The Health IT Policy Committee has asked the CMS to drop the three so-called “core measures” from its proposed rule on “meaningful use,” but that's not to say the committee has a problem with another group of core measures used by the Joint Commission, the CMS and the Hospital Quality Alliance quality measures reporting programs.
The two groups of measures are different, and the recent use of the phrase “core measures” by CMS rulemakers was an unfortunate choice of words that could lead to some confusion between the two, according to a Health IT Policy Committee leader.
“We wanted to get away from the terminology of core measures” for that reason, said Paul Tang, chief medical information officer for the Palo Alto Medical Foundation and co-chairman of the Health IT Policy Committee and its work group on meaningful use.
On Wednesday, the committee's work group on meaningful use
presented 12 more recommendations in response to the CMS' proposed rule during a 5½-hour meeting, including one calling on the CMS to give providers more flexibility in meeting meaningful-use criteria.
The American Recovery and Reinvestment Act of 2009, also known as the stimulus law, requires that quality reporting be a component part of meaningful use of an electronic health record.
The CMS rule proposes hospitals and physicians electronically submit clinical quality measures from a host of choices. The rule devotes dozens of page to multiple tables of applicable clinical quality measures for both hospitals and “eligible professionals,” generally outpatient physicians. The required measures for eligible professionals are lumped into two groups, what the CMS calls “core measures,” which are supposed to be relevant across medical specialties, and those it calls “specialty group measures,” specific to a medical specialty, such as pediatrics or oncology.
While the CMS rule contains 15 tables crammed with proposed reporting measures for medical specialists, only one table is needed for the proposed three, cross-specialty core measures, all three of which are measures approved by the National Quality Forum.
According to CMS rulemakers, “We believe that the clinical quality measures are sufficiently general in application and of such importance to population health, we propose to require” that all eligible professionals “treating Medicare and Medicaid patients in the ambulatory setting report on all of the core measures as applicable for their patients.”
The three proposed core measures in the CMS rule are:
A requirement to inquire and record whether a patient uses tobacco, which is a measure currently used under the Medicare Physician Quality Reporting Initiative.
An electronic record-keeping requirement for blood pressure measurement.
A requirement to record the percentage of elderly patients who receive either one or two prescription drugs deemed to be of “high risk” to the elderly.
In its
eight-page list of recommendations to the Health IT Policy Committee, the work group explained that the concept of adding a set of core measures to the meaningful-use criteria, measures that should apply to all providers, “was originally proposed by the policy committee, but they were different from the ones proposed” in the CMS rule.
In reviewing the applicability of the CMS-proposed core measures, the work group used a six-point criterion. They had to be:
Based on the “six aims” of the Institute of Medicine (safety, timeliness, effectiveness, efficiency, equity and patient-centeredness) as well as priorities identified by the National Priorities Partnership, a collaboration led by the NQF.
Evidence-based, with a link to improvement in outcomes.
Measurable using coded clinical data in an EHR to minimize administrative burden in collecting and reporting.
Captured as a byproduct of the care process to fit a clinician's workflow.
Applicable to virtually all eligible providers.
Outcomes measures, to the extent possible.
The work group concluded than none of the three CMS-proposed core measures “adequately met the above criteria.”
For example, the work group said the proposed measures related to smoking and blood pressure measurement “are process measures, and the group felt that the outcomes-improvement goal of the overall HIT incentive program should be reflected in any measure to the greatest extent possible.”
The measure on reporting drugs to be avoided in the elderly “suffers from a lack of consensus on definitions” of what those drugs are, “so the group felt it would be challenging to define this measure with enough precision that it could serve as a core measure.”
Thus, the work group recommended removing the three measures from the first round of meaningful-use criteria, adding it will “work with ONC to recommend strategies to identify key health priorities for which effective use of HIT has special applicability, and will re-explore the concept of ‘core measures' or ‘shared health priorities' for later stages.”
The CMS-proposed core measures lacked the requisite universality, according to Tang.
“There was a concept of whether there could be some measure that would apply to every provider and hospital and we did not find any that met all of those attributes,” Tang said.
Finally, “There is an emphasis on outcomes over process measures,” Tang said. “It's not clear that documenting whether somebody smokes will result in less complications from smoking; the same with blood pressure. So, we need a tighter connection.”
The Health IT Policy Committee adopted its work group's recommendations, but whether they will actually make it into a revised CMS rule remains to be seen.
The public comment period on the proposed rule remains open until mid-March.
ONC head David Blumenthal, during preliminary remarks at the meeting, said the current rule is “not set in stone.”
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