Quality Workgroup Summary, 03-13-08

American Health Information Community
Quality Workgroup
Summary of the 16th Web Conference of This Workgroup
March 13, 2008

PURPOSE OF MEETING
This meeting of the American Health Information Community (AHIC) Quality Workgroup (QWG) addressed the following objectives:

Discuss Draft Measurement Development Process Diagrams
Discuss potential QWG recommendations to the Community
Learn more about the latest work of the Community’s Ad Hoc Clinical Decision Support (CDS) Planning Group

All meeting materials referenced below are available at http://www.hhs.gov/healthit/ahic/quality/quality_archive.html

KEY TOPICS
1. Call to Order
AHIC Director Judy Sparrow called the Web conference to order at 1:05 p.m. She reminded participants that the meeting, like all AHIC workgroup meetings, is designed to meet the requirements of the Federal Advisory Committee Act (FACA).

2. Opening Remarks/February 8, 2008, Meeting Summary
Co-chair Carolyn Clancy asked for and received approval of the February 8, 2008, Meeting Summary.

Dr. Clancy noted the transition taking place from AHIC 1.0 to AHIC 2.0 under a collaborative/consortium effort led by LMI Government Consulting and the Brookings Institution. AHIC 2.0 is holding regular public meetings to share planning process details (see http://www.ahicsuccessor.org). A transitional Workgroup will be formed to plan the transition across existing Workgroups. Dr. Clancy and co-chair Rick Stephens have begun to anticipate the need to make AHIC 2.0 the recipient of some of the QWG’s forthcoming recommendations. QWG planning for the remainder of this year and for the transition will be addressed at the WG’s next meeting as well. Dr. Clancy added that on the basis of what she has seen and heard the transition will be smooth. There were no comments.

Discussion of Transition
Charlene Underwood expressed concern that the QWG’s vision and plan be carried forward in the transition. That “we don’t need to start over” should be reinforced. Dr. Clancy said that is an important point, but “no matter how the successor shapes up” or who is in the White House in January, issues that the QWG and other WGs have tackled will persist.

Mr. Stephens asked whether a cover letter should be sent to AHIC 2.0 when the QWG forwards its recommendations to AHIC 1.0 (the Community) for its April 22, 2008 meeting, to which Michelle Murray responded that she expects that to be made clearer when the chair of the transitional workgroup is named, but she anticipates there will be a way to pass QWG’s work on to AHIC 2.0. Dr. Clancy emphasized that she has shared the QWG’s work products with parties connected to AHIC 2.0 and that the QWG’s work seems to resonate with them, noting also that staff has recently touched base with another critical stakeholder group--consumers.

2. Discussion of Draft Measurement Development Process Diagrams
Dr. Clancy provided background on draft measurement development process diagrams produced by staff based on two meetings held last fall and winter among stakeholder groups as well as interviews (Slide 1). The draft diagrams describe current and proposed future measurement development and definition processes. Dr. Clancy said the current process for developing and using measures is “a bit fragile” and supported by few conventions. In order to identify how to move to a better future involving health information technology (HIT), it is important to gain a sense of the evolutionary flow of how measures are developed now and could be in the future.

Dr. Clancy asked for discussion of the first draft diagram, “Evolving Quality Measurement Development and Definition Process Flow,” particularly on missing elements (Slide 2).

Key ensuing discussion points included:

Mr. Stephens asked, once measures are in use, at what point and how will consumers be educated about using these criteria for their own assessment and support, to which Dr. Clancy proposed that consumers be engaged on this question.
The model of measure development displayed by the diagram is not the one the National Quality Forum (NQF) is moving toward in that it doesn’t address, for example, aspects such as care coordination or patient engagement in decision making. One way to address that is to add the National Priority setting piece or process to the diagram, which NQF is actively working on, including from patient perspectives and how they can/should inform measure development.
The evolving diagram is really the current state, but it changes or has the potential to change every few months.
The draft “‘Potential Future’ Quality Measurement Development and Definition Process (Slides 3 / 4) depicts what we want the future to look like, but it doesn’t address points just made about the process NQF is moving toward in terms of what is important to consumers, although, Mr. Stephens commented, patient and health care provider perspectives are “equally important.”
It seemed to be agreed that health plans should be added to the evolving process diagram in a measure implementation category.
A measurement framework tied to value is a good concept; however, an evaluation process is needed early on that helps identify the cost of getting needed data as well as addresses standardization of data capture.
The diagrams are intended to help develop understanding; with decision points possibly to follow that could be formalized by the QWG or handed off to another group.

Agreeing with Janet Corrigan that each step of the evolving process needs to be “crystal clear,” particularly about responsible entities, Dr. Clancy concluded discussion on the first diagram also noting other members’ calls to (1) emphasize patients and (2) to address early on key aspects of a value-based measurement process, such as identification of needed data and standardization of data capture.

Potential Future Diagram
Dr. Clancy asked for discussion of the “Potential Future” diagram on the next two slides (3/4), noting that the first page looks at the process from a quality perspective and the second outlines such aspects as data elements. Both pages contain questions to the right.

Key ensuing discussion points included:

The Centers for Medicare and Medicaid Services (CMS) should not be depicted as a Quality Alliance, and Quality Alliances should be depicted slightly differently, as in acting to prioritize use of approved measures for different purposes, such as public reporting.
National priorities should be depicted as leading to some sort of prioritization in guidelines and measures to be developed, although this also begs the issue of funding.
Public priorities inform research in different ways, some of them very selective.
Where will evidence come from when patients want information in areas where evidence is lacking? Where will funding come from to help specialty societies do what they do, because, presently, they lack funding?
The diagram should make clear that there are two national priority setting functions, one being pursued by NQF and the other, which is under discussion.
A feedback loop needs to be acknowledged between national priorities for quality improvement and gaps in the evidence base (Dr. Corrigan mentioned that an Institutes of Medicine [IOM] roundtable is developing a national priority setting process for building the scientific evidence base).
Because in the real world, many of these activities will be involved in the same funding streams, it might be well, it seemed to be agreed, to focus on the immediately important, specific tactical steps that can be taken to move toward the ultimate goal of quality improvement.

Mr. Stephens noted discussion of the need for clarity in the process and roles of the organizations involved as well as gaps, wondering about the degree to which QWG should deal with some of these questions or whether an entity such as AHIC 2.0 would. The staff responded that a narrative accompanying QWG recommendations could address some issues not specifically reflected in the diagrams.

Key continuing discussion points included:

Dr. Underwood proposed that first reference to quality data set be changed to reference a quality data “strategy,” which Dr. Clancy called “very helpful,” and that the steps between standards harmonization and certification include gathering baseline evidence on what works and what doesn’t.
Jerry Osheroff proposed that rather than discuss specific answers to some of these questions there be a mechanism for bringing stakeholders together to discuss outstanding issues. This would, Dr. Clancy commented, help cast a focus on funding and “shared responsibility,” including areas identified on the diagram in yellow boxes, such as identifying CDS content and technical standards to support quality measures.

After further discussion, of the need for precise terminology and connections related to a data strategy and data elements, for example, and possibly the need for examples, Mr. Stephens suggested that an appendix detail the who and the what. Dr. Clancy said the discussion had been very helpful and suggested that members send further, specific comments to Michelle Murray at michelle.murray@hhs.gov.

Action Item #1: Members with specific comments on the Draft Measurement Development Process Diagrams should send their comments to Michelle Murray at michelle.murray@hhs.gov.

4. Discussion of Potential QWG Recommendations to the Community
Dr. Clancy stated that this next set of recommendations, when finalized, will be brought to the Community’s April 22, 2008, meeting, then provided background on the potential recommendations before members today (Slide 2), noting that final recommendations should focus on opportunities to achieve substantial progress in the next year.

Dr. Clancy noted critical questions to consider (Slide 3), the QWG’s notional Roadmap draft, and key themes (Slides 4-6). Her comments on key themes included:

That the QWG may need to focus on functional aspects of health information exchange (HIE)
That mention of National Priorities should make clear these are for quality improvement
That proactive consideration of health information technology (HIT) needs to support quality is densely worded and needs clarification per previous discussion
That a hybrid data strategy should not disincentivize clinicians

Prelude to Draft Recommendation 1.1
Dr. Clancy noted the Roadmap component of Measure Set Evolution (Slide 7), commenting that late 2009 may be fair for the mid-state and that consumers have been added as key players. A member noted that the national priorities include cost-cutting areas that are not condition specific, such as health care infections, to which Dr. Clancy responded that the Community presentation should be clear on that point and others.

Dr. Clancy reminded members of the two major transitions soon to take place--in the Community and the Administrationand asked them to focus this latest set of recommendation more on process than on who will do the work. While in some cases, who needs to do the work will be self-evident, she added, while in other cases that question will be more sensitive due to funding issues, for example.

Draft Recommendation 1.1
Dr. Clancy characterized Recommendation 1.1 (Slide 8). Key discussion points included:

That the transition to AHIC 2.0 should not be considered in terms of the recommendation’s dates
That interconnection with CDS momentum should be considered
That although CDS is “bigger than quality,” Dr. Clancy would like to avoid compartmentalization; rather, “hand-offs to each other” in a clear fashion is desirable

Prelude to Draft Recommendation 2.1
Dr. Clancy turned to the Roadmap component of Quality Data Set (Slide 9).

Recommendation 2.1
Dr. Clancy characterized Recommendation 2.1 (Slide 10) and its sub recommendations, 2.1.1 (Slide 10) and 2.1.2 and 2.1.3 (Slide 11), commenting that in terms of 2.1.3; she is concerned about how specific the QWG should be about maintenance of a minimum quality data set over time out of concern about creating an unfunded mandate that might be disregarded. Key ensuing discussion points primarily concerned a continuing role for the NQF’s HIT Expert Panel (HITEP) in evolving the quality data set as measures evolve as opposed to HHS in coordination with the Quality Alliance Steering Committee and the AHIC successor, with questions raised about NQF’s core business functions and whether a maintenance effort could succeed if NQF was solely involved.

Dr. Clancy concluded this discussion by suggesting that key points made by staff be captured in the Letter’s preamble and prelude to the quality data set recommendationsthat is, in part, in “today’s world we fix things by testing and harmonization, and where we need to move to is fixing by design,” as in the quality data set.

Recommendations 2.2, 2.3, and 2.4
Dr. Clancy characterized Recommendations 2.2, 2.3 (Slide 12), and 2.4 (Slide 13) and asked for comments.

Key ensuing discussion points included Mr. Stephens’ summarization of the key threads in all of the recommendations, including Recommendation 3.1, i.e., that the first recommendation is about aligning and integrating all the organizations’ activities, the second set of recommendations is about trying out some stuff and making sure we have the data, and the third recommendation is about how to prioritize what needs to be deployed on a much broader scale on a priority basis. Mr. Stephens then asked if the QWG has a good mechanism for sharing all this so that stakeholders have a chance to see all the work being done and to comment on it. Additionally, there is the question about whether funding exists for such sharing, as all the recommendations seem to presuppose a mechanism for that.

Responding, Dr. Clancy said there are mechanisms for sharing, but funding issues are “particularly acute.” A number of forums exist that will be effective because interested parties are energized enough to bring information back to their home organizations. Development of the quality data set does, however, “put us in the cross roads.” Some involved will have to make decisions under conditions of uncertainty, but “most of them do not have the option to do nothing.” Dr. Clancy noted that CMS has done a terrific job in many areas, anticipating what the U.S. Congress was likely to mandate, for the most part, and has begun to put systems in place. Funding issues are interesting for two reasons: (1) As Dr. Tuckson pointed out, there is no clear-cut funding stream for the development of measures and related activities and (2) given that we are in an election year, it may be that the Federal Government will be on a continuing resolution for awhile.

Mr. Stephens asked if QWG’s recommendations could address elements that AHIC should be supportive of in terms of legislation. Dr. Clancy answered yes, adding that “what we are bringing to the successor is the product of our best thinking on what needs to happen, who are the key players, how that can happen, and where there are the gaps. One of those gaps is resources.”

It was proposed and seemed to be agreed that the Letter of Recommendation preamble could address funding concerns in the context of, for example, a three-year plan, with staff adding that the recommendations could inform future budgets under a new Administration. Staff also suggested that Mr. Stephens’ comments on the need for sustainable mechanisms for sharing data could be added to overarching comments that could address the lack of a clear revenue stream to follow through with HIE demonstrations. Dr. Clancy responded that the QWG should not dictate what HIE looks like because it is not clear at present what it will look like, in part because market models are lacking, yet agreed that sharing mechanisms could be addressed in a preamble.

Discussion turned to Recommendation 2.4. Key points included:

Whether the language clearly captures the need for electronic health records (EHRs) to capture data for the quality data set and also calculate quality measurement
Whether both the algorithm for calculating the measures and export of the information should be addressed
Whether it makes sense to have some link in this certification recommendation to CDS and also address easier calculation of numerators and denominators (although this could take longer than 2010)
Whether if the recommendation is looking to get the quality set out of EHRs, can it also address import specifications for EHRs

Staff said they would investigate key discussion points with the Commission for Certification of HIT (CCHIT) and report back to members.

Action Item # 2: Staff will investigate key discussion points regarding QWG Draft Recommendation 2.4 with the CCHIT and report back to members.

Prelude to Recommendation 3.1 and Recommendation 3.1
Dr. Clancy noted the Roadmap component of expanded data element standardization

(Slide 14) and characterized Recommendation 3.1 (Slide 15), commenting that HITSP does a “terrific job” yet has neither the mandate nor resources to anticipate and be proactive, particularly “where we need clinical depth.”

Key ensuing discussion points included:

Health plans need to be added to the Recommendation (Dr. Clancy agreed).
Additional language is needed to frame the recommended activity in a business process way that is more explicit and focused about identification of gaps and recommendations for closing them, to “insure that gaps will be addressed.”
The expert panel should be convened and appropriate Standards Development Organizations (SDOs) identified sooner rather than later, possibly 2008 and 2009.
Because the gap in production of documentation standards reflects lack of a clear HHS budget focus, AHRQ’s ALM “has a big role here,” Dr. Clancy commented.

Conclusion
Concluding the discussion, Dr. Clancy noted that members also received a Draft Letter of Recommendation, that important wording improvements had been suggested during discussion, and asked members to send additional specific changes to Ms. Murray.

Action Item #3: Members should send additional specific wording changes to the QWG draft recommendations to Ms. Murray at michelle.murray@hhs.gov.

5. Discussion of the Latest Work of the Ad Hoc CDS Planning Group
Dr. Osheroff provided an overview of the Planning Group’s work to date and updated members on the latest iteration of CDS proto-recommendations which, when finalized, will be presented to the Community at its April 22, 2008 meeting.

Key presentation points included:

CDS in this context equals a wide spectrum of interventions, not just alerts to physicians.
CDS efforts internal to the Federal Government are to be coordinated through a CDS Collaboratory (which may be in place by the Community’s April meeting), with a focus on funding and implementation activities.
Today, QWG members are being asked to provide feedback on the latest CDS Recommendations and provide more in-depth comments later as well. Staff will provide initial feedback to the Planning Group by March 20, and final recommendations will be sent to all involved WGs in advance of the April 22 meeting.
“Very substantial” revisions have been made to the Draft Recommendations based on feedback (summarized in Slides 8/9 and detailed in Slides 9-16).
The latest draft focuses on three major categories of activities: the first deals with identifying “high leverage moves” in CDS needed to drive measurable progress toward National Priority goals for quality improvement and involves the previously mentioned Collaboratory; the second deals with creating a public/private Alliance to facilitate and coordinate forward momentum; and the third deals with leveraging the Alliance to advance specific CDS activities relating to WG charges.
Key aspects of the Alliance’s “catalytic” role relate to coordination, acceleration, and bringing stakeholders together.
Dr. Osheroff asked QWG members to pay particular attention to Recommendations 1.2 and 2.2the latter because it relates to QWG Draft Recommendation 1.1.

Key initial discussion points included:

A broader framework for achieving National Priorities is needed.
As a corollary, coordination and planning for all quality work is needed, not just around CDS.
How do these recommendations relate to the strategic plan process and AHIC 2.0? Is the timing right?

New Entity Needed?
Responding to a number of additional members’ comments about whether a new entity (the Alliance) is needed even though CDS is critical and how much authority an external group could have, Dr. Osheroff commented:

That bringing CDS and measurement planning together is a point well taken, but at present, a great deal of money is being spent to improve CDS, so there is an “urgent” need to coordinate those activities, not only through the Collaboratory but also then through a non-governmental Alliance that would not be a new entity as much as a forum for communication and interchange
That “strong business drivers” exist for bringing stakeholders together around CDS because there is clamoring for better outcomes and, at present, various CDS-related activities are occurring in an un-coordinated fashion

Role of AHIC 2.0
Responding to member queries about AHIC 2.0 and the role it might play in CDS, Ms. Cronin commented that AHIC 2.0 is unlikely to take on specifics in the near future (more likely so in 18-24 months), so the question becomes whether coordination of CDS shouldn’t begin immediately, with the possibility that some activity will be folded into AHIC 2.0 as it evolves. Dr. Clancy observed that what the Community or its successor can do is speak with one voice about the explicit needs and goals of the enterprise. The biggest power there is the ability to say, we “have to have this…we have to get this right because without it, this health care system will blow up.” She added that part of her issue with creation of an Alliance is that this may simply “expand the circle of folks who think about being intoxicated with possibilities rather than trying to figure out a tighter alignment between what we have to have in health care.”

Conclusion
Kristine Martin Anderson commented that CDS is tied up with IT adoption issues, yet the “common pain” has not yet reached the point where the entities involved are coming together on their own saying they need a common CDS solution. It makes “perfect sense” to accelerate CDS, but the “hard part is how to get people to demand something for which they haven’t experienced sufficient common pain.” James Ellzy (DoD) added that providers who have invested in CDS systems feel they are not getting what they’ve been sold, setting up resistance. CDS systems require much data entry, yet there are problems in terms of what providers are getting out of them.

Dr. Clancy proposed that more of an exploratory process could be considered, such as a summit, reiterated her support for the first part of the CDS Draft Recommendations, and suggested that Dr. Osheroff take the QWG’s discussion back to the Planning Group. The QWG will communicate further thoughts through Ms. Murray.

Dr. Underwood stressed that linking CDS with some of the measures is low-hanging fruit that is already being demonstrated and that convergence of CDS and quality measures is needed rather than an additional CDS “piece.” Convergence is particularly important to smaller vendors, she added.

6. Next Steps
The next meeting of the Community is April 22, 2008, and the next QWG Meeting is April 30, 2008, from 1-4 p.m. EST.

Dr. Clancy reiterated that members should send further comments to staff on the QWG Draft Recommendations, noting that staff may also contact members for further modification and refinement of discussion points made today.

7. Public Comments
Louis Diamond, Thomson Healthcare, commented that financial metrics need to be considered in the discussion points today about CDS at point of care and quality measures, including the cost of various services as well as efficiency, because such metrics have implications for rolling out the HI infrastructure “to do what we are planning to do in something called the quality space.”

Dr. Clancy responded that while this suggestion doesn’t necessarily fit the QWG’s mandate, financial considerations and quality should be linked and that should be dealt with going forward with QWG recommendationsperhaps in the preamble or in the presentation--for at least two reasons: (1) the billing enterprise is necessary for success and (2) time and date stamps for quality measures sometimes necessitate the need for both clinical and administrative data.

8. Adjournment
Dr. Clancy adjourned the meeting at 3:53 p.m.

SUMMARY OF ACTION ITEMS

Action Item #1: Members with specific comments on the Draft Measurement Development Process Diagrams should send their comments to Michelle Murray at michelle.murray@hhs.gov.

Action Item # 2: Staff will investigate key discussion points regarding QWG Draft Recommendation 2.4 with the CCHIT and report back to members.

Action Item #3: Members should send additional specific wording changes to the QWG draft recommendations to Ms. Murray at michelle.murray@hhs.gov.

MEETING MATERIALS
Agenda
QWG Meeting Summary (February 8, 2008)
Measure Development Process Diagram
QWG Draft Recommendations Slides
QWG Draft Recommendations Letter
Osheroff: Updated CDS Draft Recommendations Presentation
CDS Draft Recommendations v 3.2 (Letter)
“Healthcare at the Crossroads: Development of a National Performance Measurement Data Strategy” (Joint Commission Press Release)

Quality Workgroup
Members and Designees Participating in the March 13, 2008 Web Conference


Co-chairs
Carolyn Clancy	HHS/Agency for Healthcare Research and Quality
Rick Stephens	The Boeing Company

Office of the National Coordinator for Health Information Technology
Kelly Cronin
Michelle Murray

Members and Alternates
Janet Corrigan, Helen Burstin, Dan Rosenthal	National Quality Forum
Mike Kaszynski (for Anne Easton)	U.S. Office of Personnel Management
Susan Postal	Hospital Corporation of America
Michael Rapp, Martin Rice (for Barry Straube)	HHS/Centers for Medicare & Medicaid Services
Jonathan Teich	Brigham and Women’s Hospital
Reed V. Tuckson	United Health Group
Charlene Underwood	Siemens Medical Solutions
Jason Ormsby (for Margaret VanAmringe)	Joint Commission
William Tierney	Regenstrief Institute, Inc.

Senior Advisors and Guests
Kristine Martin Anderson	Booz Allen Hamilton
Justine Carr	Beth Israel Deaconess Medical Center
Brittany Chow	Booz Allen Hamilton
Tammy Czarnecki	VA
Louis Diamond	Thomson Healthcare
Roshunda Drummond-Dye	American Physical Therapy Association
James Ellzy	DoD
Paul Gammill	HHS
Chris Lamer (for Theresa Cullen)	HHS/Indian Health Service
Jeanette Thornton	AHIC
Jonathan White	HHS/Agency for Healthcare Research and Quality

Presenters
Jerry Osheroff	Thomson Healthcare

Disclaimer: The views expressed in written conference materials or publications and by speakers and moderators at HHS-sponsored conferences do not necessarily reflect the official policies of HHS; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.