Jesse C James, MDONC-HITQuality Measures Work Group

EHR Incentive Program Stage 3 Request for Comment: Responses and Insight

February 6, 2013

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Step Back and Look Forward

For Stage 2 the QMWG contributed CQM sub-domains and concepts to the RFC and Transmittal Letter.

For Stage 3 the QMWG intended to take a broader view of HIT enabled quality measurement.

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• How do we achieve this with better measures?

Conceptual Framework

• What problem are we trying to solve?

Purpose E-measures

• How can we better leverage CQMs for QI?

CQM Pipeline

• Which measures should we choose?

QI Platform

In the RFC for Stage 3 the QMWG tested these ideas with the general public.

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• How do we achieve this with better measures?

- Package Process-Outcome suites

-Develop de novo instead of legacy CQMs

-Align CQMs and components with functional objectives

Conceptual Framework

• What problem are we trying to solve?

• How de we stay patient centered?

•How should we engage with a broader group of stakeholders?.

Purpose E-measures

• Which measures should we choose?

-Review Prioritized Domains

-Identify Exemplars: Expand or Refine

-Promote innovation: ”Democratize “ the measure set

QI Platform

• How can we better leverage CQMs for QI?

-Support consistent novel architecture and standards to meet provider QI needs

-Encourage development of Population Management Tools

CQM Pipeline

In the RFC for Stage 3 the QMWG tested these ideas with the general public.

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Comments

Pt. Centeredness CQM Pipeline Innovation Track QI Support0

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30

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50

60

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90

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Purpose and Engagement QMWG 01-08

The QMWG intends to capture insights broadly from stakeholders and actively engaged as providers, purchasers and recipients of care.

• How should the HITPC and QMWG capture input from a wider variety of providers, patients, organizations and societies?

• What additional channels for input should we consider?

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Stakeholder Engagement

Stakeholder Engagement-Nearly all of the 56 commenters encouraged the HITPC and QMWG to actively seek input from a broad variety of stakeholders.

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Purpose and Engagement

• Active Outreach Strategies for Stakeholder Engagement – many felt the RFC and open meetings are a “great start”

• Social media• Webinars• Open forum per measure• Outreach to professional societies and patient advocacy groups• Establishing an “e-measure steering committee” (Federation of

American Hospitals)

The majority of the responders agreed that increased patient input is necessary to improve quality measurement.

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The Quality Measure Workgroup in the October 2010 “Tiger Team Summary Report” and the December 2010 Request for Comment, has previously described our intention to support HIT-sensitive, parsimonious, longitudinal, outcomes-focused CQMs.

• Should the HITPC focus its efforts on building point-of-care process measures or value-centered outcome measures?

• Should we instead consider a third approach, to promote process-outcome measure “suites”, combinations of end outcome measures that are potentially associated with process measures?

eCQM: Process and Outcome QMWG 09-10

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eCQM: Process and OutcomeQMWG09

Both 43%

Outcome eCQMs34%

Process eCQMS6%

Should Not Build Measures

6%

Different Question Answered

11%

Should the HITPC focus its efforts on building point-of-care process measures or value-centered outcome

measures?

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eCQM: Process and OutcomeQMWG10

Support "Suites"77%

Outcome Only15%

Process Only4%

Do NOT Support Suite4%

Should we promote process-outcome measure “suites”, that attach outcomes to potentially associated with

processes?

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eCQM: Process and OutcomesInsights

For HITPC Consideration/General Suggestions• Outcomes should be the focus. Providers need freedom to choose processes that will allow

them to achieve• It is critically important that pediatrics be included in the development of such suites • Include specialist expertise to ensure relevance of measures clinically and for patient

perspective• Quality improvement should shift from quality measurement to registry reporting

eCQM Suite will be Challenging• Suites may require the same denominator for each measure. • Complexity can hinder reporting

“Suites” are an opportunity for Research• Use measure suites to evaluate strength of relationship to outcome. With time, refine the

process measures used in the suites.• Preventive health measure suite. To capture - screening, counseling, referral, and follow up

The QMWG will make recommendations both on the types of measures that are developed and on the process for measure development. The QMWG understands that “retooling”, the process of translating legacy measures into XML code, at times does not fully preserve the original intent of measures and measure components (logic and value sets). Furthermore, retooled measures often do not take full advantage of the richness of clinical data in the EHR.

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• Please comment on challenges in retooling legacy paper abstracted and claims based eCQMs.

• Is a shift away from retooling legacy paper-based CQMs in exchange for designing eCQMs de novo a reasonable and desirable course of action?

eCQM: de novo or LegacyQMWG11-12

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eCQM: de novo or LegacyQMWG12

Support more de novo62%

Support retooled15%

Support both8%

NA15%

Should development continue with de novo or retooled claims/abstracted measures?

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eCQM: de novo or LegacyComments

– Boston Medical Center – “In contrast to legacy paper measures we have found that the de novo measures, if well designed, are easier to complete.”

– HIMSS continues to call attention to the increased burden on the provider to collect data for both manually abstracted measures and eMeasures, and we continue to urge the HIT Policy Committee to reduce this burden.

– Kaiser Permanente - There are too few de novo measures designed and intended for EHR-based measurement to provide an informed comment.

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eCQM Innovation TrackQMWG 18-24

eCQM Innovation: The majority of responses either fully supported an innovation track or supported the track while describing reservations.

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To leverage CQM innovation from health systems and professional societies, the QMWG has discussed a proposal to allow EPs or EHs to submit a innovative or locally-developed CQM as a menu item in partial fulfillment of MU requirements. Health care organizations choosing this optional menu track would be required to use a brief submission form that describes some of the evidence that supports their measure and how the measure was used in their organization to improve care.

• We have considered two approaches to provider-initiated eCQMs. - A conservative approach might allow “Certified Development Organizations”, to

develop, release and report proprietary CQMs for MU.

- An alternate approach might open the process to any EP/EH but constrain allowable eCQMs via measure design software(e.g., Measure Authoring Tool).

• What constraints should be in place?

CQM Pipeline: Innovation TrackQMWG18-24

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eCQM Innovation TrackQMWG 18

Support72%

Support with reservation

13%

Object15%

Please comment on the desirability and feasibility of such an innovation track as a voluntary, optional

component of the MU CQM requirement.

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eCQM Innovation Track Insights

• Support Innovation Track: 28 comments– “We fully support this concept, as it fosters provider level innovation and

rewards them for their efforts…We have found that QI departments want to continue their work and use MU as a stepping stone.” -Boston Medical Center

• Support…with reservations: 5 comments– “We would find this to be a very challenging way to develop CQMs. However,

we do believe organizations should be recognized for their innovative work and be paid additional dollars for that work if it is broadly applicable.”-Geisinger

• Do Not Support: 6– “CHIME recommends the MU Stage 3 not engage in the development of new

quality measures …”

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eCQM Innovation TrackQMWG 19

Conservative33

Alternative22

Should we pursue a conservative approach that limits development to professional societies and IDNs ? Or an alternative that opens the process to any EP/EH within

certain constraints?

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eCQM Innovation Track InsightsQMWG19

Conservative approach(22)• “We encourage HITPC/ONC to consider the more conservative approach, which

would encourage adoption and use of EHRs among professionals by ensuring more relevant and feasible CQMs developed directly by professional societies while also ensuring a minimum level of consistency among members of the same specialty so that the data could be analyzed over time for trends and patterns related to performance.” -American Osteopathic Association

Alternative approach: (33)• “Flexibility needs to be given for the organization itself to determine its own

high priority conditions and report on CQMs relating to those conditions, preferably using a national measure if one exists already but if not, using its own proprietary measure. “ -VA

• “The innovation of eCQMs should be open to all stakeholders who wish to improve the quality of healthcare outcomes. However, the design standards should include oversight to ensure the consistent creation of eMeasure specifications.” -Federation of American Hospitals

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eCQM Innovation TrackQMWG 21

Constrain80%

Minimize Constraints

20%

Should we constrain development in the innovation track with standards for e-measures that are already in

place?

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eCQM Innovation Track InsightsQMWG 21

• Constrain to existing Standards and tools for eCQM development: (20)– Children’s Hospital Association: “Some reasonable constraints, such as conforming to the Quality Data

Model, would seem appropriate. Again, the balance between fostering innovation and measurement that is meaningful with allowing comparability across providers and hospitals is one that needs to be carefully thought through. It would be helpful to think through a trajectory for how locally developed measures could become more widely used and disseminated…”

– Greenway; “If the end goal as stated is to assess innovation, the next logical goal would be to leverage any findings back into the program… A simple HQMF would be the minimum level of detail needed to allow for decomposition and ensure reuse in the future. We encourage the use of the Measure Authoring Tool (MAT) to ensure consistent use of Values sets and QDM elements...”

– The Joint Commission: the use of standardized quality measures, ensures, at least to some extent, comparability of the data across healthcare providers and supports measure alignment across settings

• Have no constraints, maximize innovation in measures that fit clinician need: (5)– MN Department of Health: ““100% of the measures should not be constrained. That may stifle innovation.

Instead, allow a very limited number with the understanding that the measure logic would be submitted along with the measure result. “

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QI Support: Population ManagementQMWG 28-30

There is strong support for population management software to leverage ECQMs for QI.

The QMWG intends to encourage the development of HIT tools that leverage use of eCQMs for population management. The work group is especially interested in development of CQM population mapping and task-management platforms that allow users to view, track, and identify care gaps and assign tasks both for individual patients and for user-determined cohorts. The workgroup understands that this technology is desired by providers and requests comments on the potential role of the HITPC and HHS in this space.

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• Please comment on the value of these tools. Is there a sufficient evidence basis for clinical population management platform use? Is there a business case??

• What are the technological challenges to widespread release and adoption? Can the HITPC encourage technology in this area without being prohibitively prescriptive?

QI Support: Population ManagementQMWG 28-30

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QI Support: Population ManagementQMWG 28

Support75%

Guidance Only22%

Do not Support3%

Please comment on the value and feasibility of eCQM Population Management Platforms.

There is broad consensus that a business case exists for population management platforms.

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QI Support: Population ManagementQMWG 28

• Support Population Management Software and standardization:– The majority of commenters (24), especially the providers, feel there is a

role for increased standards and possibly certification for population health platforms or features.

– Demonstrated evidence and value- a number of commenters provided specific evidence of value, especially in chronic disease management, managed care and public health

– A few commenters, especially software companies and some organizations, worry that the market and standards are too immature for certification at this time. • They propose a combination of guidance, incentives and grants with continued work

on data and interoperability standards (7) rather than certification.

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• “Population management tools should be part of CEHRT. The market will likely lead to the development and implementation of these tools as ACOs and CCOs pick up steam. However, HITPC can and should set a baseline for functionality of such a system.” Tom Yackel- OHSU

• “We feel that there will be a role for this type information from a population management platform for ACOs. Since this is a recommendation we suggest that HITPC takes this back to the industry to look into this issue and talk to providers to see what they are expecting.“ -AHIMA

• “Given the immaturity of this market, CHIME believes it is better to let the market evolve without further federal involvement at this time. The technology is not currently available, and there would be additional cost.”

QI Support: Population ManagementQMWG 28

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Recurring Themes

• Listen more…engage with specialty societies and patients

• Go de novo

• Liberate the data…and the providers

• Care coordination, patient engagement, and safety should be high priority domains for development

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Discussion

To members of and contributors to the QMWG: We appreciate the your time, insight, suggestions, comments and edits. Thank-you, -ONC Staff

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ADDENDUM RFC SLIDES

• Patient-Centeredness• CQM Pipeline– Process and Outcomes– Measure Development– Objective Alignment– Domains and Exemplars– CQM Innovation Track

• Quality Improvement Support– Architecture and Standards– Measure Development

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Person Centeredness

Patient Centeredness: Broaden Stakeholder Input

The QMWG intends to capture insights broadly from provider, patient, and stakeholder groups across the health landscape that have been previously less engaged in HIT policymaking but actively engaged as providers, purchases and recipients of care.

Additional Channels

How should the HITPC and QMWG capture input from a wider variety of providers, patients, organizations and societies? What additional channels for input should we consider?

Patient Centeredness: Patient-reported and Patient-Directed Data

The QMWG recognizes that both patients and providers generate and consume clinical quality data. Contributors have challenged the workgroup to develop CQMs that accommodate personal care goals in addition to guideline-directed care goals. This is a commendable aspiration; still significant barriers to integration of patient-generated data with EHR clinical data remain.

Patient- Reported Data

How can consumer-reported data can be incorporated into CQMs?

Patient- Directed Data

Please provide examples of how patient-directed data is informing shared decision making. There How does the health public view the integration of EHR derived data with patient generated data for quality measurement? How important is it to keep this data separate? Should it be separate?

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CQM Pipeline: Process and Outcomes

CQM Pipeline: Process and Outcomes

The Quality Measure Workgroup in the October 2010 “Tiger Team Summary Report” and the December 2010 Request for Comment has previously described our intention to support the development of HIT-sensitive, parsimonious, longitudinal outcomes-focused CQMs for the EHR Incentive Program.

The Quality Measures Workgroup also recognizes that there remains value in developing and deploying real-time, point-of-care, process measures for immediate clinical use that may provide nuance to the data captured by value-oriented, outcomes.

Process versus Outcomes

Should the HITPC focus its efforts on building point-of-care process measures or value-centered outcome measures?

Process/ Outcome measure "suites"

Is this a false or unnecessary dichotomy?

Should the HITPC consider a third approach, to promote process-outcome measure “suites”, combinations of end outcome measures that are potentially associated with process measures?

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CQM Pipeline: Measure Development

CQM Pipeline: Measure Development Lifecycle

The QMWG is considering recommendations both on the types of measures that are developed and on the process for measure development. The QMWG has heard from eCQM measure developers that “retooling”, the process of translating legacy measures into XML code, may not fully preserve the original intent of the legacy measures and measure components (logic and value sets). Furthermore, retooled measures often do not take full advantage of the richness of clinical data in the EHR. Consequently, the QMWG is considering recommending that HHS efforts shift from retooling paper chart/claims measures to designing de novo EHR-enabled measures.

Challenges to "Retooling"

Please comment on challenges and ambiguities in retooling legacy paper abstracted and claims based eCQMs.

Support versus Resistance to de novo measures

Is this a shift away from retooling legacy paper-based CQMs in exchange for designing CQMs de novo a reasonable course of action?

Provider Experience

Please comment on the provider/payer/patient experience with using retooled measures as opposed to experience with de novo measures designed and intended for EHR-based measurement.

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CQM Pipeline: Objective Alignment

CQM Pipeline: CQM Alignment with Functional Objectives

The QMWG understands that EHRs are a powerful tool with both the potential to increase clinical efficiency and to hamper it. For Stage 3, the workgroup intends to reduce administrative burden by further aligning the eCQM logic and value sets with EHR Incentive Program Functional Objectives. For example, care coordination CQMs can be refined/or designed de novo to better align with the Summary of Care objective.

Provider Value Please comment on aligning CQMs with MU Objectives. Would eCQM-MU Objective alignment be clinically valuable to providers or might this be a redundant exercise in shifting resources?

CQM-Functional Objective Opportunities

Which measures and objectives, in particular, have the greatest potential to maximize meaningful alignment? Please recommend eCQM/Objective alignment opportunities.

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CQM Pipeline: Domains and Exemplars

CQM Pipeline: Domains and Exemplars

The QMWG continues to encourage development and release of eCQMs that cover the six priority domains identified by the National Quality Strategy. The QMWG intends to identify exemplar measures/concepts that both address underrepresented NQS priority domains and leverage the current and near future capabilities of HIT. .

Priority Domains for MU3

Which, if any, high priority domains should receive prioritized attention in MU 3? What measure concepts, addressing these domains, should be considered for development? What EHR capabilities should be leveraged to realize these concepts?

Exemplar Measures for MU3

Are there EHR based exemplar measures that exist, or that are being conceptualized or developed, that address these domains and theses concepts?

What scientific evidence supports these concepts and exemplars?

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CQM Pipeline: CQM Innovation, 1

CQM Pipeline: MU and Innovation

The QMWG recognizes that many health systems, ACOs, and other provider networks have developed, tested and deployed locally generated CQMs that address high priority conditions or processes relevant to their local patient population or organizations.

In order to leverage some of the innovation by health systems and professional societies, the QMWG has discussed a proposal to allow EPs or EHs to submit a locally developed CQM as a menu item in partial fulfillment of MU requirements (in lieu of one of the existing measures specified in the MU program). Health care organizations choosing this optional menu track would be required to use a brief submission form that describes some of the evidence that supports their measure and how the measure was used in their organization to improve care.

Interest and Feasibility

Please comment on the interest in and feasibility of such an innovation track as a voluntary, optional component of the MU CQM requirement.

Possible Approach

We have considered two approaches to provider-initiated eCQMs.

A conservative approach might allow “Certified Development Organizations”, to develop, release and report proprietary CQMs for MU.

An alternate approach might open the process to any EP/EH but constrain allowable eCQMs via development software(e.g., Measure Authoring Tool).

Please submit comments on either, both or unique approaches.

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CQM Pipeline: CQM Innovation, 2

CQM Pipeline: MU and Innovation

The QMWG recognizes that many health systems, ACOs, and other provider networks have developed, tested and deployed locally generated CQMs that address high priority conditions or processes relevant to their local patient population or organizations.

In order to leverage some of the innovation by health systems and professional societies, the QMWG has discussed a proposal to allow EPs or EHs to submit a locally developed CQM as a menu item in partial fulfillment of MU requirements (in lieu of one of the existing measures specified in the MU program). Health care organizations choosing this optional menu track would be required to use a brief submission form that describes some of the evidence that supports their measure and how the measure was used in their organization to improve care.

CQM Innovation Submission

What information should be submitted with a locally developed CQM to help CMS and other healthcare providers assess the innovative measure? 1) importance/rationale of the measure domain; 2)evidence basis for the specific measure; 3) feasibility, and 4) usefulness of the measure?

Constraints What constraints should be in place?

Should individual providers have an option to choose and/or design their own measures outside of the established CQM EHR Incentive Program set?

Should these “practice-level” measures be required to conform to the Quality Data Model data elements and/or entered into the Measure Authoring Tool?

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Quality Improvement Support: Architecture and Standards

Quality Improvement Support: Architecture and Standards

The QMWG recognizes that there is an opportunity to design measures that improve the user experience and leverage technologic capability of certified EHR software to affect quality improvement. The workgroup considers the features below for eCQMs and EHRs to valuable both for users and meaningful in clinical practice.

Features Please comment on the value and feasibility of the eCQM and EHR features • Ability to accept downloaded specifications for new measures with little tailoring or new coding• Virtually no manual data collection or manipulation• Ability to aggregate measure data to varying business units (practice, episode, ACO, medical home, MA plan, etc)• Ability to build measures that incorporate cross-setting records for episodes, medical homes, outcomes (e.g., readmissions)• Ability to build multi-source data records, including claims, patient reported data• Ability to accommodate new measures and conduct testing and validation

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CQM Pipeline: Measure Development

Quality Improvement Support: CQM Population Management Platform

The QMWG intends to encourage the development and expansion of HIT tools that leverage use of eCQMs for population management. The work group is especially interested in development of CQM population mapping and task-management platforms that allow users to view, track, and identify care gaps and assign tasks both for individual patients and for user-determined cohorts. The workgroup understands that this technology is desired by providers and requests comments on the potential role of the HITPC and HHS in this space.

Evidence Basis and Business case

Please comment on the value and feasibility of the CQM Population Management Platforms.Is there an evidence basis for clinical population management platform use? Is there a business case?

Is this an area that could benefit from HITPC policy guidance or will the market mature and evolve without input?

Features What features might be present in a basic population management view (patient-level data element map, provider comparison, ad-hoc queries, etc)?

Barriers to Adoption

What are the technological challenges to widespread release and adoption? Can the HITPC encourage technology in this area without being prohibitively prescriptive?