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March 6, 2007

The Honorable Michael O. Leavitt

Chairman

American Health Information Community

200 Independence Avenue, S.W.

Washington, D.C. 20201

Dear Mr. Chairman:

The American Health Information Community has identified and prioritized several health information technology applications, or “breakthroughs,” that could produce a specific tangible value to healthcare consumers. To address one of these breakthrough areas, the Quality Workgroup was formed and given the following broad and specific charges:

Broad Charge for the Workgroup: Make recommendations to the American Health Information Community so that breakthroughs in HIT can provide the data needed for the development of quality measures that are useful to patients and others in the health care industry, automate the measurement and reporting of a comprehensive current and future set of quality measures, and accelerate the use of clinical decision support that can improve performance on those quality measures. Also, make recommendations for how performance measures should align with the capabilities and limitations of HIT.

Specific Charge for the Workgroup: Make recommendations to the American Health Information Community that specify how certified health information technology should support the capture, aggregation and reporting of data for a core set of ambulatory and inpatient quality measures.

[Discussion point: Should a paragraph be added near the beginning of the letter to describe the need for common framework that is aligned with a variety of organizations, including payers and employers, to ensure that scalable approaches to quality measurement and reporting are adopted? Also, if added, the paragraph should describe the urgency of the broad charge, and mention that the success of the Quality Workgroup will be judged by how information is used to inform consumers’ health care decisions and to improve care.]

The Workgroup’s deliberations to date have highlighted a number of key needs that must be addressed in the near-term to meet the group’s specific charge, including the following:

  1. Automate data capture and reporting to support core sets of AQA clinician-focused and Hospital Quality Alliance (HQA) inpatient quality measures.

  2. Provide feedback to providers in real or near-real time

  3. Enable data aggregation to allow public reporting of quality measures based on comprehensive clinical data that is pooled across providers and merged, as appropriate, with other data sources.

  4. Align performance measurement with the capabilities and limitations of health information technology.

This letter provides both context and recommendations for how these issues can be addressed so that health information technology can enable and accelerate the consistent delivery of high-quality, safe and efficient care.

BACKGROUND AND DISCUSSION

The Quality Workgroup has developed a high level vision for the future.

The quality enterprise is integral to all aspects of health care in the U.S.:

  1. Every citizen expects consistently high-quality, safe, and efficient care and expects the nation’s unified quality agenda to work toward that goal.

  2. All stakeholdersconsumers, purchasers, providers, regulators, policymakers, and researchersinclude quality performance, measurement, and improvement in their strategies, projects, and routine work.

  3. Information technology and information sharingin the form of electronic health records, personal health records, and other networked technologies, combined with effective clinical decision support, assists consumers and providers in delivering care and improving health consistent with evidence-based practices; in providing information to consumers and policy makers about the performance of individual providers and organizations and the health of the population.

  4. Performance information is timely, comprehensive, and trusted as an accurate and reliable measure of how well the nation is addressing high-priority gaps in quality and safety.

  5. Performance improvement is accelerated.

  6. Progress on quality goals is reinforced by public reporting on metrics and a payment framework that aligns expectations and resources among providers, employers, public payers and private payers.

Consensus on quality metrics is foundational to the realization of the Workgroup’s high-level vision. Therefore, it was important for the Workgroup to first define what “core set” of inpatient and ambulatory measures should be automated first. The Workgroup agreed that the consensus process is critical to convergence on a core starter set and that the measures selected by AQA and HQA represent the current national consensus.

Since discussions about ensuring the quality of healthcare delivery tend to lead naturally into a dialogue about overall health system reform and many aspects of the system are evolving dynamically, the Workgroup needed to bound its work and acknowledge the overlap between the Workgroups efforts and other efforts. The following emerging principles have emerged from those discussions:

  1. The Quality Workgroup will not prescribe specific solutions in areas where market experimentation is currently helping to inform emerging consensus (e.g., data aggregation approaches, public reporting formats, payment reforms).

  2. The Quality Workgroup is likely to take a requirements approach that is focused on enabling the foundational elements of health IT that can support various market approaches to health transformation (e.g., standardization and discrete capture of data elements that are critical for reporting).

  3. As electronic health records will not be the only form of data capture in the foreseeable future, an array of solutions for decreasing the burden of data collection is necessary (e.g., enhancing the use of claims data with clinical electronic data elements such as lab results and medications).

  4. Quality reporting is just one of several secondary uses of clinical data; the synergies with other uses should be reviewed carefully.

  5. Developing an efficient and effective quality measurement and reporting solution will require the skills of many EHR vendors, clinicians, coders, quality experts and cannot be developed in a vacuum.

Through testimony and the development of the vision, the Workgroup has identified critical barriers and enablers for its near-term priorities:

  1. The business case for automating quality measurement must be developed in concert with the incentives for EHR adoption and the sharing of clinical data.

  2. Data aggregation strategies are needed to support public reporting of clinical care at a regional, state and/or national level.

  3. Business process and workflow changes will likely be required to ensure uniform capture of data.

  4. Security and privacy concerns must be addressed.

  5. Consensus is required on a patient identification system that will support quality measurement and reporting.

  6. Translating quality measurement and reporting into improved results for patients requires rapid development and evolution of market competition and collaboration across multiple stakeholder groups.

The Workgroup recognizes that the quality measurement and reporting enterprise is in an early stage and is evolving alongside a health information exchange enterprise that is also nascent. The following recommendations will be subject to periodic review and possible revision as the Workgroup continues to work on both its broad and specific charges from the Community.

RECOMMENDATIONS

The Workgroup identified the following actionable recommendations to meet the specific charge.

  1. Automate data capture and reporting to support a core set of AQA clinician-focused and HQA inpatient quality measures.

The AQA was formed to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician or group level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians, and other stakeholders to inform choices and improve outcomes. www.aqaalliance.org; George Isham, American Journal of Managed Care The AQA has developed a consensus around a starter set of 26 measures of physician quality, and has recently adopted an additional ‘X’ measures. However, the AQA measures are not widely deployed due to adaptive challenges related to collecting data and technical challenges related to aggregating physician data from multiple sources to allow for meaningful comparisons.

The Hospital Quality Alliance (HQA) is a public-private collaboration to improve the quality of care provided by the nation's hospitals by measuring and publicly reporting on that care. The ultimate goal of the HQA is to identify a set of quality measures that would be reported by all hospitals, and accepted by all purchasers, oversight and accrediting entities, payers and providers. The twenty-one measures currently reported on www.hospitalcompare.hhs.gov reflect recommended treatments for heart attack, heart failure, pneumonia and surgical care improvement/surgical infection prevention. Under Section 5001 (a) of the Deficit Reduction Act (DRA) of 2005 (P.L. 109-171), hospitals who choose not to voluntarily report data to CMS for display on Hospital Compare lose 2% of their market basket adjustment for Fiscal Year 2007. Furthermore, the DRA lays the foundation for a nationwide Medicare hospital value based purchasing (VBP) program. Section 5001(b) of the DRA mandates that CMS propose a plan for a VBP-program for Medicare hospital services that could commence in FY 2009. The HQA measures are expected to be strongly considered for that program. The vast majority of the data required to support HQA measures is collected manually, even among hospitals with electronic medical records installed. A major barrier to electronic collection of the data required to measure quality, and therefore a barrier to the rapid expansion of measurement requirements, is the lack of standards for documentation, storage and transmission of such data.

The Quality Workgroup sees opportunities to advance the use of the AQA and HQA measures and to gradually lower the burden associated with manual data collection by accelerating the use of electronic health records to capture and transmit the data required to support the measures and by standardizing the claims data that can be used as a proxy for electronic health records data.

Recommendation 1.1: The Quality Workgroup should create an expert panel to further the current efforts to analyze the data elements, standards, and workflow changes required for core sets of AQA and HQA measures.

Recommendation 1.1.1: The expert panel should consolidate current efforts to analyze the data elements required for each AQA and HQA measure in the core sets. The expert panel should present their detailed findings with a recommended priority list of measures to be targeted for automation and/or a priority list of inpatient electronic medical record modules to be targeted for enhancement to the Community, to AQA, and to HQA by July 31, 2007.

Recommendation 1.1.2: The expert panel should map the requirements for automating the collection and reporting of core sets of AQA and HQA measures to available standards to identify any gaps in agreement or availability of standards and identify groups of measures with similar data collection requirements by July 31, 2007.

Recommendation 1.1.3: The expert panel should consolidate current efforts to identify documentation and any other workflow changes that need to be adopted by providers and vendors to enable data capture concurrent with care delivery for core sets of AQA and HQA measures by July 31, 2007.

Recommendation 1.2: The Health Information Technology Standards Panel (HITSP) should use the work of the Quality Workgroup’s expert panel recommended in 1.1 to identify the data standards to fill identified gaps for data elements required for automation of core sets of AQA and HQA quality measures.

Recommendation 1.3: The Certification Commission for Health Information Technology (CCHIT) should develop appropriate criteria necessary to support the reporting of core sets of AQA and HQA measures in the next round of criteria development.

  1. Provide feedback to providers in real or near-real time

The most effective way to use evidence based medicine to improve health care is to provide feedback to providers regarding recommended treatments in real or near-real time through clinical decision support systems. In the inpatient environment, intervention should occur pre-discharge. In an ambulatory environment, interventions should be synchronized with the timeliness recommended in the medical evidence. Today’s clinical decision support is hampered by the same challenges as retrospective quality measurement; for example, the lack of standards for data capture impedes the timely identification of patients for whom intervention is recommended.

At the population level, clinicians need rapid feedback on their performance. Hospital Compare currently publishes results 9 months after the patient is discharged. Population-level feedback to physicians varies by program, but is also generally at least 6 months old. The Quality Workgroup recognizes opportunities to leverage the data capture that supports the development of the denominator for quality measures, and to leverage the translation of those patient identification algorithms into clinical decision support functionality to help providers know precisely what they need to do (and for whom) to ensure quality of care.

Recommendation 2.1: The U.S. Department of Health and Human Services (HHS) should identify and evaluate patient identification algorithms for AQA and HQA measure populations to assess their fit with automated quality measurement and clinical decision support by October 31, 2007.

  1. Enable data aggregation to allow public reporting of quality measures based on comprehensive clinical data that is pooled across providers and merged, as appropriate, with other data sources.

There is wide agreement that there should be only one quality score per clinician or hospital for each measure in a time period. In other words, neither clinicians nor patients should receive mixed signals about an individual clinician or hospital’s performance. Data aggregation is required to support the uniform measure of quality across providers.

Recommendation 3.1: HHS, working with relevant public and private sector leaders, should identify and articulate the key challenges associated with linking claims data from multiple sources (e.g. physician IDs, claims adjudication processes, data storage/purge policies), and the benefits and challenges of linking clinical data to other data sources, including claims, by June 30, 2007.

[Discussion point: Should there be a recommendation about how to ensure that quality information is usable by consumers, possibly through web-based interfaces?]

Recommendation 3.2: HHS should recommend to the NHIN that its contracting process support effective strategies for enhancing aggregation of administrative data with clinical electronic data to support quality measurement and reporting.

  1. Align quality measurement with the capabilities and limitations of health information technology.

Quality measure design and health information technology development are currently pursued independently of each other, yet the efficient implementation of quality measurement and reporting systems is reliant upon the effective use of health information technology. The Quality Workgroup recognizes an opportunity to reduce the future burden of data collection for quality purposes through increased collaboration and communication between measure developers and health information technology vendors.

Recommendation 4.1: HHS, through the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), along with major measures development organizations, should identify opportunities to enhance the measure development enterprise by consideration of data needs when measures are developed.

These recommendations are supported by information obtained through research and testimony to the Quality Workgroup, which is contained in the supporting documents available at http://www.hhs.gov/healthit/.

Thank you for giving us the opportunity to submit these recommendations. We look forward to discussing these recommendations with you and the members of the American Health Information Community.

Sincerely yours, Sincerely yours,

<<Paste Signature>> <<Paste Signature>>

Carolyn Clancy Richard Stephens

Co-chair, Quality Workgroup Co-chair, Quality Workgroup