41 Responses to “Quality Measures Workgroup Seeks Comment on Clinical Quality Measures Concepts for Stage 2 and Stage 3 Meaningful Use by December 31, 2010”

1. Marge Lewandowski, RN says:

   December 31, 2010 at 11:21 pm

   Thank you for the opportunity to provide feedback for the proposed Meaningful Use Phase 2 quality measure framework. I have worked in Catholic Healthcare for 25 years in an organization comprised of clinics, critical access facilities, community hospitals and a tertiary care facility. Throughout my professional career as a nurse, my roles have varied from direct patient care to nursing management to clinical informatics.

   The Tiger Teams and the Quality Measures Workgroup have been thorough in setting forth a broad array of concepts addressing the entire continuum of care which is key to ensuring further evolvement of healthcare IT in a meaningful manner. Stage 1 quality measures focused on the ability to collect data electronically. Stage 2 and Stage 3 should focus on the quality aspect of the measure rather than the capability to abstract and submit.

   Health outcome measures should build on existing measures allowing for continued development and refinement of healthcare IT while also minimizing the burden on healthcare environments. Each environment of care has required reporting requirements and these should be considered when finalizing outcome measures. Final outcome measures should complement existing measures, they should not be new, additional measures. For example, hospital acquired conditions such as nosocomial ulcers, ventilator-associated pneumonia and surgical site infections all provide potential measures. Additionally, if existing outcome measures are utilized, data definitions should match the existing measure.

   Self-management skills are essential for patients to become active participants in their care; however before we can expect substantial improvements in patient engagement, patient healthcare literacy issues need to be addressed. Measures in this area could focus on availability of tools & strategies that support improvements in health literacy. If measures specific to self-management skills are implemented, the workgroup should consider the reliability and completeness of such measures as self-management measures often rely on patient self-reporting.

   As the concepts are finalized and measures are delineated, the workgroup needs to be conscientious about those concepts which do not apply as well across various settings. For example, chronic disease management is an important aspect of patient self-management; yet preventative care for chronic conditions is more fully within the realm of clinic practices. The workgroup asks for examples of measures which are parsimonious. While it is understandable to look for measures that fit across a multitude of care environments, it is more imperative to initiate measures that are value-added to the care of the patient within each specific environment.

   Sincerely,
   Marge Lewandowski

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2. John Ritter (serving as scribe for a few PHR advocates) says:

   December 31, 2010 at 5:27 pm

   Possible PHR–related Quality Measures:
   1) Do you provide a PHR level-of-awareness survey mechanism to your patients?

   2) Do you offer your patients the government-supplied PHR level-of-awareness aides in your practice (E.g., CMS Brochure 11397 – see http://www.medicare.gov )? (Or perhaps AHIMA’s brochure?) http://www.medicare.gov/Publications/Pubs/pdf/11397.pdf

   3) If you offer a patient portal, how often do your patients access their information?

   4) What percentage of your patients did you provide info about PHRs to?

   5) What mechanism(s) do you use to provide PHR level-of–awareness information to your patients?

   6) What percentage of your patients PHRs did you make entries into? Was it clinical or educational?

   7) What percentage of your patient census did you have an encounter with?

   What percentage of your chronic care patients did you offer PHR educational awareness to?

   9) What percentage of your patients (that you’ve had contact with in the previous X months) report that they have a PHR?

   10) What percentage of your patients have multiple PHRs?

   11) What percentage of your patients use social networking to discuss PHR-related issues?

   General Comment: Since the quantity of existing PHR users in the United States is currently small, it seems reasonable that ONC should first gauge the level-of-awareness that clinicians and clinical staff have regarding PHRs (via a Quality Measure), before attempting to gauge the level-of-awareness that patients have regarding PHRs.

   The question (above) regarding “the percentage of your patients that have multiple PHRs” ought to be tailored to include the nuance currently being offered by certain vendors whereby a single PHR can be “profiled” by the patient according to “multiple views”. For example, a given PHR can seem to possess differing amounts of data when viewed by the patients’ nutritionist, the patient’s general practitioner, and the patient’s gynecologist. Thus, per our example, ONC must ask whether the patient has three PHRs, or has one PHR that has three views. To complicate this issue a bit further, consider the fact that two major PHR vendors in the United States offer Application Programming Interfaces (API) to their systems that allow developers to create applications that serve as a front end to the vendors’ PHRs. In other words, the patient would never need to go to the actual PHR website to create, modify, or delete their PHR data. Rather, the patient could use a third-party application to perform data access actions instead. A clever entrepreneur might someday even set up a standalone website that would serve as a PHR portal, giving patients access to any PHR system that published an API.

   Google’s API
   http://code.google.com/apis/health/

   Microsoft’s DK and DDK
   http://msdn.microsoft.com/en-us/healthvault/bb802509.aspx

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3. Ruth Perot says:

   December 31, 2010 at 4:51 pm

   Thank you for this opportunity to respond to the Clinical Quality Measures Concepts for Stage 2 and 3 Meaningful Use. The National Health IT Collaborative for the Underserved (NHIT) commends the Quality Measures Workgroup for providing such a robust set of concepts and measures to guide the next stages of meaningful use of health information technology (HIT) for the improvement of health and health care quality. NHIT shares the Workgroup’s commitment to quality enhancement, with emphasis on the underserved, particularly communities of color, and those who care for them, and we see the meaningful use (MU) of HIT as an essential tool to achieve that goal.

   We offer general observations and illustrative comments about selected measure concepts at this point and would welcome other opportunities to present additional recommendations to the Workgroup. Having enthusiastically endorsed the requirement for the collection of demographic data (race, ethnicity, primary language and gender) in Stage 1 of MU as a prerequisite to reduce/eliminate health disparities, NHIT urges the Workgroup to maintain that visible focus in Stages 2 and 3. At present, there is only one measure that specifically addresses health equity. However, each of the measure concepts offers an opportunity to collect and report data using Stage 1 demographic variables at a minimum. Indeed, it would be important to know how minorities and other priority populations fare in Stages 2 and 3 with respect to Patient and Family Engagement, Care Coordination, Patient Safety and Population and Public Health. Disaggregated reporting in each of these categories may have been the Workgroup’s intention, but we would urge that intention to be made explicit.

   Generally, the measure concepts are clinically based and only a few (12 out of 40) make reference in the concept definition to HIT, suggesting how the measure might integrate or implicate HIT. The absence of an explanation of HIT’s specific relationship to the measure concepts requires the reviewer to make assumptions about the intended use of HIT in these contexts. As such, efforts to illustrate meaningful use are diluted without such clarity. In several cases, the EHR, PHR, a registry or other type of HIT tool or application potentially could be used as a data source, or to monitor and track information, or to support data collection activities; however, such use is not stated.

   Relative to the content of selected measures, we recommend further refinement of definitions. We also believe it will be important to reflect how parameters will be assessed and how HIT will be implicated. Illustrative examples follow:

   #1, 2 and 3. There is a need to concretize the phrase: “led in the ‘right direction’” through the provision of tangible support for patient self-management, shared decision-making and the observance of patient preferences. Possible measures could address the availability of culturally and linguistically- appropriate materials and services (e.g., interpretation), geared to the literacy level of patients.

   #8. (Measures assessing ambulatory care-sensitive preventable admission) – The definition states, “This measure concept relates to admissions caused by unaddressed ambulatory conditions at the onset of symptoms due to multiple reasons such as inappropriate clinical management of inefficient system issues.” This concept may also be influenced by a patient’s access to primary care, a medical home or insurance. In this instance, it is not clear how other potentially confounding factors will be addressed. It is also not clear how HIT is to be implicated in this measure.

   #12,13,15 The appropriate/efficient use of medications may be influenced by provider instructions to the patient and/or patient knowledge and understanding of how much medication (dosage) to take at a given time (frequency) over a specified period of time (duration). Such information could be tracked by various components of the EHR, PHR or other HIT tool. Here, too, the availability of culturally and linguistically appropriate services and materials has relevance and could serve as an appropriate measure of effectiveness.

   Again, our appreciation for your leadership with respect to this important work!

   Ruth T. Perot
   Managing Director
   National Health IT Collaborative for the Underserved

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4. Carol Sakala says:

   December 30, 2010 at 3:47 pm

   Thank you for the opportunity to recommend Meaningful Use Phase 3 priority quality measures within the scope of the proposed Phase 2 and 3 quality measure framework. I write on behalf of Childbirth Connection, a national not-for-profit organization that works to improve the quality of maternity care and ensure that it meets needs and interests of childbearing women and families.

   We applaud the Quality Measures Workgroup for including within the Patient and Family Engagement focal area the crucial measure concept of Patient Health Outcomes. We are also grateful to know that the Meaningful Use Workgroup seeks outcome measures where possible (Paul Tang 12/13/10 presentation). Unfortunately, few measures to date address this priority concern for patients, purchasers, and others. Outcome measures are essential for assessing effects of care, providing feedback to caregivers and facilities, enabling consumers to make wise choices, and fostering value- based purchasing. They are also crucial tools for ensuring that the many delivery and payment innovations under development (e.g., health care home, ACOs) lead to higher quality, higher value care.

   At present, there is no NQF-endorsed maternal postpartum outcome measure. A composite newborn outcome measure is currently being considered within Patient Outcomes Phase III-Child Health (OT3-031-10). We are writing to strongly urge the Workgroup to call for the rapid development and testing of a composite measure of postpartum maternal morbidity for inclusion in Meaningful Use Phase 3.

   Childbirth Connection became deeply concerned about this matter after asking postpartum women to identify new-onset physical and emotional problems in our national Listening to Mothers surveys carried out with the assistance of Harris Interactive. Survey results reveal that the primarily healthy population of new mothers experiences a very broad range and striking prevalence of new-onset infection, pain, and other conditions in the first two months postpartum, with problems persisting to six months of more for numerous conditions in a notable proportion of women. Many of these conditions are associated with overused intrapartum practices and are modifiable. After hospital discharge, there is virtually no routine and standard measurement of these conditions in the United States. In the context of the conclusion of maternity care and inadequate transition to and awareness among primary caregivers, these conditions largely go unrecognized and unaddressed. In our first Listening to Mothers survey, the women reported that only infections were reliably brought to the attention of a caregiver. Table 1 of New Mothers Speak Out, the most recent report from these surveys, provides our fullest understanding of this concerning profile of new-onset morbidity in this population. The survey reports are available at http://www.childbirthconnection.org/listeningtomothers/.

   Inclusion of the relevant standardized data items in EHRs is urgently needed. Childbirth Connnection urges the Quality Measures Workgroup to call for the rapid development and testing of a composite measure of maternal outcome at the end of the full episode of maternity care. To our knowledge, postpartum maternal outcome measures have been explored conceptually, but have not been developed, with the exception of a measure of third- and fourth-degree lacerations. With prioritization, the proposed measure could be included in Meaningful Use Phase 3.

   Among numerous benefits, the proposed measure would:
   • address the crucial question of health outcomes for a major segment of the health care system: 23% of individuals discharged from U.S. hospitals are childbearing women and newborns, representing by far the most common and most costly hospital condition
   • bring to light for the various stakeholders currently hidden outcomes of the full episode of maternity care, and enable them to use this information for quality improvement, consumer choice, value-based purchasing, and other purposes
   • provide a measure that is urgently needed to increase the effectiveness of delivery and payment innovations such as care coordination and woman- and family-centered maternity care homes, bundled maternity care payment systems, and accountable care organizations
   • achieve effective EHR integration across caregivers and care settings.

   There is considerable evidence that the point of hospital discharge is too early to gather data for such a measure. For example, a recently reported study based on a Danish registry found that 77% of the incidence of maternal postpartum infectious morbidity was identified after hospital discharge (Leth et al. Acta Obstet Gynecol Scand 2009, July 29: ePub ahead of print). It would be appropriate for caregivers to complete data needed for this measure with input from women at the postpartum visit that occurs around six weeks after birth, which the majority of childbearing women experience. Such a measure would also serve the valuable purpose of facilitating a caregiver-woman conversation that can foster more appropriate clinical care in the postpartum period.

   There are important examples of tools that have been used to measure a broad range of maternal postpartum outcomes (e.g., Lydon-Rochelle et al. JAMA 2000;283:2411-16). These reports suggest great scope for improveability.

   One of the Quality Measure Workgroup’s criteria for the Phase 2 and 3 measures is enabling the assessment of longitudinal, condition-specific, patient-focused episodes of care. Maternity care is an exceptionally well-demarcated and common episode of care. The proposed measure is impacted by decisions made in pregnancy and during the intrapartum period. Women experience the adverse effects in the postpartum period.

   The volume and costs of maternity care justify inclusion of maternity-specific measures. Further, maternity care is currently characterized by very broad unwarranged practice variation. Condition-specific measures for childbearing women and newborns are also appropriate as quality measures that apply to diverse clinical areas often expressly exclude these populations. With respect to the Quality Measure Workgroup’s other proposed measure criteria, the recommended measure is capable of being incorporated into EHRs, would apply to multiple caregivers (obstetricians, family physicians, midwives) and settings (hospitals, birth centers), and addresses a preventable burden of morbidity in both mothers and newborns.

   Thank you for your consideration. We would be pleased to assist the Workgroup and respond to any questions about these matters.

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5. Elise Burns says:

   December 29, 2010 at 3:10 pm

   Health Dialog thanks the Quality Measures Workgroup for the opportunity to submit the following comments on the quality measures for Stages 2 and 3 of Meaningful Use. Health Dialog currently supports over 20 million individuals by providing population analytics and outcomes measurement, and health coaching for chronic conditions, medical decisions, and wellness.

   I. Patient and Family Engagement
   Self-Management/Activation
   Measures of patient activation, including skills, knowledge and self-efficacy
   Measures of patient activation are necessary to ensure patients are fully engaged in their care. In addition, patients need to participate in their care choices so they can influence key decisions about treatments that affect them. HIT can enable physicians to document patients’ understanding of their healthcare including recommended behavior changes. Surveys can confirm that patients have the needed skills and knowledge to manage their care in an informed and proactive manner.

   Measures of self-management
   Care management must consider the spectrum of healthcare needs across individuals and take into consideration not only their conditions but their living situations, values, preferences, along with their ability to take an active role in their care. Individuals can influence their health care destinies by learning appropriate self-care while changing behaviors that put their health at risk such as poor nutrition, low physical activity, smoking, and excessive alcohol use. Measures need to be developed that document a physician’s assessment of these areas and use and distribution of educational materials and/or referral to a health care coach or other appropriate resource. In addition, a patient’s understanding of his/her condition and self-management skills should be assessed via an on-line survey that can be shared with a physician and/or health care coach.
   To the extent that definitions of meaningful use of HIT promote and expand the capabilities to collect, store, and analyze patient reported experience and outcomes, then these survey tools and capabilities need to be built into an electronic health record (EHR).

   Honoring Patient Preferences and Shared Decision Making:
   Measures of shared decision making or decision quality that address a combination of patient knowledge and incorporation of patient preferences
   Shared decision-making is the process of interacting with patients in arriving at informed, values-based choices when multiple effective treatment options exist. Shared decision-making encourages patients to work with their providers to choose treatment options that are right for them based on their individual situations. Decision aids to support fully informing patients of their choices have been tested since 1980 and in commercial use since 1997. Evidence in the scientific literature shows patients generally choose less invasive treatments and are more satisfied with their care when they have access to such aids.

   Documenting patient knowledge and values is an outcome measure that can be implemented as a routine part of care. Shared decision-making questions should be included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and they should be used in conjunction with additional measurement tools, such as knowledge questions included in decision aids. Completion of the knowledge questions enables documentation of patient participation in shared decision-making.

   On-line decision aids are one effective way of disseminating such knowledge questions. Today, patients at Massachusetts General Hospital receive decision-aids that can be ordered directly through an electronic health record. We should strive to fully integrate this type of on-line decision aids into EHRs through HIT enabled technology. CMS and ONC should work with the Foundation for Informed Medical Decision Making and others to refine and validate knowledge questions, along with the National Quality Forum to endorse knowledge and decision quality metrics that can be incorporated into the measure concepts for Stage 2 and Stage 3 Meaningful Use.

   Measures of patient preferences/experiences of care
   Measures of patient experience of care and patient-centeredness should include transparency and access to care, but also care coordination, care transitions, shared decision-making, health literacy, patient activation, and patient self-management. Documenting and incorporating a patient’s preferences and values when faced with a treatment decision is an important first step toward ensuring care is patient-centered. As described by Sepucha et al. (Health Affairs, Oct.7, 2004), “the quality of a clinical decision, or its patient-centeredness, is the extent to which it reflects the considered needs, values, and expressed preferences of a well-informed patient and is thus implemented.” Providers should be measured on their engagement in shared decision-making including their documentation of a patient’s preferences and values along with incorporating a patient’s preferences into actual treatment decisions. CAHPS medical-home measures include items about the interaction between patients and providers that could be used to determine whether shared decision-making occurred. These measures are currently being tested.

   II. Care Coordination:
   Effective Care Planning
   Measures assessing adherence to a comprehensive care plan in the EHR with an up to date problem list and care plan that reflects goals of care
   This measure focuses on the importance of keeping all health information, such as diagnoses, conditions, allergies, medications, along with advance directives in one place. Measures on the use of care plans by patients and providers must be developed and enabled through EHRs. Care plans must be transferable between providers, health care coaches and patients to encourage same-page care.

   Measures of an advance care plan as a product of shared decision-making
   There is great potential for improvement in both quality of care received and member satisfaction with end of life treatments. By documenting and communicating advance care plans, patient wishes can be honored, which can lead to higher patient and family member satisfaction with end of life treatments. Measuring the use of advance care plans will encourage physicians and patients to enter into these difficult discussions as a serious illness progresses. the end of life. Measuring shared decision-making between a provider/health care coach and a patient (including the use of a decision aid) is important to provide patients with the opportunity to express their values and preferences at this time in their life.

   Measures of reconciliation of medications when receiving a patient from a different provider
   This measure is integral to successful care transitions and chronic care management as it ensures providers discuss medication awareness and knowledge gaps, review new medications, identify contraindications or interactions, , and provide guidance in developing a medication management system. Medication reconciliation measures must be developed to assess the sharing and reconciliation of medication information among providers along with health care coaches and family caregivers.

   Measures of patient and family experience of care coordination across a care transition
   An effective care transitions model teaches patients and/or their caregivers to manage their conditions and navigate the health care system. Measures must be developed to assess a patient’s and caregiver’s understanding of his/her care plan including symptom management and medication reconciliation. In addition, readmissions measures are integral to measure a provider’s coordination with other providers/health care coaches and family members to avoid the risk of readmissions.

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6. Sam Ho, MD says:

   December 29, 2010 at 11:42 am

   UnitedHealth Group submits the following comments on the quality measures for Stages 2 and 3 of Meaningful Use laid out by Quality Measures Workgroup. UnitedHealth Group is dedicated to making our nation’s health care system work better.

   Recognized as America’s most innovative health care company by Fortune magazine, our highly diversified and comprehensive array of health and well-being products and services empowers individuals, expands consumer choice, and strengthens patient-provider relationships.

   Our 80,000 employees serve the health care needs of more than 75 million individuals, develop and advance new health technologies and enhance financial and operational connectivity across the health care system. Our role as a national leader in the quality arena through our benefit and services products in both private and public health benefits programs enables us to foster innovative health solutions aimed at creating a modern health care system.

   We applaud the Workgroup’s initial measure concepts and measure sets as progress in fostering a higher quality structure for the meaningful use program that, if leveraged well, will help improve the quality of care delivered by participating providers. We are especially appreciative of the efficiency measures as they hold the potential to foster appropriate cost containment while at the same time improving care quality.

   We support the approach of working down from conceptual and outcomes based domains, as opposed to building up from percentages of specific measures based on processes. We do not believe the two are incompatible, however. It is important to patients that we identify and fill gaps in areas delineated by the Workgroup. We believe the top down approach will be most fruitful in the long term.

   While we appreciate this initial progress, we urge the Policy Committee to adopt a more robust set of quality measures to help improve the care patients receive. If adopted along with the proposed efficiency measures, we believe the measure sets will also promote cost reduction by promoting care coordination, reducing hospital readmissions and enhancing patient safety efforts.

   Finally, we believe our recommendations fit into at least one of the categories outlined by the Policy Committee (HIT sensitive, parsimonious, demonstrates preventable burden, assesses health risk status and outcomes, and longitudinal).

   Where available we cite as examples NQF Endorsed® measures applicable to our recommendations and not already adopted under Stage 1 meaningful use. In many areas there are limited or no applicable NQF Endorsed measures, indicating a gap that should be filled in order to address the measure concept. Important areas include, but are not limited to, emergency room utilization and a broader array of iatrogenic complications and infections occurring in hospital or other settings. We have drawn attention to a number of those areas in our comments below, and further work will be required to develop the many important measures delineated.

   Domain: Patient and Family Engagement
   • Self-Management/Activation – support
   • Honoring patient preferences and Shared Decision making – support
   • Effective care planning – support
   • Patient Health Outcomes: These are important and we agree that they should address physical, mental and social domains. The key will be to operationalize the measures and develop appropriate action items. The personal health record could be expanded to take these domains into account, and the EHR could be expanded to collect the necessary data during visits.
   • Community Resources Coordination/Connection: this measure set should be viewed as an extension of the prior item in the sense of addressing gaps identified by patient health outcome measures. Resource and provider directories could be coupled with measures of their use, and the outcomes of that use, for example.
   • Applicable NQF measures:
   – NQF 310, Low Back Pain: Shared Decision Making
   – NQF 326, Advance Care Plan

   Domain: Clinical Appropriateness
   • Appropriate/Efficient use of facilities: We strongly support an all condition all cause re-admissions measure, as well as the adjusted length of stay measure (for example the ones currently in use developed and maintained by UnitedHealth Group, NQF #0329 and #0328), and believe that these should be coupled together for use in tandem. They form a conceptual and practical balanced pair of measures that, together, calibrate appropriate utilization and quality of care.
   • Appropriate/Efficient use of facilities: We urge adding back the recommended measure of emergency room to inpatient/observation escalation rate, which supports appropriate use of facilities as well as decreasing patient exposure to hospital acquired conditions and infections
   • Appropriate/Efficient use of diagnostic tests: We recommend adding diagnostic procedures performed by physicians, as well as diagnostic imaging. Overuse of diagnostic testing procedures exposes patients to safety issues as well as unnecessary costs. In all cases efficient use of diagnostic tests includes measures of interoperability such that one EHR user has knowledge of other users’ tests and their results.
   • Appropriate/Efficient use of treatments: We strongly urge retaining the general concept of efficient use of invasive treatments, as well as including the two specific concepts of other measures into this domain (see comments in “Other” below).
   • Appropriate/Efficient use of medications: We suggest adding measures related to polypharmacy, an important patient safety issue. These should include measures that reflect careful documentation and communication about all medications (all medications prescribed, all OTC, vitamins, etc.). Measures of related to medication safety should be included as well, either under this concept or the patient safety concept
   • Applicable NQF measures:
   – NQF 021, Therapeutic monitoring: Annual monitoring for patients on persistent medications
   – NQF 051, Osteoarthritis: assessment for use of anti-inflammatory or analgesic over-the-counter (OTC) medications
   – NQF 097, Medication Reconciliation [at outpatient follow up]
   – NQF 293, Medication Information [transfers from one acute care hospital to another]
   – NQF 309, Low Back Pain: Appropriate Use of Epidural Steroid Injections
   – NQF 312, Low Back Pain: Repeat Imaging Studies
   – NQF 315, Low Back Pain: Appropriate Imaging for Acute Back Pain
   – NQF 328, Inpatient Hospital Average Length of Stay (risk adjusted)
   – NQF 329, All Cause Readmission Index (risk adjusted)
   – NQF 514, MRI Lumbar Spine for Low Back Pain
   – NQF 548, Suboptimal Asthma Control (SAC) and Absence of Controller Therapy (ACT)
   – NQF 552, HBIPS-4: Patients discharged on multiple antipsychotic medications.
   – NQF 553, Care for Older Adults: Medication Review (COA)
   – NQF 554, Medication Reconciliation Post Discharge (MRP)
   – NQF 567, Appropriate Work-up Prior to Endometrial Ablation Procedure
   – NQF 555, 556, 586, and 612 regarding warfarin monitoring
   – NQF 595, 596, and 609 regarding lithium monitoring
   – NQF 597, 598, and 599 regarding methotrexate monitoring
   – NQF 614, Steroid Use – Osteoporosis Screening

   Domain: Care Coordination:
   • We support these measures and suggest that these measures should be used as a foundation for the standard or model for primary care medical homes and ACO care coordination measures and vice versa.
   • Applicable NQF measures:
   – NQF 488/490 regarding use of health information technology to perform care management at the point of care.
   – NQF 491 regarding tracking clinical results between visits. This includes: lab results, diagnostic studies (including preventative screenings), as well as patient EHR-generated referrals and reminders.
   – NQF 494 regarding medical homes medical home setting.
   • In addition we support the AMA PCPI transition of care measures:
   – Reconciled Medication List Received by Discharged Patients
   – Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges)
   – Timely Transmission of Transition Record
   – Transition Record with Specified Elements Received by Discharged Patients

   Domain: Patient Safety
   • We urge adding measures of hospital acquired conditions in general, of which thromboembolic events and falls are only two examples, and hospital acquired infections
   • EHRs should report never events as well. While this will generally be a small number of events, it will promote an understanding that they should never happen.
   • Meaningful use of EHR should include never events, HAC and HAI in the ambulatory surgery and outpatient hospital settings, as well as the inpatient hospital settings.
   • Applicable NQF measures:
   – NQF 464 , Anesthesiology and Critical Care: Prevention of Catheter-Related Bloodstream Infections (CRBSI), Central Venous Catheter (CVC) Insertion Protocol
   – NQF 345, Accidental Puncture or Laceration (AHRQ PSI 15)
   – NQF 346, Iatrogenic Pneumothorax (AHRQ PSI 6) (risk adjusted)
   – NQF 347, Death in Low Mortality DRGs (AHRQ PSI 2)
   – NQF 349, Transfusion Reaction (AHRQ PSI 16)
   – NQF 351, Death among surgical inpatients with serious, treatable complications (AHRQ PSI 4)
   – NQF 363, Foreign Body Left in During Procedure (AHRQ PSI 5)
   – NQF 368, Post operative Wound Dehiscence (AHRQ PSI 14) (risk adjusted)
   – NQF 474, Birth Trauma Rate: Injury to Neonates (AHRQ PSI #17)
   – NQF 533, Postoperative Respiratory Failure (AHRQ PSI #11)

   Domain: Population and Public Health
   • We urge consistent inclusion of outcomes as well as screening for the relevant factors. For example, tobacco quit rate is noted as a measure but for alcohol use it is only screening (rather than decreased alcohol use rate).
   • We encourage the measures to reflect ongoing (e.g. each visit) screening activities.
   • Effective Preventive Services – Mental Health Screening: Depression screening should include populations at high risk for example, post-partum period, adolescents, the elderly, and those with chronic diseases including chronic pain.
   • Health Equity: We agree that this is an important area but the measure concept described seems extremely complex and difficult to implement within individual EHRs. The amount of discrepancy requires not only the outcomes but also aggregation and comparison across populations of interest due to small sample sizes within each sub-population. Such work might be supported by data gathered through EHRs, but is larger in scope than a given physician or hospital EHR itself. Therefore we would support more straightforward direct and concrete measures, such as the ability to communicate in the patient’s language of preference.
   • Applicable NQF measures:
   – NQF 076, CAD: optimally managed modifiable risk

   Domain: Other
   • Measures that assess preventable ED visits: we suggest including this in the Appropriate/Efficient use of facilities category.
   • Measures that assess adherence to clinical practice standards (appropriate cardiac/cancer treatments): are two specific instances of the concept, efficient use of treatments, and those should be added as examples under the general concept in the domain of clinical appropriateness.
   • We support the measures that assess combined quality and cost measures at each level and site of care reflecting potential defects in care and suggest moving this important measure into the care co-ordination domain.
   • A measure of “near miss” in medications implies that the potential error could be identified through logic from data supplied. This can be done through clinical decision support. We suggest that tying this concept to CDS and then measuring the number of times the physician overrides the clinical decision support would be more appropriate to measure.

   UHG recognizes the excellent work done by the Policy Committee members and the Quality workgroup to advance a higher quality, more efficient health system. We look forward to continuing to work together to ensure all Americans have access to a higher value, quality driven health system.

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7. Douglas Duncan MD says:

   December 28, 2010 at 12:34 am

   In viewing the responses, I have made the following observations.
   1. Most of the responses are from organizations or physicians who are involved in information technology or data intensive activities.
   2. Many of the comments and suggestions are specialty oriented pointing out that true “quality measures” vary by specialty. Measures and requirements for meaningful use for a family practitioner should not be the same as a surgical subspecialist who provides episodic care. “One size does not fit all.”
   3. The suggestions on this site list items that one would find listed in a research project design. Such a list of data items is very labor intensive and appropriate for researchers whose job it is to gather and record the data from their research lab. For many who have offered suggestions and whose mindset is in the realm of information technology and research, the meaningful use agenda would provide a gold mine of data for them and save a lot of time and effort. However, by far, the majority of practicing physicians are not “computer geeks.” Such data gathering and data entry is not appropriate for most practicing physicians and will interfere with “tried and true” workflows for taking care of their patients.
   4. Little consideration seems to be given to the impact the meaningful use project has on most physicians’ practices in terms of both workflows and costs.

   Where are all of the practicing physicians in this picture? Where are the doctors who are on “the front lines” taking care of patients? It appears to me that they are being run over by a bureaucratic bus of well meaning techno nerds and left in the dust.

   HHS and CMS are trying to push through a massive agenda in a very poorly thought out timeline that is unrealisitically short. The goals are worthy and noble; however, achieving this goal has to be both a process and an evolution. The criteria (demands, requirements etc.) for meaningful use need to be limited, concise, relevant and tailored to each specialty. There can be some limited criteria that apply to all providers.

   With an excessive amount of data required, much of which is not pertinent for every physician, there is a danger of interfering with individual doctor’s ability to provide care for their patients. The demand for data input by doctors or the increased cost of adding staff to input the data required for measuring quality and “value” has a tremendous impact on doctors’ practices.

   Many of the suggestions made on this site are in keeping with the popular catch phrase “leveraging health IT infrastructure.” But this also leveraging the good will of physicians who have already been pushed to their limits of tolerance by the demands of government and the government’s incompetence regarding reimbursement methods. In the business world, leveraging means using money that does not belong to you to invest and make money. The government’s and other entities’ use of the IT infrastructure is using time (doctor’s time) that does not belong to them. Doctors are becoming increasingly intolerant of this. I see this as a physician EMR facilitator in our 110 multispecialty clinic where we are trying to use the EMR to achieve “meaningful use.” Most doctors’ offices run very lean. Everyone is busy doing something. Unless data entry generates revenue equivalent to revenue from treating patients, the extra time or staff for data entry becomes very costly and an imposition produced by “leveraging” IT structure.

   It appears to me that those involved with the meaningful use planning and implementation need to take the time to take a bird’s eye view of the whole project and process. It should not be a “plan as you go” process. Rethink the plan and timeline. Put together a reasonable plan that takes into account the above observations. You can’t be faulted for any change in plan that results from putting more time and thought into your strategy.

   Doug Duncan MD

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8. Joel White says:

   December 23, 2010 at 4:50 pm

   Quality Measures

   The Health IT Now Coalition (HITN, http://www.healthitnow.org), a group of 62 organizations that came together to promote adoption and use of HIT to lower costs and improve quality, is pleased to offer comments on the measures for Stages 2 and 3 of Meaningful Use laid out by Quality Measures Workgroup. Our membership is diverse; it includes health care providers, small businesses, large employers, unions, patient advocates and consumers, insurers, brokers and agents, and others that share our views. These comments reflect those of the Coalition and not necessarily those of any individual member.

   We applaud the Workgroup’s output as the quality measures are a major step forward compared to the Stage 1 standards. We are especially appreciative of the efficiency measures as these sets will help foster appropriate cost containment while at the same time improving care quality. In particular, we support the inclusion of the following measures as they meet the five goals outlined by the Workgroup.

   Domain: Patient and Family Engagement

   · Self-Management/Activation – We support this measure set and believe that Patient activation is directly proportional to a patient’s perception of his or her access to their healthcare. Ensuring that patients have timely access to relevant information contained in their longitudinal record is critical. We believe that the Stage 1 requirements were dramatically low and that all patients should have timely access to their health information in a human readable form that they can easily provide to a specialist or other clinician. We believe that the MU WG draft recommendation for Stage 3 should be accelerated to Stage 2 and all “Data [is] available in a uniformly structured form by 2015 (HITSC to define; e.g., use of CCD or CCR).” Thus, these measures will help facilitate patient activation.

   · Scope of data sources – data collected from the patient outside of clinical settings(as part of a care plan) should be included in the patient summary as part of the uniformed structured form.

   · Community Resources Coordination/Connection – We believe measuring availability of provider and resource directories and their use would reflect patient access to information on the availability of resources in their community. Informing the patient about their the resources available to them in their care community is critical to ensuring that patients remain active in their health, take preventative steps, and to reduce emergency admissions to care settings.

   Domain: Clinical Appropriateness

   · Appropriate/Efficient use of facilities: We suggest adding a measure of preventable emergency department visits.

   · Appropriate/Efficient use of diagnostic tests: We suggest this measure should include both inpatient (facility) and outpatient and ambulatory settings as office based diagnostic imaging has proliferated.

   · Appropriate/Efficient use of medications: We suggest adding measures for polypharmacy, including documentation of patient communications regarding all medications taken, whether prescribed or not.

   Domain: Care Coordination:

   · We support these measures and urge the Policy Committee to suggest these measures as foundational to primary care medical homes and ACO care coordination measures.

   Domain: Patient Safety

   · Measures monitoring drug safety for patients who are on chronic medical therapy: We suggest a measure for reporting patient outreach for medication therapy management and follow up to ensure compliance with a care plan. These measures are consistent with standards for patient education and follow up used elsewhere in the MU program.

   · Hospital Associated Events: We suggest reporting on never events as defined in the Medicare program. While the number of reports will be small, it is important to continue to highlight problems associated with these events.

   · Other: we encourage extending measures of hospital acquired infections and conditions to physician office, outpatient hospital and ASCs where appropriate.

   Domain: Other

   · Measures that assess combined quality and cost measures at each level and site of care reflecting potential defects in care: We support these measures and believe their inclusion improve patients transitioning to other sites of care by raising provider awareness.

   As a Coalition we believe that quality measures must be strengthened and harmonized with other federal programs in Stage 2 to achieve the measureable outcomes targeted in Stage 3. We believe that pairing increases in meaningful use requirements to existing program standards will raise the bar on system-wide adoption while setting realistic expectations of EHR vendor as well as provider communities.

   We believe that workgroup should create a core set of quality measures that focus on provider delivered outcomes to leverage the abilities of their EHRs to increase the quality and lower the cost of their services. We should also use the quality data to provide feedback to hospitals and physicians so they can learn from their experiences and those of their peers. To achieve this end, we recommend that the workgroup adopt the following National Quality Forum measures as a principled foundation for EHRs to build upon iteratively as best practices are defined:

   · NQF 488/490 requires that provider is able to “use health information technology to perform care management at point of care”; this measure will address the beginning of a patients’ care.

   · NQF measure 489 will provide a firm definition for laboratory exchange by indicating that all patient-encounters that require at least one laboratory test be ordered electronically if it is know that the lab system can return the results as structured data directly into provider’s EHR system; this should be paired with an increase in CPOE requirements to the 65% defined in the Stage 1 IFR

   · NQF 486/487, and an increase of the e-prescribing threshold to the Medicare Part D standard of 75%, will improve clinical quality through systems that can perform drug formulary checks, drug-drug interaction warnings, adverse drug reports, and medication reconciliation for patients being transferred between care-settings.

   In addition to creating a principled foundation, the Health IT Now Coalition would like to comment on what these measures should be working towards in the EHR system: leveraging best outcomes through the ability for providers to use decision-making tools that are only possible because of the EHR technology itself. We believe that clinical support tools are crucial in facilitating high quality inpatient care and strict adherence to care plans. Support tools have the highest capacity to increase the quality of care while dramatically reducing its cost through the elimination of unnecessary interventions. Tying CDS to the quality measures, particularly for patient safety and care coordination should be the highest priority.

   The Health IT Now Coalition recognizes the tremendous scope of the work before the Quality Measures Workgroup and is thankful for the opportunity to comment in this process and we look forward to continuing to work along side the HIT committees and its workgroups.

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9. Elliott Main, MD says:

   December 23, 2010 at 4:32 pm

   There are two areas that i would like to be sure are covered inthe proposed framework. (1) postoperative complications such as wound infections, bleeding and pain are not captured in hospital data sets and require a linkage of office records. THis is critiaclly inmportant as currently many, and in the future most, surgeries will be done as outpatients (and even in surgi centers). Hospital absed and even system-based QI efforts currently suffer greatly form this issue. (2) a critical hand-off that fails in many hospitals is the assurance taht as close to 100% of the time the prenatal record is avaialbale whn the mother comes to the delivery site to give birth. There is critiacl information tha can be lacking.
   Regards
   -Elliott Main MD
   Director, California Maternal Quality Care Collaborative

   Like or Dislike: 2  0 (+2)