enabling quality measurement

www.qualityforum.org

Enabling Quality Measurement

Daniel Rosenthal, MD MSc MPHProgram Director, Health Information TechnologyNational Quality Forum

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Quality

HIT

content structure

+ * promotion

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How do we get quality measurement into and out of EHRs?

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Content » Participants

national priorities

create measures

endorse measures

implementation strategies

implement, test and aggregate

results

public reports

evaluate health care

improve quality

incentive policies

Consumer

Outcomes

1. High Quality 2. Equitable 3. Affordable4. Patient-Centered

AHRQ Foundations

QIOs Regional Collaboratives Providers Oversight Organizations Employers Health Plans Fed/State Govt Health Plans Employers Consumers Providers

Regional Collaboratives Fed/State Govt. Health Plans Others

QASC Quality Alliances Joint Commission NCQA Medical Specialty Boards

NCQA The Joint Commission AMA PCPI Medical Societies Medical Specialty Boards CMS AHRQ Others**

NQF National Priority Partners

NQF

QASC Regional Collaboratives RHIOs/HIEs CMS States Health Data Stewards

NQF

DRAFT - Quality Alliance Steering Committee

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Content

NQF

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Content » NQF » Mission

• improve the quality of American healthcare by setting national priorities and goals for performance improvement

• endorse national consensus standards for measuring and publicly reporting on performance

• promote the attainment of national goals through education and outreach programs

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Content » NQF » Consensus Standards

National Technology and Transfer Advancement of Act of 1995 (NTTAA)

– five key attributes of a “voluntary consensus standards-setting body:” openness, balance of interest, due process, consensus, and an appeals process

– obligates federal government to adopt voluntary consensus standards

– encourages federal government to participate in setting voluntary consensus standards

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Content » NQF » Membership

• A private, non-profit voluntary consensus standards-setting organization

• Broad membership (350+ members) organized into 8 Councils that– Provide stakeholder perspectives to all NQF deliberations;– Enable various groups within a council to convene,

identify issues and relay information in a unified voice; and

– Promote collaboration among different groups within a stakeholder perspective.

• Councils:– Consumers– Health Care Professionals– Health Plans– Provider Organizations– Public/Community Health Agencies– Purchasers– Research and Quality Improvement Organizations– Supplier & Industry

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Content » NQF » Selected Projects

National Voluntary Consensus Standards for

Nursing Home Care

Hospital Care

Healthcare-associated Infections

ESRD Care

Ambulatory Care

Health IT Structural Measures

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Content » NQF » National Priority Partners

national priorities

• establish national priorities and goals for performance measurement and public reporting

• focus measurement and improvement efforts on achievement of these goals

• multi-stakeholder Committee with representation from 27 leadership organizations

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27 multi-stakeholder organizations• Consumers• Purchasers• Quality alliances• Health professionals/providers• Public sector: CMS, NGA, CDC, AHRQ, NIH• Accreditation/certification groups• Health plans

Co-Chairs:Donald BerwickInstitute for Healthcare ImprovementMargaret O'Kane National Committee for Quality Assurance

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CONSUMERS• National Partnership for Women and Families• Consumers Union• AARP• AFL-CIO

PURCHASERS• National Business Group on Health • The Leapfrog Group• Pacific Business Group on Health • Chamber of Commerce

PUBLIC SECTOR• Centers for Disease Control and Prevention • Centers for Medicare and Medicaid Services • Agency for Healthcare Research and Quality • National Institutes of Health • National Governors Association

QUALITY ALLIANCES• AQA• Hospital Quality Alliance• Quality Alliance Steering Committee• Alliance for Pediatric Quality

HEALTH PROFESSIONALS/PROVIDERS• AMA’s PCPI • American Nurses Association • National Association of Community Health Centers

ACCREDITATION/CERTIFICATION• American Board of Medical Specialties • The Joint Commission• National Committee for Quality

Assurance • Certification Commission for

Healthcare Information Technology

OTHERS• America’s Health Insurance Plans• Institute for Healthcare

Improvement• Institute of Medicine

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Content » NQF National Priority Partners

Provide Effective

Care

EliminateHarm

EradicateDisparities

RemoveWaste

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• Patient and family engagement• Population health • Safety• Palliative care• Care coordination• Overuse • Management of patient-focused

episodes

High Impact Areas

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Content » NQF » NPP Framework

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Content » NQF » Measures

national priorities

create measures

endorse measures

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Content » NQF » endorsed measures

0

20

40

60

80

100

120

2005 2006 2007

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Content » NQF » Strategic Goals

• high system performance

• composite measurement

• outcomes

• disparities

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Content » NQF » Consensus Development Process

• importance

• scientific acceptability

• usability

• feasibility

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Content » NQF » CDP

specs

evaluate

endorse

do not endorse

share

submit

supportinginformation

specs

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How do we get quality measurement into and out of EHRs?

Structure

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Structure

Measure Specificatio

ns

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Structure

Clinical Guidelines

Decision Support

Quality Measures

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Structure » Interoperable Measure

A “well-defined quality measure” is

composed of a set of common data elements,

encoded using standard taxonomies,

structured logically into a standardized expression

that can be shared and applied to patient data

and reported

NQF HITEP

HITSP

AMA-NCQA Collaborative

PQA QRDA

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Structure » HITEP » Goals

QASC charged NQF to establish a Health IT Expert panel for:

1. Establishment of a priority order for a subset of existing AQA and HQA measures;

2. Development of a generic prioritization framework that could be used across many clinical conditions; and

3. Identification of a set of common data elements to be standardized to enable automation of AQA and HQA measures through electronic health records and health information exchange.

Convened twice in Washington, DC on May 31, 2007 and September 24, 2007.

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Structure » HITEP » Priority Order

AQA/HQA NQF-Endorsed™ measures related to IOM Priority Conditions defined by maximal impact, improvability, and inclusiveness:

1. Asthma2. Cancer screening3. Care coordination 4. Diabetes 5. End-of-life6. Frailty associated with old age7. Immunization8. Ischemic heart disease 9. Major depression10. Medical management11. Pregnancy and childbirth 12. Severe and persistent mental illness13. Stroke14. Tobacco dependence treatment in

adults

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Structure » HITEP » Priority Framework

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Structure » HITEP » Common Data Types

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Structure » HITEP » Common Data Types

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Structure » HITEP » Pareto

Numerators, Denominators, Exclusions

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Exclusions only

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Structure » HITEP » Measure Scores

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Structure » HITEP » Measure Scores

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Structure » HITEP » outcome

• concepts HITSP Quality Interoperability Specifications

• measure quality ~ fx(data quality)

• billing code problem list

• allergy != side effect

• coded diagnostic summary

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Structure » HITEP » NQF

limited medical record review

clinically enriched administrative data

EHR functional requirements

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Structure » HITEP » next steps

develop a Quality Data Set that provides the core data elements needed for quality measurement and clinical decision support built off of clinical guidelines

collect and synthesize clinical workflows within and across healthcare settings

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A “well-defined quality measure” is

composed of a set of common data elements,

encoded using standard taxonomies,

structured logically into a standardized expression

that can be shared and applied to patient data

and reported

NQF HITEP

HITSP


PQA QRDA

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NQF HITEP

HITSP


PQA QRDA

Task Example

common data elements

diagnosis_outpt_problist, laboratory_result

common data element coding

ICD-9, SNOMED-CT, LOINC

measure logic representation

IF (diagnosis_outpt_problist A) AND NOT (diagnosis_outpt_problist B) THEN (laboratory_result)

patient data representation

Pt Jones: DM, HTN, HgA1c

NQF HITEP

HITSP


PQA QRDA

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Where do we find quality measurement specifications for our EHR?

Structure

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Structure

One-stop shopping

for measures

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Structure » Measure consumption

specs

evaluate

endorse

do not endorse

share

submit

supportinginformation

specs

NQF

?

NQMC

QMIS

specs specs

specs specs

xml

1. content

2. representation

3. transmission4. reconciliation

specs

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Promotion

Why should we enable quality measurement within our EHR?

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Promotion

HIT Structur

al Measure

s

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Promotion » Goals

1. e-Prescribing, including drug interactions, safety alerts, and formulary management tools;

2. Electronic Health Records (EHRs), including capability for interoperability;

3. Evidence-based clinical decision support systems (CDSS);

4. e-Referrals (consultations, diagnostic studies);

5. computerized provider-order entry (CPOE);

6. reporting to clinical registries and tracking systems that, in addition to a data repository function, analyze and report process and outcomes data that

• provides feedback to member practitioners for quality improvement; or

• are used in quality recognition programs; or • are used for maintenance of board certification.

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HIT adoption

pop

ula

tion

#2#1

Promotion » Adoption

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Promotion » Measures

e-prescribing1. decision support (including stand-alone/non-EHR applications) 2. in EHR

EHR interoperability3. adoption of CCHIT or core-functional EHR4. receive labs electronically

care management 5. @ point of care 6. between visits

quality reporting registry 7. local 8. national

9. medical home

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Promotion » CCHIT a. CCHIT certified EHR at the time of measurement, or

b. if CCHIT certification is available (in primary care or a specialty) on or before

August 1, 2008, but the system in use is not CCHIT certified, the EHR must

meet the following criteria:1. Ability to manage a medication list AND2. Ability to manage a problem list AND3. Ability to manually enter or electronically receive, store and display laboratory results as discrete searchable data elements AND4. Ability to meet basic privacy and security elements AND5. the EHR must be CCHIT certified on or before August 1st 2011 or

another CCHIT certified product must be in use for compliance after August 1, 2011 or

c. if CCHIT certification is not available for a specialty on August 1, 2008 the

EHR must have capabilities 1, 2, 3, AND 4 in section b above.

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Quality

HIT

content structure

+ * promotion


promote the development and use of electronic health records that contain functions for automated collection, aggregation, and transmission of performance measures

“

”

(Content + Structure) x Promotion


Daniel Rosenthal, MD MSc MPHProgram Director, Health Information [email protected] Quality Forum

enabling quality measurement

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