Quality Improvement and Measurement with HIT Kevin Larsen MD Medical Director, Meaningful Use Office of the National Coordinator of Health IT March 7 2013
The only way you can achieve the triple aim is not to do one thing but to do everything. Don Berwik
3/29/2013 Office of the National Coordinator for Health 3
3/29/2013 Office of the National Coordinator for Health 4
3/29/2013 Office of the National Coordinator for Health 5
Computer assisted flying as CDS It is winter, sometimes there is snow. Be careful. Press here to document you read this. Scheduled maintenance due in 2 months, mark here to accept Bathroom water pressure is low
New Care Models Medicare ACOs (CMMI) Medicaid ACOs (SIM) Commercial ACOs National Quality Strategy Standards Health IT 3/29/2013 Office of the National Coordinator for Health 7
Advanced clinical processes Improved outcomes Data capturing and sharing Stage 3 Stage 2 Stage 1 8
I am the expert about me. 9
Hurricane Sandy
INTEROPERABILITY
Complex Adaptive System 12
Quality 13
Quality Ecosystem Local EHR Registry or data intermediary Benchmarking Coaching Technical support 3/29/2013 Office of the National Coordinator for Health 14
Only those who provide care can improve care
HIT enable practice of the future 16
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
Small Data is our short term focus Small Data is our Short Term Focus. Dr. Joe Kimura Dr. Joe Kimura 18
Source: CDC, July 2012 19
HHS Core HIV Indicators Measure Numerator Denominator HIV positivity Number of HIV positive tests in the 12-month measurement period Number of HIV tests conducted in the 12- month measurement period Late HIV diagnosis Linkage to HIV Medical Care Retention in HIV Medical Care Antiretroviral Therapy (ART) Among Persons in HIV Medical Care Viral Load Suppression Among Persons in HIV Medical Care Number of persons with a diagnosis of Stage 3 HIV infection (AIDS) within 3 months of diagnosis of HIV infection in the 12-month measurement period Number of persons who attended a routine HIV medical care visit within 3 months of HIV diagnosis Number of persons with an HIV diagnosis who had at least one HIV medical care visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between the first medical visit in the prior 6 month period and the last medical visit in the subsequent 6 month period Number of persons with an HIV diagnosis who are prescribed ART in the 12-month measurement period Number of persons with an HIV diagnosis with a viral load <200 copies/ml at last test in the 12 month measurement period Number of persons with an HIV diagnosis in the 12-month measurement period Number of persons with an HIV diagnosis in 12-month measurement period Number of persons with an HIV diagnosis with at least one HIV medical care visit in the first 6 months of the 24 month measurement period Number of persons with an HIV diagnosis and who had at least one HIV medical care visit in the 12-month measurement period Number of persons with an HIV diagnosis and who had at least one HIV medical care visit in the 12-month measurement period Housing Status Number of persons with an HIV diagnosis who were homeless or unstably housed in the 12-month measurement period Number of persons with an HIV diagnosis receiving HIV services in the last 12 months 20
Research What s happening? Guidelines What SHOULD Happen CDS It will happen Quality Measures Did it happen?
Quality Measurement Alignment MU, PQRS, IQR, ACO, VBP, HRSA,CDC Unified Measures current EHR Reporting
Medicare Data Sharing for Performance Measurement NOW FUTURE INSURANCE COMPANIES MEDICARE? INSURANCE COMPANIES MEDICARE? Qualified Entity COMPREHENSIVE CONSISTENT FAIR ACTIONABLE 23
emeasures emeasures are software queries Need to find space for clinical judgment Easy and broad dissemination Innovation model from the start- continue to innovate Tools for local use and for accountablity 24
Future State: HIT Enabled QI Toolkit Stakeholder s Unambiguous human readable Value Set Authority Center Public Domain Unambiguous machine readable EHR Certification Tools Electronic Health Records Population Health Tool Clinical Registries Clinical Decision Support CMS Quality Reporting Other HIT Tools 25
Electronic Clinical Quality Measure Development Kaizen Future & Current States Development Time Future Process 1 year Major Changes Future vs. Current: -Single Piece Flow vs. Batch Flow Processing -Upfront vs. During Stakeholder Engagement -Streamlined vs. Redundant Approval Loops -QA throughout the process vs. only the end = Measure in Development Development Time Current Process Jan 2013 3-5 years Rework Loop
Measure Development Ecosystem USHIK STANDARDS HQMF CDA QRDA RIM QDM VSAC MAT ecqms NQF? MAP? Rule? CDS vmr HeD PopHealth Cypress SEVT (reporting to CMS) cehrt
28
pophealth 29
6. Reliability & Validity Field Testing 5. Implementation Field Testing 4. Data Element QA and e-spec 3. Measure Concept Research 2. External Stakeholders 1. HHS Contracts HHS Post Kaizen Event Notional Future State Clinical Quality Measure Testing Process Flow Proposed National Testing Development Efforts Measure Related Contract Modifications Testing Templates (Plan, SOW, DUA) National IRB/HIPAA Waiver National Test Bed Criteria National Test Tools Allocate Test Bed Funding Incorporate Agile/Lean Add Task Cross- Stakeholder Innovation Allocate New Task Funding Modify Deliverables Schedule SOW/DUA Paperwork Submit IRB Application Approved Test Bed Vendors Hosps Beacons HIEs EPs Vet Prospective Testing Entities Potential Testing Entities Vendors Hosps Beacons HIEs EPs Identify Measure Concept HL7/Standards Organizations Select SME Panel Clinicians Methodologists EHR Data Experts Standards Experts Review Materials Preliminary Face Validity Assess Preliminary Data Element Assess (see sub-flow 1) National Data Element Repo 1 Measure Fail Early? N Narrative Modifications N 2 Fail Early? Updated HQMF Answer Key Vetting Process Simulated Test Cases Draft HQMF MAT Entry Measure Developer VSAC / NLM Draft Measure National Cypress & Create Test Cases Require. Tool VS Repo Bonnie ETL Title Update AMA National Template Data Element Table Tool (DET) Update National Template Query Vendor Review Vendor Data Warehouse Completed DET Query Counts 3 Fail Early? Feasibility Analysis N Vendor Implementation ETL Measure Calc Performance Report 4 Answer Key Comparison Fail Early? N Update National Templates Approved IRB/ HIPAA Waiver Executed Contract/DUA Data Collection Form (DCF) Binomial Analysis Code Determine R&V Testing Approach Does DB Volume/Struct. Support Binomial Analysis? N Production EHR System Y Perform Binomial R&V Analysis Perform On-Site Validity Against Gold Standard Binomial R&V Analysis Results R&V Compare Results 5a Fail Early? 5b Fail Early? 30
Health edecisions http://wiki.siframework.org/health+edecisions +Homepage 3/29/2013 Office of the National Coordinator for Health 31
I wouldn t give a fig for simplicity on this side of complexity but I d give my right arm for simplicity on the other side of complexity. Oliver Wendell Holmes
Questions? Kevin.larsen@hhs.gov For more information about ONC visit: healthit.gov 3/29/2013 Office of the National Coordinator for Health 33