Aligning Healthcare Theory and Reality: The Challenge of Electronic Quality Measurement
For the better part of two years, one of the least fun aspects of my life was explaining electronic quality measurement to US-based hospital organizations participating in the EHR Incentive Program. It wasn’t the explanations themselves that were painful – it was watching the dawning realization in the faces of the audience. The realization that the eMeasures they would be reporting to demonstrate meaningful use did not replace any existing quality measurement effort; they were additive. The sudden understanding that even where the measure descriptors seemed to be the same, the logic and data elements were very different. The discovery that work-arounds put in place years before within healthcare billing systems produced negative values when they flowed through to automated quality measures. The “stroke centers of excellence”, horrified to review terrible looking electronic stroke measures driven by physician populated SNOMED problem lists rather than by trained ICD-9-CM coding professionals.
All of this frustration was compounded by the fact that in order to get eMeasurement in place rapidly, the program adopted the only inpatient measures available in electronic format; a set of pilot specifications developed several years before as a proof of concept under the auspices of the Health Information Technology Standards Panel (HITSP), and never fully tested in real life. Explaining to physicians why they were being measured against out of date clinical standards and code sets was never pleasant.
Hospitals are used to having quality measures reported on Hospital Compare, to rigorous data quality audits, and to being paid for quality. The one point of comfort I could offer in the early stages of eMeasurement was that, at least for the time being, all they had to do was report the eMeasure data – it would not be published, and payment depended only on reporting what was calculated by certified EHR technology.
December 28, 2012, The Center for Medicare & Medicaid Services, CMS, published a Request for Information asking about the state of industry readiness to begin using eMeasures for the Hospital Inpatient Quality Reporting (IQR) program beginning with calendar year 2014 discharges. So much for that last measure of comfort.
Done right, alignment is actually a good thing. It means there will no longer be two separate processes for quality reporting, it will drive up the quality of the data in eMeasures, and it will help to scale up measurement programs. So the theory of all this is great. CMS has a major initiative in place to try to align all of the various healthcare quality measurement programs under its auspices. The real questions are when and how they do so.
A recent KPMG study showed 47% of hospital and health system leaders are only “somewhat confident” they can attain Stage 2 of meaningful use. They know they have a lot of work to do. EHR vendors need to upgrade their entire customer base to new versions of EHR software, hospitals need to implement the workflow and content to support the next version of the quality measures, and adoption levels for problem lists and other physician-generated data need to go up substantially to approach anything like the required data quality necessary for publicly reported measures. While the Stage 2 measures are of much higher quality than original measure set, they are still in their infancy. So moving to public measurement in 2014 is a pretty scary concept.
At the November 30 Health IT Policy Committee hearing on the quality of quality measurement data, the overwhelming message was that given the maturity of healthcare electronic measurement, “pay for reporting” rather than “pay for performance” was the correct use of these measures. The other overwhelming message, as I reported then, was that the structured data capture required by the current generation of measures is inconsistent with the way caregivers think and deliver care.
I’m glad to see CMS thoughtfully evaluating how to move forward with alignment and trust they will receive considered responses from the provider, vendor, and measure developer community to help craft an effective transition. There is generally a fairly positive public view of Electronic Health Records – a number of surveys have shown that patients believe they enhance care. It would be a shame to see that view sullied by publicly reporting immature measures that portray healthcare provider quality in a negative light.