HIT Policy CommitteeQuality Measures Workgroup

October 28, 2010

Fred D Rachman, MD

History and Mission of Community Health Centers

• first funded by the Federal Government as part of the War on Poverty in the mid-1960s.

• designed to provide accessible, affordable personal health care services for people living in medically underserved communities

• Mission encompasses quality, access, and responsiveness to particular needs of the community served.

• Typical services include primary care (Including Pediatrics, Internal Medicine, OB/GYN, and Family Practice), dental, behavioral health, nutrition, case management and health education.

Facts about Community Health Centers

• Nearly 1,100 health center grant recipients operate more than 7,000 community-based clinics

• One of every 19 people living in the U.S. now relies on a HRSA-funded clinic for primary care.

• HRSA-supported health centers treated more than 16 million people in 2008.

• Nearly forty percent of patients treated have no health insurance and one-third are children

Health Centers at the Forefront of Quality and Health Information

Technology• Comprehensive model of comprehensive primary care• Long history of formal chronic disease management,

focus on evidence based practice and reporting on national measures.

• Focus on quality while respecting limitations in resources have led Health Centers to explore strategies to promote effectiveness and efficiency, including use of data driven performance improvement

• Federal investment Health Center Controlled Network model to support adoption of HIT has resulted in examples of advanced use and resembles REC strategy of ONC in promoting “learning communities”

Alliance of Community Health Services Overview

• HRSA funded Health Center Controlled Network founded by 4 Federally funded Health Centers located on the Near North Side of Chicago

• Aim is to provide infrastructure through which Centers can share services at higher quality and lower cost.

• Focus on Information Technology as tool for quality• Initial demonstration project funded by AHRQ and

HRSA in partnership with AMA to integrate clinical decision support related performance measures into a commercial EMR

• Included collection of race ethnicity and socioeconomic barriers

• Ongoing HIT related research and evaluation

Reporting

• Simple reporting done directly from the EHRS• More complex reporting done through the clinical

data warehouse

Health Outcomes – Preventive Care

DOQ-IT Preventive Care Measures General PopulationAlliance Centers vs. MQIC National

89%

42%

23%26%

36%39%

73%

56%53%

82%

46% 44%

36%

52% 54%

76%

85%

64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Visits WithBlood

Pressure

% Women 50-69 With A

Mammogram

% >=50Screen forColorectal

Cancer

% >=50 WithInfluenza Vax

% >=65 WithPneumo Vax

% w/LDL % w/LDL WithLast <130

% w/SmokingStatus

% Smokers w/Cessation

Interv

ALLIANCE (N=25K)

MQIC Primary Care (N=1.5M)

ALLIANCE CTR HIGH

ALLIANCE CTR LOW

Health Outcomes Diabetes Disparities

DOQ-IT Diabetes MeasuresHealth Disparities by Race

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% WithHgbA1c Test

% withHgbA1c with

Last >9.0

% w/BP and<140/90

% with LDL % with LDLand <130

mg/dl

% with UrineProtien Test

% with EyeExam

% with FootExam

ALLIANCEAfrican AmericanAsianHispanicWhite/Caucasian

Typical Health Center tracks/reports multiple quality measures

• HRSA UDS • Health Disparities Collaborative program• HIV measures – Ryan White/HIVQUAL• State required reporting• Third party payer measures• Measures for individual funding programs

(private/public)

Why are measures important?

• Required for funding; have helped to provide recognition for CHC services and quality

• Guide practice, performance improvement efforts and system level change

• Basis for benchmarking and identifying best practices

• Document and address disparities

How has measurement evolved

• Manual chart audit• Claims based/practice management system

derived reporting• Chronic disease management systems• EMR

How Quality Measures are used

• Incorporated into decision support at patient level/point of care

• Basis for performance and outcomes benchmarking

• Objective measures for performance improvement efforts

• Used for Provider level feedback and goal setting• Guide program and services development• Lead to targeted interventions/programs

Evolution

• Expansion of scope of services covered beyond medical concepts

• Inclusion of reasons for non-adherence• Closer alignment to practice recommendations

Opportunities

• Balance measures across dimensions of quality: Timeliness, efficiency, effectiveness, safety, equitableness, and patient centeredness.

• Expansion to other important health aspects: eg; nursing, nutrition, behavioral healsh, social services, health education

• Patient level measures• Layered measures aligned to levels of system• Structural measures• Integration of measures across programs (eg,

substance abuse, housing)

Capture of data element from data source outside the EHRS – no formal arrangement (e.g. colonoscopy)

Capture of data element from data source outside the EHRS - formal arrangement for resulting (e.g. eye exam from formal referral resource)

Capture of data element requiring entry of observation in standardized way by practitioner(e.g. foot exam)

Capture of data element as easily objective defined observation captured by EHRS (e,g. blood pressure)

Direct electronic of data element and/or result through order entry or interface(e.g. Hgb A1C measure and result)

What are we truly measuring?

Considerations

• Acknowledgement of complexities of data capture• Need for measure alignment• Importance of defining disparity populations and

identifying consistently • Being thoughtful of  level of

accountability  ( individual practitioner, practice, system, society)

• Addressing magnitude of change• Ability to respond to measures

04/19/23

At what level do we want to measure performance?