quality measurement overview - using health it to support delivery system reform november 19, 2015

Quality Measurement Overview-

Using Health IT to Support Delivery System Reform

November 19, 2015

•Clinical Quality Measures (CQM) - Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.1

•Electronic CQM (eCQM) - CQMs that are specified in a standard electronic format and are designed to use data from Health IT systems for measurement.

Common Definitions

Sources: 1 http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/QualityMeasures/ index.html 2. Office of the National Coordinator, “ Health IT Enabled Quality: A Vision to Achieve Better Health and Health Care”, * http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html

Common Definitions

• QRDA is a standard document format for the exchange of electronic clinical quality measure (eCQM) data. QRDA reports contain data extracted from electronic health records (EHRs) and other information technology systems. The reports are used for the exchange of eCQM data between systems for quality measurement and reporting initiatives

–QRDA Category I report contains raw applicable patient data. When pooled and analyzed, each report contributes the quality data necessary to calculate population measure metrics.

–QRDA-III report is an aggregate quality report using data collected in patient-level QRDA-I reports. Each QRDA-III report contains calculated summary data for one or more measures for a specified population of patients within a particular health system over a specific period of time.

3https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/qrda_ep_hqr_guide_2015.pdf

•Clinical Decision Support (CDS) - A key functionality of health IT and certified EHRs that provides health care providers and patients with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.

•Common Data Element (CDE) - Clinical concepts that contain standardized and structured metadata, have unambiguous intent, and a clearly delineated value domain. These CDEs, such as “systolic blood pressure,” would define a curated, universal specification for each clinical or administrative concept, optimizing the data to be reused across the QI ecosystem.

Common Definitions

Sources: 1 http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/QualityMeasures/ index.html 2. Office of the National Coordinator, “ Health IT Enabled Quality: A Vision to Achieve Better Health and Health Care”, * http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html

Why electronic quality measures?

• Claims measures only capture activity, not quality– e.g. how many visits for blood pressure- not

what is the blood pressure• Paper abstraction measures are expensive-

• Hospital Core measures- very expensive to run

• Claims + chart abstraction (ala HEDIS+) are also expensive- (estimate $75 per chart)

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Percent of patients with diabetes who had at least

From Claims and Paper to EHR Measures

One visit with a

provider

One HbA1c obtained

One HbA1c < 8

Sustained control or

improvement in HbA1c

…during the measurement period

80% of blood glucose readings

within goal range

Claims Paper EHR

Current evolution from manual to electronic CQMs

11/13/15 Office of the National Coordinator for Health Information Technology 7

Why eCQMs?

HQMF – a machine readable XML model of a quality measure

Measurement Vision for the Future

• Measures Drive Improvement–Real-time–Local ownership with benchmarking–Linked to decision support and patient dashboards

• Measures Drive Value-Based Purchasing–Reliable–Accurate–Outcomes-based

• Measures Inform Consumers–Meaningful–Transparent

•Measurement Alignment

Conway, P. H., Mostashari, F., & Clancy, C. (2013). The future of quality measurement for improvement and accountability. JAMA: The Journal of the American Medical Association, 309(21), 2215-2216. doi: 10.1001/jama.2013.4929

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HHS Delivery System Reform Goals

▪ Encourage the integration and coordination of clinical care services▪ Improve population health▪ Promote patient engagement through shared decision making

▪ Create transparency on cost and quality information▪ Bring electronic health information to the point of care for

meaningful use

▪ Promote value-based payment systems – Test new alternative payment models– Increase linkage of Medicaid, Medicare FFS, and other payments to

value▪ Bring proven payment models to scale

Delivery System Reform: Focus Areas

Pay Providers

Deliver Care

Distribute Information

“Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system…” }{

Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

MACRA HR 2

ENCOURAGING USE OF CERTIFIED EHR TECHNOLOGY AND QUALIFIED CLINICAL DATA REGISTRIES FOR REPORTING QUALITY MEASURES.—Under the methodology established under subparagraph (A), the Secretary shall—I) encourage MIPS eligible professionals to report on applicable measures with respect to the performance category through the use of certified EHR technology and qualified clinical data registries;

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• In 2009, ONC initiated the development of popHealth® as open source software to be used for the calculation of electronic clinical quality measures (eCQMs), which included a web-based user interface.– ONC subsequently contracted with the MITRE Corporation to perform

the development and management of popHealth®.

• Originally envisioned as an off-the-shelf-type tool that could be downloaded and used by non-technical providers for CQM reporting and visualization and supporting Meaningful Use.

• From 2011 through 2013, strategy was shifted to focus on popHealth®’s use as a reference implementation for health IT, HIE, and analytics developers. – Also, it was proving itself valuable for its component parts.

popHealth® Background

• In 2014, ONC ended its stewardship of popHealth® and the community migrated to the Open Source Electronic Health Record Alliance (OSEHRA). There popHealth® has become their first tool in their population health analytics suite.

popHealth® and OSEHRA


popHealth® and OSEHRA

• Home of VistA – the EHR for 9MM Veterans• VistA used by largest health system in the US• Additional 1800 hospitals

• Established by VA to be Hub of Global Open Source EHR Community

• Modeled as a “Foundation”• 501(c)(6) Membership Non-profit, 2011• Membership Corp

• 28 Corporations, 2,800 Individuals• We do not compete.• Dr. Seong Ki Mun

• Became the steward of popHealth® in 2014

ViViAN™ -VistA Visualization

popHealth® Components

• Data Importer – For following file types:– QRDA – Category 1– CCDA

• Quality Measure Engine– Software maintained by ONC for use in a separate tool used for certifying

EHRs for Meaningful Use eCQMs. – Patient data stored in modern, document-based, noSQL database– HQMF measure converted to map-reduce function– Highly scalable, acts as data warehouse or CDR

• Data Exporter – Of the following file types: – QRDA – Category 3– PQRI XML Exporter

• Graphical User Interface (GUI)


Provider

EHR

Payer

Payer

Payer

Payer

Medicaid

Claims Clearinghouse(s)

Claim

s Dat

a

Clinical Data (QRDA1)

Claims Data

Raw DataQuality

Measure Engine

Measure 1

Provider

Result

Provider A

923 / 10,023

Provider B

1,930 / 15,335

Provider C

123 / 3,089

Provider D

10,330 / 12,000

Measure 2

Provider

Result

Provider A

923 / 10,023

Provider B

1,930 / 15,335

Provider C

123 / 3,089

Provider D

10,330 / 12,000

Measure 3

Provider

Result

Provider A

923 / 10,023

Provider B

1,930 / 15,335

Provider C

123 / 3,089

Data Importer

$

Data entry (through workflow)

popHealth®

Graphical User

Interface

Data Exporter

GeneratesDatabase

popHealth – Software Within a Provider’s Network Model

QRDA

3


How popHealth® Works

Quality Data Reporting Models


Conceptual eCQM Submission Process

Quality Data Reporting Models

• Model 1 - Apply Analytics to SLR/MMIS (using popHealth or other tools)

• Model 2 - Build Quality Reporting into HIE

• Model 3 - Enhance APCD to Integrate Quality

• Model 4 - Blended Models


Provider

EHR

Payer

Payer

Payer

Payer

MMIS

Claims Clearinghouse(s)

Claim

s Dat

a

Claims Data

State-Level Registry (SLR)

$

Data entry (through workflow)

Provider Manually Enters

Data

popHealthGraphical

User Interface

Model 1: Analytics Built upon SLR/MMIS

eCQM EHR

Module

Measure 3

Provider

Result

Provider A 923 / 10,023

Provider B

1,930 / 15,335

Provider C

123 / 3,089

Medicaid

Quality Measure Engine

System Automatically

Submits Data

OR

view

Wyoming


Quality Measure EngineData

Importer

Model 2: Build Quality Reporting into HIE

Data Interchange

Engine

popHealth’s Quality Measure Engine

Clinical DataData Store

Provider

EHR

EHR

Provider

EHR

Lab Systems

Registries

ProviderPayer

Payer

Payer

Payer

Medicaid

view

Provider Portal

HIE

Community Members Primary Use CaseWyoming Medicaid Agency Display CQMs from PCMH practices

as part of Quality Care Coordination Program

Maryland, others eCQM reporting, calculation, and storage solution for Medicaid

eHealth Connecticut FQHC, PCMH, and PQRS quality measure reporting

Illinois Department of Health Quality measures for CDC healthy hearts grant and for FQHCs

Northwestern University Meaningful Use CQMs (Certified EHR Module)

MITRE/Veteran’s Health Administration Meaningful Use CQMs


popHealth Use Cases

Reality Check

• popHealth makes certain things easy• Parts of paying based on quality are hard

– Developing a thorough plan with stakeholder buy-in– Establishing governance of data exchange– Data capture in workflow– Data extraction – Linking clinical data to claims data


Additional Background Slides


popHealth® and Tacoma

• Tacoma Ecosystem – BONNIE: Companion service for creating synthetic test

patients.– Cypress: Testing tool for evaluating eCQM calculations

in EHRs.– Data Element Catalogue: Summary of data elements

required by CQMs. – Measure Authoring Tool: HQMF editor.– Value Set Authority – National Library of Medicine

• Value Set management


popHealth® - Part of the Electronic Clinical Quality Improvement Ecosystem

Build Your Own Measures

11/13/15 Office of the National Coordinator for Health Information Technology

Measure Authoring Tool

https://bonnie.healthit.gov

Author custom measures Create test patients

https://emeasuretool.cms.gov https://vsac.nlm.nih.gov/#

Manage Value Sets

https://bonnie.healthit.gov/

https://emeasuretool.cms.gov/

https://vsac.nlm.nih.gov/

Other Resource

• eCQI Resource Center– http://healthit.gov/ecqi-resource-center/ecqm-to

ols/index.html


http://healthit.gov/ecqi-resource-center/ecqm-tools/index.html

http://healthit.gov/ecqi-resource-center/ecqm-tools/index.html

CMMI – Demonstration Models

Source: CMS website, Innovation.cms.gov; “Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care,” Burwell, NEJM March 5, 2015

Incentivize providers to provide coordinated care and held accountable to a patient population

CMS Innovation Center – Demonstrations models

Accountable care

Bundled payments Primary Care Medicaid/ CHIP

Dual- eligibles Model acceleration

Model in which providers receive a lump-sum payment for a specific episode of care

Transform’n of practices into medical homes:team approach, prevention, HIT, care coordinat’n, shared decision making

Initiatives administered by individual states (e.g., Enhanced Prenatal Care Models)

Initiatives to practice person- centered care for people enrolled in bothMedicare and Medicaid

Partnerships to test new models of disseminatingevidence-based best practices and increase the speed of adoption

Local and state partnerships to accelerate other innovative models (e.g.,State Innovation Model)

Best Practices

Medicaid Delivery System and Payment Reform

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Alternative models require quality measurement

Source: http://kff.org/interactive/delivery-system-and-payment-reform/

Private Sector Payment Reform Initiative

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Private Payers Moving to Value Based Models

Source: https://www.ahip.org/Map/AlternativeDeliveryPaymentModels

Health IT Stack for Value-based Payment Models

Data Aggregation

Reporting Services

Notification Services

Consumer Tools

Analytic Services Provider Portal

Data Quality & Provenance

Patient/Provider Attribution

Data Transport and Load (Warehouse/Repository)

Data Extraction

Identity Management Provider Directory/Registry

Security Mechanisms Consent Management

Governance

Financing

Policy/Legal

Business Operations

Claims data (HEDIS)

Advanced quality

improvement ecosystem to

collect, share, and use data

Provider/Practice/Encounter Level Data

Appendix: eCQM Continuum

HEDIS data collected from surveys, chart reviews, and claims data

Live automated data

Automated data acquisition from EHRs to central aggregator tool for calculation, comparison, reporting, and population level measures

Self-reported

Data captured and; eCQM calculated in EHR and only numerator/denominator reported

Integrated data

Claims and clinical data integrated to analyze quality and address population health needs

Patient-Centric ReportingProvider-Centric ReportingPractice-Centric ReportingSystem-centric ReportingPopulation-level Reporting

Value-based Payment Models – HIT Objectives

Source: “Measuring Success in Health Care Value-Based Purchasing Programs,” 2014, RAND Corporation

Value

QualityCos

t

“VBP refers to a broad set of performance-based payment strategies that link financial incentives to providers’ performance on a set of defined measures.” RAND Corporation

1. Accelerate the adoption of value based payment models2. Use standard and aligned measures will support effective use of the

measures3. Standardize measures and supporting data to minimize

administrative burden of implementing quality improvement programs

4. Make data actionable with clear quality and cost goals & standardized shared information accelerates progress towards action

5. Build trust among key stakeholder groups6. Support “glide path” for quality improvement programs7. Improve ability to evaluate capacity of VBP models

quality measurement overview - using health it to support delivery system reform november 19, 2015

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