While physician practices and hospitals are busy readying themselves for the first phase of meaningful-use requirements for electronic health-record systems, quality experts are trying to identify outcomes-based performance measures that are up to the task of assessing patient-centered care.
NQF seeks better outcomes data
One such group is the National Quality Forum's Health Information Technology Advisory Committee, a 25-member panel announced in May, whose roster includes practicing clinicians, IT professionals, payers, vendors and patient advocates. The committee is charged with providing feedback and guidance to the NQF on its health IT projects, while also analyzing how quality data can be successfully extracted from EHR systems.
"The committee is part of the NQF's interest in taking advantage of the move toward EHRs,” says Paul Tang, M.D., vice president and chief medical information officer of the Palo Alto (Calif.) Medical Foundation and chairman of HITAC. “It doesn't create standards, but it does influence which criteria are eventually endorsed, and that opens them up for use in the public and private sector.”
The big challenge at hand, Tang says, stems from the fact that providing truly patient-centered care—touted as the overarching goal of health reform and the health IT provisions in the stimulus bill—requires carefully crafted clinical quality measures that rely on rich patient data from EHRs. And the reality, he says, is that most of the existing quality measures are still a far cry from that ideal.
“Existing quality measures are often based on administrative claims data instead of EHR data, and that is a problem,” Tang says. “But with the HITECH Act, we're going to be seeing a lot more new measures and we want those to be defined using clinical data. It's a moment of opportunity for us to better understand the care we are providing and really transform the healthcare system.”
HITAC had its inaugural meeting on July 30, and according to Tang, the committee's first discussions were dominated by one main theme: How can we make sure measures address patients' health status, goals and experiences?
Marcia Thomas-Brown, chief operating officer of the Washington-based National Health IT Collaborative for the Underserved and a member of HITAC, called the first meeting's focus on patients' needs refreshing.
“I'm not a techie by any means, so it was great, as a representative for consumers, to see how diverse the group was and how interested they were in addressing the concerns of patients,” Thomas-Brown says. “It's exciting because healthcare is one of the few businesses where we develop services and measures with very little input from the consumer. I'd like to see us move in a direction where measures give us a more holistic view and take into account issues like quality of life.”
HITAC is an outgrowth of two previous NQF Health IT Expert Panel efforts—HITEP-I and HITEP-II—which were created to help standardize existing measures and to identify the role that the EHR platform would play in measuring quality and performance. HITEP-I met twice in 2007 and published its recommendations in 2008.
The 20-member group, which was also chaired by Tang, identified a list of common data categories and types, such as outpatient diagnoses and medication orders. They also identified a set of more than 80 high-priority quality measures in areas such as diabetes care, medication management, cancer screening and care coordination. Finally, they also developed a framework for judging the quality of electronic information available for each measure.
“Measures with high quality scores are ready for EHR implementation,” the committee wrote in its final report. Low-scoring measures should be modified with higher quality data types, retired, or replaced with better measures, they said.
HITEP-II, on the other hand, was tasked with addressing the issue of reliance on administrative billing data by developing the NQF's quality data set, a framework of common language and standardized clinical data to be used in electronically measuring clinical performance.
The QDS framework, released in 2009, includes three types of information: standard elements, such as a code for a specific condition or medication; quality data elements that describe a particular part of the care process, such as medication administration or diagnosis; and data-flow attributes, which identify the source, setting and recorder of the quality data.
“NQF wanted to get advice from HITEP about how best to leverage the data in these systems to measure quality, but also how to use these systems to improve quality,” Tang says. “Measurements help us to understand what is happening now and they also act as effectors of change, through clinical decision support. The framework was developed to be a common resource to get everyone on the same page and moving forward.”
And the next step after the work of those committees was complete, says Floyd Eisenberg, M.D, the NQF's senior vice president for health IT, was to form HITAC, “a standing advisory committee to help develop and manage strategic planning and provide ongoing guidance about NQF's health IT portfolio.”
“They will offer feedback that will help us continue forward and evolve our infrastructure as we move from process measures to advanced clinical outcomes measures,” Eisenberg says.
For Richard Baron, M.D., president and CEO of Philadelphia-based Greenhouse Internists, a spot on HITAC has given him the opportunity to share his perspective as a practicing physician who struggles daily with the limitations of his EHR. Baron's small practice has implemented a comprehensive EHR and is also taking part in a state-led medical home pilot project.
The reality, Baron says, is that quality metrics are rarely “baked in” to existing systems, and for everyday users such as him, assessing performance is an arduous task. Vendors need targets that dictate clearly defined numerators, denominators and exclusion criteria, Baron says, and that's where the NQF's involvement is critical.
“As a physician, I look forward to the day when I can get useful quality data easily, and when I am paid based on the care I provide rather than visits,” Baron says. “Doing a better job at outlining real performance will be one of the most important parts of healthcare delivery system redesign.”
And one component of improving existing measures and creating new ones, Tang says, will require taking into account factors such as patients' functional status, pain level, mobility, daily activities and ability to live independently. For instance, he says, while A1C hemoglobin test levels are commonly used to assess the quality of care for diabetes patients, more detailed measures are needed that consider patients' symptom management.
“A diabetic person wants to avoid complications of their disease, not just manage their blood sugar,” Tang says. “Patients' health goals usually include an active, independent life, and if we can capture those goals, that would be truly patient-centered.”
The committee spent its first meeting brainstorming about how to enter those types of data into an electronic record, and it will present those thoughts to the NQF's board this month. If the board likes the approach, Tang says, HITAC can start building its ideas into the framework of NQF's IT strategy.
That's an exciting prospect, says Martha Roherty, executive director of the National Association of States United for Aging and Disabilities, a Washington-based group that represents 56 federally designated state agencies on aging and disability. Roherty says she was interested in serving on HITAC to ensure the interests of the long-term-care community were addressed.
According to Roherty, electronic quality measures should encompass an even broader scope of patients' health status including nutrition, fall-prevention instruction, patient self-management education and caregiver status.
“If they get meals delivered, we want that to be in the record,” Roherty says. “We also want to know if they have a homemaker service, or someone that comes in and does light cleanup, because that helps people stay in their homes longer. These things are not thought of as clinical, per se, but the evidence says they greatly impact health and quality of life.”
Roherty says she hopes the committee is able to move away from the medical model and look at ways to measure the whole picture. “The things that ensure success are often support and overall well-being,” she says. “It's a very different way of thinking.”
HITAC members acknowledged the job will not be an easy one. And while Tang is pushing the committee to “seize the moment” and think big, others spoke out in favor of more incremental changes, says Shannon Sims, director of health informatics in performance improvement at Rush University Medical Center, Chicago.
Sims says he joined the committee because he saw the need for standardization and because he wanted to make sure the resulting requirements and benchmarking would be fair to providers. “I see it on the ground level, and I don't want to set up targets that are hard for physicians to meet,” he says.
According to Sims, having patient-centered measures means knowing easily if someone receives the right services at the right time. That's in contrast to present quality data, he says, which often indicate only whether a clinician did the right task at the right time. For example, he says, a patient's medical record includes data about whether a patient was immunized for influenza, but does not tell the end user when the patient was vaccinated.
Eventually, Sims says, providers will need to be able to access data from drugstore clinics and other sites they haven't thought of before. The first step, he says, will be to build on the work of the QDS framework to try to think about how these broader measures can be captured electronically in a standardized way.
“Right now, we are on the cusp of aligning quality measures in a framework that incorporates patient preferences and health goals,” Tang says. “Wouldn't that make a lot more sense and do much more to serve patients' interests?”
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