Quality Workgroup: December 2007 Meeting Summary

American Health Information Community

Quality Workgroup

Summary of the 14th Web Conference of This Workgroup

Friday, December 14, 2007

PURPOSE OF MEETING

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

Learn more about the National Committee on Vital and Health Statistics (NCVHS) work on data stewardship
Learn about the Centers for Medicare & Medicaid Services (CMS) and their experiences with required data sets
Discuss the QWG’s Draft Vision Roadmap and potential recommendations to AHIC
Discuss 2009 use case priorities

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

KEY TOPICS

1. Opening Remarks / October 31, 2007, Meeting Summary

QWG Co-chair Carolyn Clancy reflected on highlights of the WG’s year, including ongoing work to create a Quality Vision Roadmap to advance from the current “snapshot” state, where measures are oriented to sites of care, to a “movie” state that is oriented longitudinally, following patients as they traverse the healthcare system. Over the past year, the WG has envisioned an electronic health record (EHR) infrastructure that helps physicians to do the best job possible from the outset.

2. Data Stewardship Presentation

Dr. Justine Carr, who, in addition to her NCVHS service, is Senior Director, Clinical Resource Management, Beth Israel Deaconess Medical Center. The NCVHS is a long-standing advisory committee to the Secretary that has conducted in-depth analysis of complex technical and policy issues for many years, including work this year on data stewardship, which recently resulted presentation of recommendations to AHIC at its November meeting.

Dr. Carr gave a presentation entitled, “Enhanced Protection for Uses of Health Data: Recommendations to HHS on a Data Stewardship Framework.” This slide presentation reiterated background on the NCVHS Quality Work Group’s (WG) preliminary findings on uses of health data previously provided to the QWG in October.

While Dr. Carr’s testimony highlighted the great benefits of health information technology (HIT), it also outlined two areas of concern: (1) the potential for erosion of trust in the healthcare system and the subsequent impact on healthcare quality and (2) the potential for discrimination and confidentiality problems due to an increased ability to collect longitudinal data, coupled with sophisticated means to re-identify data. Ongoing areas of WG focus and study include uses of de-identified data and overlap between quality and research in uses of health data.

Discussion of Data Stewardship Presentation

Discussion highlights focused on the following issues:

The critical importance of further NCVHS study of the spectrum of possible uses of de-identified data, including sale of such data and the potential for re-identification of such data
The need to educate the public about the benefits and uses of health data
Growing interest in transparency in quality reporting, as evidenced by recent agreements between the New York State Attorney General’s Office and several healthcare plans that begin to clarify the need for transparency conventions
The need for institutional or organizational oversight of data uses for quality, in part to assist understanding of these uses and add value

In response to a question about next steps and timeframes for moving forward toward NCVHS recommendation implementation, Dr. Carr responded that the report (approved by the NCVHS but not yet formally released) references using current demonstrations to learn how real issues play out. Most immediately, there may be ways to use NHIN trial implementation to test the recommendations and explore the concept of more specificity and accountability in business associate agreements about what data is of interest, where it goes, who is using it, and if it is being sold how and for what purpose.

In concluding remarks, Dr. Clancy made two additional suggestions: (1) Present the NCVHS recommendations to the HHS Data Council, and (2) Include hearings in the NCVHS further exploration of the continuum between quality and research.

Regarding NCVHS exploration of de-identified data issues, Dr. Clancy noted that proposed rule-making for the Patient Safety and Quality Improvement Act may make challenges regarding aggregation of de-identified data from patient safety organizations more publicly apparent.

3. CMS and Required Data Sets Presentation

Dr. Rapp’s slide presentation entitled “Post-acute Care Resident Assessment Minimum Data Sets” focused on the purpose, history, and uses of post-acute data sets and implications for use in the hospital setting; challenges associated with current patient assessment tools; and the benefits of the Continuity Assessment and Record Evaluation (CARE) instrument as a driver of healthcare measures and outcomes. Following the presentations, discussion focused on the CARE instrument and the Quality Data Set concept.

Discussion of the CARE Instrument

Margaret VanAmringe asked how burdensome a CARE-like instrument would be to hospitals. Judy Tobin, who served as a CMS project officer for development of the CARE instrument, responded that CMS is sensitive to burden issues and that the demonstration (which will involve 10-15 markets across the country with a minimum of 150 providers) is expected to teach CMS a great deal about how to pare the instrument down. Dr. Rapp added that the concept of care coordination would dovetail nicely with the concept of broadening use of the CARE instrument after demonstration and that the utility of such an instrument might be substantial to hospitals, given proper interfacing with their IT infrastructure.

It was also noted that CMS intends to work with relevant groups about import and export of data from EHRs and CMS is striving to make instrument use fit with workflow and front-end systems. Additionally, it will be useful for CMS and vendor organizations and CMS and staff to talk further about standards emerging from the HIT Standards Panel (HITSP) and Certification Commission for HIT (CCHIT) EHR certifications. Later discussions between CMS and National Quality Forum (NQF) representatives may also address how CMS’ work could be harmonized with NQF’s comprehensive chronic care measurement framework.

Discussion of the Quality Data Set Concept

Discussion of the quality data set concept included the following comments and observations:

Addressing the quality data set concept, Dr. Rapp noted that some quality measures can already be calculated from the CARE instrument. He suggested that the workgroup examine additional data elements that hospitals need for quality reporting and consider data elements that are more broadly useful to collect on anyone who is hospitalized, given that the MDS has already been expanded to include vaccinations.
The concept of MDS could be synergized with current work on the standard for the Continuity of Care Document (CCD) to export data in a discharge summary
Clinical effectiveness nurses in hospitals who assemble core measures information could benefit from an MDS for core measures
CMS expects to revise the CARE instrument overtime so that only useful items are retrieved, such as those needed by nurse clinicians
The CARE instrument can be imported into the CCD and other similar architectures and vice-versa.
Dr. Clancy reminded members that the HIT Expert Panel (HITEP) has tried but so far has been unable to derive a core set of data elements from a prioritized subset of AQA and Hospital Quality Alliance (HQA) measures. She also noted that HITEP’s report will be released through HHS and NQF at some point for public comment and that the QWG may want to add discrete questions to the Federal Register notice to get more feedback on the concept of a quality data set.

4. Draft Quality Vision Roadmap and Potential Recommendations

Dr. Clancy noted that the Draft Quality Vision Roadmap has been updated and refined; that milestones, timelines, and key players have been identified but may need further refinement; and that potential QWG action items and recommendations have been identified for some future state components based on previous WG discussion.

Discussion highlights and action items from the rest of the presentation are summarized below.

CDS

The presentation showed a notational draft of the Roadmap, with future state components ranging from “Incentives” to “CDSPatient and Provider” (Slide 4). Dr. Clancy noted that while CDS is a key aspect of the quality vision, other AHIC WGs are addressing CDS as well, and members can expect a report on that in the near future from a cross-cutting CDS group.

Expanded Data Element Standardization

During discussion of the Expanded Data Element Standardization (Slide 5), the workgroup agreed to add measure developers and the NQF as key players in the endorsement of measures and specifications.

ACTION ITEM #1: Add measure developers and the NQF as key players to the “Expanded Data Element Standardization” section of the Quality Vision Roadmap.

The presentation also included the potential recommendation idea to “expand and promote standardized, consensus-based data elements that support automated quality measurement and reporting” (Slide 6). Discussion led to agreement to add a fourth bullet addressing incentives to the recommendation.

ACTION ITEM #2: A fourth bullet addressing incentives will be added to the recommendation for the “Expanded Data Element Standardization” section of the Quality Vision Roadmap.

Coding Improvements

In response to “Coding Improvements,” members made the following comments and observations:

There is a need for a more standardized coding system for the problem list
Physicians and other healthcare professional organizations would need to be involved
The problem list should be collected in the CARE instrument so that it could cross settings and be subject to accurate revision
In-patient settings lack attention to the accuracy of the problem list between admission and discharge
The American Health Information Management Association (AHIMA) is working on coding improvement and may be interested in discussing ideas or recommendations.

Data Exchange and Aggregation

In regards to “Data Exchange and Aggregations”(Slide 8), Dr. Clancy commented that while measures and reporting are transparent, the intervening steps are not, and that New York State agreements previously mentioned might drive more transparency here. She proposed that key players should include NQF and measure developers. Further discussion indicated that purchasers, insurers, and specialty societies and registry owners should be added as well. Dr. Clancy commented that challenges facing those trying to aggregate claims data across multiple plans have a great deal to do with “internal coding specs and other conventions.” Additional discussion points included the observation that the QWG might examine further how various sites are approaching aggregation and the concept of whole data banks being integrated, as well as the role of registries.

Quality Data Set

Discussion of the “Quality Data Set” included the following comments and observations:

There are “sweet spots” between the Joint Commission’s and HITEP’s work
Dots could be connected between Integrating the Healthcare Enterprise (IHE) work on patient care coordination (PCC) and the Joint Commission’s work (Dr. VanAmringe will resend to staff a report on the commission’s work)
Representatives from HITEP, the IHE, the Joint Commission, and vendors should meet to discuss data elements.

Based on discussion, Dr. Clancy noted that the first recommendation will require some later consensus about how to move forward and that the second recommendation is “a keeper.”

Patient and Provider Entity Record Matching

During discussion of this issue, it was noted that a quality data set would begin to balance measures’ impact on workflow and possibly assist EHR vendors.

Kelly Cronin commented that the Letter of Recommendation could make the overarching point that this process should be driving infrastructure development and other processes over the next several years, with enabling mechanisms placed in specific recommendations.

NCVHS will hold a hearing on January 29, 2008, on this and related issues. It was proposed that an ultimate Letter of Recommendation to AHIC address all the Roadmap’s important aspects and issues raised in regards to realizing value-based healthcare, even those not addressed through recommendations.

Concluding Remarks

Discussion continued on the following points:

The interim need for a better coding infrastructure and the need to update members on the current state of wisdom
The need to re-specify and retool current quality measures that can run off of a limited quality data
The need to clarify and share lessons from the American Medical Association/National Committee for Quality Assurance (AMA/NCQA) Collaborative
The need to identify a set of high priority national “dials” that link back to quality improvement efforts and to hold display them for the system
The possibility that the NQF’s Priorities Partners effort could result in identification of a small set of high priority areas and metrics for public comment in spring or summer
The need to reconvene HITEP, possibly periodically, to review a quality data set in light of new priority measures data needs
The need to determine whether the priorities selected are “the right ones” that will actually impact health (AHRQ might be able to address some of these issues and observations in a future annual report to Congress)

Dr. Clancy noted the possible need to create a more precise recommendation in the “Expanded Data Element Standardization” area, to address the issue of problem lists in the “Coding Improvements” area, and to pursue “Quality Data Set” recommendations. Based on discussion, Dr. Clancy proposed that retooling measures remain in the WG’s work plan.

5. 2009 Use Case Priorities

Ms. Cronin briefed members on the use case prioritization process underway, which was described in an email with relevant attachments sent to members on November 27. To date, QWG has identified two 2009 priorities: (1) Enabling longitudinal quality measures, and (2) CDS.

Enabling Longitudinal Quality Measures

Sub categories for this priority could include the following:

Data aggregation across multiple providers over time, with HIE enabling data sharing across care settings over time
Standardization of data
A hybrid approach for merging data from disparate sources
Specific aspects of record- linking or matching for patients and providers

Discussion of sub-categories included: identifying needed data capacity; the fact that applicable longitudinal measures might be easier to identify after the 2008 use cases advance through HITEP, HITSP, CCHIT, and NHIN; and the idea that initial longitudinal measures should be practical, such as for hospital episodes to 60 days after.

CDS

Ms. Cronin noted that previous QWG discussion of CDS included the need for both (1) longitudinal records to contain specific information on patient characteristics to enable point-of-care CDS and (2) identification of workflow issues and integration of CDS into EHRs and other applications.

Discussion of CDS identified two questions of inquiry: (1) How might quality data need to expand in order to satisfy associated CDS needs? (2) How can top priority targets be used to address issues such as workflow and standards, including standards related to CDS interventions? WG members also noted that if trade-offs are needed in terms of a quality data set and its size, it might be best to address fewer conditions so as to ensure sufficient data availability to support both quality measurement and CDS.

ACTION ITEM # 3: QWG members with additional comments or observations on 2009 use case priorities should contact staff by e-mail.

The next QWG meeting is Friday, February 8, 2007, 1-4 p.m.

MEETING MATERIALS

Agenda

October 31, 2007 QWG Meeting Summary

Justine Carr - “Enhanced Protection for Uses of Health Data: Recommendations to HHS on a Data Stewardship Framework”

Michael Rapp - “Post-acute Care Resident Assessment Minimum Data Sets”

Meeting Slides “Workgroup Discussion on the Vision Roadmap and Potential AHIC Recommendations”

SUMMARY OF ACTION ITEMS

ACTION # 1: Add measure developers and the NQF as key players to the “Expanded Data Element Standardization” section of the Quality Vision Roadmap.

ACTION ITEM #2: A fourth bullet addressing incentives will be added to the recommendation for the “Expanded Data Element Standardization” section of the Quality Vision Roadmap.

ACTION ITEM # 3: QWG members with additional comments or observations on 2009 use case priorities should contact staff by e-mail.

Quality Workgroup

Members and Designees Participating in the December 14, 2007 Web Conference


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

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

Members and Designees
Janet Corrigan, Helen Burstin,and Dan Rosenthal	National Quality Forum
Anne Easton and Mike Kaszynski	U.S. Office of Personnel Management
Jane Metzger	First Consulting Group
Ann Janikula (for Susan Postal)	Hospital Corporation of America
Michael Rapp	HHS/Centers for Medicare & Medicaid Services
Jonathan Teich	Brigham and Women’s Hospital
Charlene Underwood	Siemens Medical Solutions
Margaret VanAmringe	Joint Commission

Presenters
Justine Carr	NCVHS
Michael Rapp	HHS/CMS

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.