Measuring and Managing Quality

Clinical quality measures are the element of the Meaningful Use (MU) program that take the rich database of EHRs and transform those data into usable, meaningful information.

Unfortunately, “we are still largely reporting on old quality measures,” says Paul C. Tang, MD, vice president and chief innovation and technology officer at the Palo Alto Medical Foundation (PAMF) in Palo Alto, Calif. “We need to develop new measures of quality and outcomes that take into account the richer set of data we have available.”

There has been “an explosion of quality measures in the last decade on both the facility side and in the ambulatory setting,” says Brent Asplin, MD, MPH, president and chief clinical officer of Fairview Medical Group in Minneapolis, a practice that has partly shifted its physician compensation to a system based on quality measures (see sidebar, page 11). And in this sea of measures, many leave a lot to be desired in terms of outcomes such as patient safety, population health and reduced costs.

Improving the quality measure system is a work in progress, says Tang, who also serves as the vice chair of the federal Health IT Policy Committee. “Our first goal is to capture rich clinical data in the process of care and develop quality measures that accurately reflect not only the quality of care but also functional outcomes from the care that’s delivered, such as health status and outcomes. Those are the things most important to patients.”

An evolution

Quality measurement is still an emerging science, says Peter Basch, MD, medical director for ambulatory electronic health record and health IT at MedStar Health, an integrated delivery system based in Baltimore. While many quality measures have been around for a long time, most physicians haven’t really paid attention to them. “They haven’t achieved the importance of ‘here’s what I’m paying you for, so make sure it’s an accurate reflection of how you treat your patients,’” says Basch. They haven’t been presented in a way that is transparent or understood by physicians, he adds.  

Numerous hurdles stand in the way of improving quality measure presentation. Basch analyzed the MU Stage 1 quality measures and found that many contained flawed logic. “In fact, if we look carefully at the results depending on the EHR used and how the data were used by a particular physician or practice, the results may be completely inaccurate.” That’s not an indictment of quality measurement, he says, because quality measures traditionally have relied on paper chart and claims abstraction. That requires interpretation which introduces margins of error.

Tang agrees. “At PAMF, we supplemented externally defined measures with our own since most of the legacy measures relied on data from claims and administrative databases. We have found that those are not necessarily good measures of quality and rarely address outcomes.”

Asplin’s practice has proceeded with other quality efforts in the state of Minnesota, which Tang says holds promise, citing the Minnesota Community Measurement as a collaborative designed to accelerate the improvement of health by publicly reporting healthcare information.

Despite strong competition among providers in the state, stakeholders have come together to be transparent about healthcare quality. Ideally, this system could be adapted on a national level. “We want to move toward a widely adopted set of guidelines and a widely adopted set of measures,” says Tang. That allows physicians to compare themselves with each other and work to improve. A standardized system results in quality measures that physicians find “credible and reflects what the physician would like to achieve according to the guidelines they believe in.”

Minnesota’s Institute for Clinical Systems Improvement generated collaboration around care guidelines and quality measures, says Asplin. Another ingredient driving motivation is the public transparency. “We are seeing a lot more transparency about how systems are doing for quality, as well as cost.” The combination of quality and cost measures is affecting consumer behavior about which system to choose.

“That’s just going to accelerate [the process],” says Asplin. “There can be a lot of collaboration around the guidelines and the reporting requirements, but there is still intense competition around execution and who is going to do the best job for the patient. That is a very healthy dynamic for the people we are trying to serve.”

The role of vendors
As providers work to improve guidelines and quality measurements, vendors have room for improvement as well. Specifically, vendors need to improve their products’ usability, says Tang. The biggest challenge for most users, he says, is whether the system can support workflow. Not just any workflow, however, but an efficient clinical workflow. “For example, if you are going to record smoking history­—one of the MU requirements—it’s inefficient to require a physician to go down five clicks to record it in the field specified by the vendor. You need to make the right thing easy to do and I don’t think that’s true of many of the EHR systems.”

Asplin agrees. “The efficiency piece is killing us,” he says. Although EHRs are “wonderful reservoirs of information” and most physicians don’t want to return to paper, “we have to be more efficient at the workflows of delivery of care. I would submit that one of the biggest myths is that electronic health records are already reducing the cost of healthcare. The public believes that, but to date it’s demonstrably untrue both from the standpoint of the investments that delivery systems are required to make and the efficiency challenges. The amount of cost and time to get the information into the record is just dramatic.”

Better and more appropriately designed quality measures also could help with usability, says Basch. We should always be asking whether the measures are based on current evidence and thus current practice, or based on something that is no longer a standard of practice, and thus adds extra work and even cost if a doctor wants to score well on a particular measure. “We don’t just care about measurement for measurement’s sake.”

Basch also compares the current quality measurement process to testing someone’s ability to drive a car in a single lane when the car’s windows are painted black and the dashboard is removed. Of course, the driver isn’t going to be very successful. “I need to see where I’m going, where I’ve been and be able to see and trust dashboard-like indicators.” It’s also more useful for physicians to see their own measurement data themselves, in as close to real time as possible, says Basch, and have the ability to "slice and dice" the data. This allows for physicians to validate measured data, which is necessary for them to trust it, take appropriate actions to modify their performance or even take the extra steps to see how they are doing compared to their peers, even in particular subpopulations, he explains.

Efficiency and usability are closely related to the culture change required to overhaul the way clinicians practice. EHRs and quality measures affect their day-to-day operations and workflow, says Jonathan Kolarik, MBA, BSN, director of health IT for the Oklahoma Foundation for Medical Quality (OFMQ). The organization has used technical expert panels to establish a trusted advisory relationship.

OFMQ works with the state's healthcare organizations to conduct a workflow analysis and find ways to efficiently integrate EHRs into their operations. Workflow analysis is not just how patients move through the facility, but also what the provider feels is important to delivering care, Kolarik says. That includes work on the quality initiatives the provider already has been following. Then, when the EHR is implemented, users can start to pull reports for MU as well as reports applicable to providers that may not fall under MU. “That gives providers ‘a-ha’ moments,” he says. “They realize ‘this really is about me and my patients,’ which brings the effort full circle and provides context to providers.”

“The team begins with the end in mind. As early as the first days of go-live, the team already is thinking about clinical quality measures and documentation. Even as providers are worrying about getting the documentation done, we’re already  guiding the process to help them document faster and more efficiently.”

OFMQ currently works with 26 critical-access and rural hospitals and hopes to assist more facilities with their quality measure efforts. Of the critical-access hospitals in Oklahoma that have attested to MU Stage 1, 70 percent have been successful. “That speaks volumes that our process and our onsite model is a successful one,” says Kolarik.

The organization is fortunate in that they have numerous highly qualified health IT experts on its roster. Because many smaller hospitals cannot access those resources on their own, “we bridge that gap wherever we can,” says Kolarik. “We work hard to collaborate with providers to train ourselves out of a job. We give them as many resources as they need and can handle, so they can make smart decisions without us there every day.”

Stage by stage

Meanwhile, the stages of the MU program move forward. Stage 2 increases the requirements for patient engagement which is good for Oklahoma facilities, says Kolarik. “We’ve discovered through our efforts in the past three years that Oklahoma providers respond best when we’re involved with them at the community level, face to face. Consumer awareness is likely to be successful at a grass roots level. Providers initiate conversations with patients about portals, health information exchange and opportunities for their data to become more discrete.”
Many quality measures in Stage 1 were “problematic,” says Basch, because of the rushed deadline to get something out for Stage 1. The quality measures of Stage 2 are in many cases improved “and they point toward activities that need to be done to make care better.” The Stage 2 quality measures also are more inclusive of specialties. Basch expects continued improvement in measure logic and their electronic specification into EHRs for Stage 3, as he expects Stage 3 will call on providers to use their EHRs to show high quality care, as demonstrated by their scores on relevant quality measures. “We’re still in flux, but we’re moving to a better place. When measures were theoretical, providers didn’t care about them but with hundreds of thousands of clinicians using them, doctors will want to join in the work to make them better.”

The HIT Policy Committee has been working on Stage 3 for some time, says vice chair Tang. Top priorities include interoperability and care coordination. Care coordination is an area “where there is opportunity to get better care and better outcomes. We also know that’s where the errors are occurring with handoffs or transitions. Care coordination manifests itself in many ways which all contribute to providers being on the same team.”

Tang says the committee also is focused on improving patient-generated data. Functional status, for example, is an outcome that’s important to both patients and providers but is not currently measured. “The best people to ask are the patients,” says Tang, about such things as mobility and pain level. With patient portals and personal health records, “we now have access to information that can come from patients on a continuing basis and can be structured and reported on.” Data from mobile devices also interest providers, he says, and can drive better measures going forward.

Meaningful Use needs to increase its focus on care coordination and transitions of care, as well as improve inclusion of specialists, says Asplin. His organization is emphasizing coordination between primary care and specialty care through its incentive programs.
He’s also interested in the quality measures that the Centers for Medicare & Medicaid Services has released for the Medicare Shared Savings Program and the Pioneer accountable care program. The two programs use the same set of 33 quality, experience and safety measures.

“Those measures support value-based care for populations and performance on the triple aim because ultimately that connection of delivering better quality, a better care experience and getting at cost trends over time is the ‘sweet spot’ of what we are trying to do. It will be very interesting to see how that set of measures performs and how we need to alter it, modify it, add to it, subtract from it in our efforts to deliver the triple aim for our patient populations.”

The Stage 2 quality measures also are more inclusive of specialties. Basch expects continued improvement in measure logic and their electronic specification into EHRs for Stage 3, as he expects Stage 3 will call on providers to use their EHRs to show high quality care, as demonstrated by their scores on relevant quality measures. “We’re still in flux, but we’re moving to a better place. When measures were theoretical, providers didn’t care about them but with hundreds of thousands of clinicians using them, doctors will want to join in the work to make them better.”

The HIT Policy Committee has been working on Stage 3 for some time, says vice chair Tang. Top priorities include interoperability and care coordination. Care coordination is an area “where there is opportunity to get better care and better outcomes. We also know that’s where the errors are occurring with handoffs or transitions. Care coordination manifests itself in many ways which all contribute to providers being on the same team.”

Tang says the committee also is focused on improving patient-generated data. Functional status, for example, is an outcome that’s important to both patients and providers but is not currently measured. “The best people to ask are the patients,” says Tang, about such things as mobility and pain level. With patient portals and personal health records, “we now have access to information that can come from patients on a continuing basis and can be structured and reported on.” Data from mobile devices also interest providers, he says, and can drive better measures going forward.

Meaningful Use needs to increase its focus on care coordination and transitions of care, as well as improve inclusion of specialists, says Asplin. His organization is emphasizing coordination between primary care and specialty care through its incentive programs.
He’s also interested in the quality measures that the Centers for Medicare & Medicaid Services has released for the Medicare Shared Savings Program and the Pioneer accountable care program. The two programs use the same set of 33 quality, experience and safety measures.

“Those measures support value-based care for populations and performance on the triple aim because ultimately that connection of delivering better quality, a better care experience and getting at cost trends over time is the ‘sweet spot’ of what we are trying to do. It will be very interesting to see how that set of measures performs and how we need to alter it, modify it, add to it, subtract from it in our efforts to deliver the triple aim for our patient populations.”