality could slow the rate of increase for health care expenditures,
(3) how quality measures affect resource use and health care value, (4)
how quality improvement could affect treatment of chronic conditions
positively, and (5) how quality measures could help reduce the cost of
infections and other avoidable medical mistakes for payers and
hospitals. References to the business case for quality will be added
where appropriate in the letter.

### 3. Discussion of Future Meeting Topics

Before Dr. Foster turned the discussion to future QWG meeting topics,
Ms. Cronin asked to address the topic of dissemination of the QWG
Vision.

Ms. Cronin noted that the QWG Vision is currently packaged with the AHIC
January 23, 2007, meeting materials but that staff would like to broaden
dissemination by placing it on AHRQ's web site through a link to AHIC's
web site. Members also suggested dissemination to the NQF; the American
Hospital Association; Joint Commission on Accreditation of Healthcare
Organization's advisory groups; the Integrating Healthcare Enterprise
(which includes the Healthcare Information and Management Systems
Society (HIMSS)), the Radiological Society of North America, the
American College of Cardiology; and EHR vendor associations.

#### Action Item #7: ONC staff will follow up with members on dissemination of the QWG Vision, providing hard copies and/or electronic files. In addition, the QWG Vision will be re-posted to the AHIC web site on the QWG home page.

###### Discussion of Future Meeting Topics

Ms. Cronin asked that the topics proposed for future meetings in the
next few months take into account that the QWG will be moving to its
broad charge and will begin to address some of the issues raised in its
visioning exercise in more depth. Two issues for future QWG
consideration are (1) what needs to be done to advance clinical decision
support and (2) how HIT could enable development of more patient-centric
measures. Ms. VanAmringe offered to explore the possibility of getting
information from organizations providing performance feedback to
clinicians in real time and reporting on that information back to the
QWG. Dr. Jon White of AHRQ offered to provide copies of the report from
the AHRQ conference in Chicago to the workgroup.

###### 

Ms. Cronin asked if members would want to take testimony on the issues
discussed during an all-day meeting, similar to the PHCCC WG's recent
all-day meeting on adverse events reporting. Member reactions included
the following:

-   Such an all-day meeting could involve testimony from the consumer
    and consumer's caregiver's perspective, the provider perspective,
    and perhaps the nursing home perspective.

-   One focus could be testimony from entities that have achieved
    advances in terms of clinical decision support, such as the
    Regenstrief Institute and the Indiana Health Information Exchange.
    Other entities mentioned were the Intermountain Health Care System;
    the Cleveland Clinic; Partners HealthCare in Boston, and other
    academic medical centers.

#### Action Item #8: ONC staff will review the discussion of future meeting topics and forward a draft workplan to QWG members.

Ms. Cronin reminded the QWG that ONC is developing a Quality Use Case as
a result of the priorities forwarded to the AHIC in the fall. A draft of
the Quality Use Case will be shared with the QWG members when it becomes
available, possibly in advance of the next QWG meeting.

### 4. Public Comments

Dr. Lou Diamond made two comments about Recommendation 4.1: (1) there
are a number of issues that need to be addressed in a coordinated
fashion between implementers and measure developers, including issues
relating to workflow; and (2) the QWG might add language about the need
for integration of efforts between clinical practices guidelines and
evidence, and measurement development. Dr. Diamond also suggested that
the Letter of Recommendation's contextual text should not imply that
measurement and information feedback are separate from clinical decision
support because, at the point of care, clinical decision support is not
only integrated with performance measurement for individual patients but
also for entire populations.

Jonathan Teich agreed with Dr. Diamond's last observation, noting that
Sections 2 and 4 of the Letter should be vetted for explicitness on
whether what is being addressed is individual clinical decision support,
population-based clinical support, or both.

**SUMMARY OF DECISION POINTS AND ACTION ITEMS**

##### **Action Item #1: QWG discussion about Recommendation 1.1 will be addressed by altering the recommendation's language to reflect the discussion.**

##### 

#### Action Item #2: Per QWG discussion, Recommendation 2.1 will be broken into distinct segments (possibly separate recommendations) that are clear, specific, and actionable. Dr. Jerry Osheroff will assist, and staff will send revisions to QWG members for their review.

##### **Action Item #3: Recommendation 3.1 will be expanded (1) to call for the identification of the top three activities that would better facilitate obtaining integrated information; (2) to involve multiple stakeholders in this effort; and (3) to call for subsequent recommendations for action to be reported back to HHS, possibly directly to the Secretary. Recommendation 3.1 will retain the structure of HHS working with relevant private and public sector leaders but be expanded to require that the initial analyses be reported back to the QWG. The revised recommendation will be shared with QWG members for their review.**

#### ACTION ITEM #4: Recommendation 4.1 will be revised to clarify that its goal is to encourage better HIT alignment up front in measures development, with data needs taken into account, so that EHRs and network services can then be developed and certified in a way that makes the data more readily available over time. 

#### 

#### Action Item #5: The suggestions about the NQF endorsement process made by Dr. Corrigan and Ms. Foster should be considered for incorporation in the section about quality measurement alignment, possibly as one or two new recommendations. 

#### ACTION ITEM #6: QWG members will provide ONC staff with any useful, relevant information and/or graphics for the development of a scenario. In particular, Dr. Osheroff will further articulate his concepts for the scenario to staff.

#### Action Item #7: ONC staff will follow up with members on dissemination of the QWG Vision, providing hard copies and/or electronic files. In addition, the QWG Vision will be re-posted to the AHIC web site on the QWG home page.

#### 

#### Action Item #8: ONC staff will review the discussion of future meeting topics and forward a draft workplan to QWG members.

**MEETING MATERIALS**

Agenda

Draft Recommendation Letter for AHIC

Vision Executive Summary

Vision Summary

**[Quality Workgroup 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

*Members*

Janet Corrigan NQF

Helen Darling National Business Group on Health

Nancy Foster AHA

Michael Kaszynski (for Anne Easton) Office of Personnel Management

Carol Ostrowski NQF

Susan Postal Hospital Corporation of America

Gerald Shea AFL-CIO

Sunil Sinha (for Abby Block) CMS

Jonathan Teich Brigham and Women's Hospital

Phyllis Torda NCQA

Reed Tuckson UnitedHealth Group

Charlene Underwood Siemens/HIMSS EHRVA

Margaret VanAmringe Joint Commission

Jonathan White AHRQ

Josie Williams Quality and Patient Safety Initiatives

*Other Attendees*

Judy Sparrow, AHIC Director ONC

Jerry Osheroff Thomson Healthcare

Jonathan White AHRQ

#  

**Disclaimer:** *The views expressed in written conference materials or
publications and by speakers and moderators at DHHS-sponsored
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.*