[This Transcript is Unedited]
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
QUALITY WORK GROUP
February 20, 2008
Hilton Garden Inn
814 14th Street, NW
Washington, D.C.
Proceedings By:
CASET Associates, Ltd.
10201 Lee Highway
Fairfax, Virginia 22030
(703) 352-0091
P R O C E E D I N G S [4:58 pm]
DR. CARR: Okaythe Quality Work Group is now open. Thank you for being here late in the day. What we want to do in this short amount of time is two things. The first is at the request of the Chair of the NCVHS, we have updated the 2004 Quality Work Group Report. I would like to use some of our time to go through that and hit the highlights on it with an eye toward polishing it to bring to the Full Committee as an update in May of 2008 if that seems appropriate after we’ve done it.
Then, I would like to have some time at the end to reflect on directions for the Quality Work Group. Since it is a work group, do work groups continue in perpetuity? Is quality the focus? The relationship with populations and the topic – how do we configure ourselves? Where do we belong, and what should be our focus? So, we will go quickly.
I think you all have a copy of the February 2008 Quality Work Group Update. You may have gotten the earlier copy, but the current one has seven pages, not six. Of course we will try to reduce this. You also have a copy of the candidate recommendations from the May 2004 Report.
What I have done, and thank you for help from others, I have tried to look at the candidate recommendations and reflect on what has happened since then. Thank you also to Michelle Williamson who did a lot of the very detailed work.
I am going to just jump right in and take us through it at a high level. Let us think about what this tells us and what we do next.
MS. GREENBERG: Can you just tell us since it is seven pages rather than six –
DR. CARR: Right, there was some clarification we needed in one area.
MS. GREENBERG: Not any significant section?
DR. CARR: No, it is not significant. It is just a little refinement and a little bit of additional – added something additional.
So, in May of 2004, the NCVHS Work Group on Quality put together a report that reflected five years of hearings and discussion and development. It was entitled Measuring Health Care Quality: Obstacles and Opportunities. They put forward 23 candidate recommendations in the four areas you see. One is assessing health care and health outcomes. Second is reducing disparities and outcomes. The third is building data infrastructure to support quality improvement, and the fourth, balancing patient’s interests in health care quality and privacy.
As you see, the purpose of this then is to review the status and also to identify are there areas that we said were important but haven’t moved forward that we might want to think about? So, I have grouped them a little bit. In the category of assessing healthcare and health outcomes, there were three things that are related: create a mechanism for reporting selected inpatient/outpatient lab results in a standard transaction, create a mechanism for reporting selective vital signs and objective data measurement on inpatient/outpatient encounters in a standard transaction, and third, facilitate the reporting of a diagnosis modifier to flag conditions that were present on admission.
What I find very interesting is that this synchronizes very much with the hearing that we had on June 19th where we heard about the hybrid data. The concept of refining administrative data with clinical elements remains very much in the forefront of the contemporary thinking about quality. AHIC has identified that even though we are moving toward electronic health record, administrative data is going to be with us for a while. A hybrid data strategy could make use of existing sources of data. I do not want to read this whole seven-page report, but my point is that by raising this in the 2004 Report, in fact we are still saying this that hybrid data having these elements is so very important. How did they get there? I think that data remains to be seen, but I think these were three good recommendations and they seem to be underway today.
So, let me just stop there and say, are there any thoughts about that? Should we just sort of run through these things?
MS. GREENBERG: First of all, in general, I would say I am in favor of going in and finalizing this in some way as a document. I think it is a useful thing to do. I think it needs a little editing. It was Michelle Williamson and she was working with Bob Davis who is a consultant to us. He is really techy. Some of the language needs to be –
DR. CARR: When I do not understand it, I just cut and paste.
MS. GREENBERG: Generally, I think it could be these are things that could easily be done well for the May meeting. In this section here, I thought we should actually mention that – it just says that CMS is implemented. Actually, this was the one that the committee did bring forward and a specific recommendation to the NUBC. The NUBC initiated an extensive process in which coding guidelines for collecting it were agreed to. That was one of the recommendations we made though.
DR. CARR: That is why I wanted to make sure that our bringing that forward as the one when we held that meeting in May, that was the one recommendation we moved forward. That then led to that.
MS. GREENBERG: In the letter that we brought forward, it recommended the NUBC defining exactly how it should be collected. That work then was done. NCVHS recommended to the NUBC define just how that indicator should be used or collected.
DR. CARR: Was that a letter?
MS. GREENBERG: Yes. That was a letter to the secretary. It is on the website. It was the only candidate recommendation that then emerged.
DR. CARR: Because it does not appear on the Quality Work Group page. I will check on that.
MS. GREENBERG: Maybe you didn’t count it. Maybe today was 101. That really did trigger that work, and that then contributed. Then at the same time, the congress came up with the hospital acquired infection thing. CMS was able to pick it up, but it also got into the 5010 transaction. So, there is other stuff to say here that the committee can take some credit for too.
DR. STEINDEL: I think one of the themes that is going on in this section and other sections of this report is using hybrid data into administrative messaging that is now occurring so we can gather data for other purposes. I think this is a scenario that we should be investigating very vigorously. We can move things forward a lot faster. At the meeting I was at this last weekend, I actually talked with Rob Plogner because many of us felt we got mixed signals from him at the last Executive Committee Meeting. He noted to me that that was misread. ONC actually is in favor also of moving this type of data through administrative means in the end term period. This is consistent with the way everybody is thinking. I think we are a perfect group to look into those areas.
DR. CARR: Recommendations four and five were modify usage instructions on existing data elements for the operating physicians so that it is a required data element for the principle and patient procedure. The other one was modify requirements for reporting admission date and time and selected procedure data and times on institutional claims transactions. My understanding is we do have the operating physician on the inpatient and the outpatient sides. We have dates. We just do not have times. This, again, knowing the operating physician is the infrastructure for physician reporting, volume of procedures, and in some cases outcomes. I think it contributes to the public reporting that is going on today.
Moving on to number six, encourage payers to modify billing instructions to providers to align procedure start and end date with services included in selective global procedures in a standard HIPAA claims transaction. Here, I actually – this aligned very much for me with this whole concept of longitudinal episodes of care. I think at the time – I do not think that this actual global date range is really being used on the claims form for the most part. That is what we heard from Michelle and Bob Davis. The concept of understanding an episode of care I think is very much in the forefront today in what we are trying to do. As I mentioned here, a few examples, CMS is now reporting the 30-day mortality after discharge for acute myocardial infarction and congestive heart failure.
DR. SCANLON: I think there is a lot of interest in episodes in terms of being exposed to this. It is an issue of how to define an episode. The global fee associated with the surgical procedure that has been defined. Now we are talking about the issue of a whole series of things that made precedes of an event and the things following it intermediate sort of events that occur and complicates other activities that are going on. While there is progress to get a lot of episodes defined, there are these fringes that are very difficult to deal with. It is kind of like, maybe if you get 80 percent of things can be put into an episode and 20 percent cannot. Then those 20 percent, depending on the physician you are trying to measure and some other type of provider, they become very problematic because they may swing someone from the good side to the bad side in terms of measurement.
DR. CARR: So there are two parts to it. One would be the idea of measuring – so measuring a physician. These globals were very much surgically based, but I think the thinking now independent of measuring a physician or measuring anybody, but understanding an outcome. The outcome is not just the myocardial infarction, and it may begin sooner than the myocardial infarction.
DR. GREEN: This comes back to the discussion we were having in the other room. In the spirit of looking for intersections, this is a big one. The episodes issue is crucial to the value equation.
DR. CARR: I was profoundly struck by relooking at these things several things later and realizing the importance of these themes.
DR. GREEN: There is an urgency to it. With all due respect for getting everything we can out of administrative databases – I am not speaking in opposition of that, but once you start off with the purpose of the claims form is to adjudicate payment. You basically can never go home again. That form is going to operate to adjudicate payment. There are a lot of issues and questions about episodes that have nothing to do with that that are in fact distorted, hidden, distracted, avoided, lied about, and misrepresented.
DR. CARR: I think this is an important topic as well. To get us through the 23, I am going to keep moving ahead and ask for comments. Number seven, review the available options for quoting patient’s functional status in the EHRs and other clinical data sets and recommend standard approaches. Conduct the research recommended by NCVHS in 2001 and CHI in 2003 as endorsed by NCVHS. Create a mechanism for reporting functional status codes in a standard transaction. Here, I do not know quite where to say we are except the progress is noted. Most notable in 2007, the IOM Committee on Disability In America issued the report entitled, Future of Disability in America and advocated the adoption of refinement of the ICF as the conceptual framework for disability monitoring and research.
MS. GREENBERG: I think there have been some significant things. The CIHI recommendations – I think this is in here. I think I wrote this. There have been a number of things. There have been the CIHI, the IOM, and then also we had another conference call with NOM and WHO and we are really just tying that up in a bow too.
DR. CARR: Are these areas that are underway and what should have happened has happened? Are there areas in need of more work?
MS. GREENBERG: What we said should happen is being enabled by these things, but – I think we did review the available options for coding patients’ functional status and I think that – and did some of the research, which is number seven. As for creating a mechanism for reporting functional status codes in a standard transaction, well the EHR model does include functional status. I think there isn’t a – I do not know what the CCD does.
DR. GREEN: I do not believe it is in the data set right now.
DR. STEINDEL: I think the reporting of functional status falls under the roof break of we should be investigating hybrid ways of moving this information. What we come up with, I think it is important for us to look at it.
DR. CARR: Number nine and ten, develop survey sampling approaches that can assure the availability of adequate benchmarking data at the state metropolitan area levels and for racial and ethnic sub populations. Ten, standardize currently inconsistent items that are used to report the same measure of quality across federal surveys, coordinate with states in private sector, quality measurement, oversight organizations, and the adoption of common items across federal, state, and privacy sectors. Here, I just kind of cut and paste what we had in the update.
DR. GREEN: I have a question about number nine. Is there a reason why the word rural does not occur in there?
DR. CARR: Well, I am just copying what was written in 2004. That was the work of the earlier group, so I think we are working with what they said. The concept –are you raising an issue of what needs to be looked at?
DR. GREEN: Yes.
DR. STEINDEL: I read this as items that NCVHS noted as open issues with suggestions on how to solve them in 2004. I read the comment coming back that it is still an open issue. I think that is what we need to say about it. This is an area that needs to be addressed. NCVHS is not the group that is going to address this.
DR. SCANLON: Isn’t a major portion of this issue the budget? It is not really hard to develop sampling strategies to get representative data from different areas. Once you have got a budget that says this is the total. You need to have a representative sample for the US. Okay? You end up sort of spreading your data across the country so thinly that you cannot report smaller area information. CPS faced this in terms of unemployment statistics and they ended up having to increase their sample size. That costs a lot of money.
DR. CARR: Reducing disparities in quality, eleven, twelve, and thirteen. Modify existing mechanisms for reporting race and ethnicity of subscribers on the HIPAA enrollment transaction. Twelve, investigate how best to capture race and ethnicity on a standard provider transaction. Thirteen, modify existing mechanisms for reporting the primary language of subscriber’s independence. Part of the opportunity of updating this report is to report work done by NCVHS, including two hearings that we had for Quality Work Group and didn’t really result in a report. I was trying to incorporate that as well. I made note of the November 2005 NCVHS Report on eliminating disparities. What do we think about this?
DR. STEINDEL: Again, this is the same sort of as before. This is an extremely important issue. I think this issue actually is a tad more advanced than the previous one. The big problem here is there is a lot of pushback from the provider community in not so much in collecting the data, but trying to find out how to really collect the data and what it means when you collect it. What we hear is all sorts of conflicting comments from them. How do you determine race and ethnicity?
DR. CARR: We heard in some testimony that depending on who asks them, you get different answers. Sometimes they tell you something different.
DR. STEINDEL: How do you adjudicate differences given between – especially when you go to an NHIN. There are a lot of complex issues in this that are very societal.
DR. SCANLON: During the discussion of this report, I think we actually focused a lot on number twelve. The idea was that this is maybe not a good idea because what it may produce is a whole of inconsistent information. The better focus is to try and find some way to at one point in time get this information right and have it in a place where you can use it for multiple circumstances. This is the kind of thing that does not change. Therefore, one of our principles about multiple uses seems to apply because the idea that every provider is going to report something kind of goes back to Larry’s. They are going to report something, and then you have this data set, which has all these values for this individual. What do you do with them? That is the problem.
DR. STEINDEL: I am not certain I agree with your statement that we can gather this at one important point in time. Unless you do that by definition. People change their race and ethnicity over time.
DR. SCANLON: There is something about the validity of that measure then if they do change their race and ethnicity over time because if we define it in a way that this is your race and ethnicity, then you do not change that over time. Your reported race and ethnicity may, but that is a different issue. This goes back to if we knew how to collect it and did it right and got valid measurements, then it would not change over time.
DR. CARR: My question for this is –
MS. GREENBERG: We do not want to get into this whole discussion obviously. I would say that I thin if anything, there have been more recognition of the importance of information and language. I do not think anyone has said since then, this isn’t information we need. I know Kathy who was the previous chair before Bob of the Quality Work Group felt that there was some value. If it is collected by the provider not by self-report to what the provider thinks a person’s race is. If you want to do some kind of study as to whether this impacts on their recommendations. We know women get different treatments for heart disease. People may think less about treating one racial group than another for certain conditions or who knows what. It is very complicated. There is one additional – it does focus on the enrollment data, which is more along the lines of what Bill was saying that if you could collect it by self-report by some kind of defined way on the enrollment data, then you wouldn’t have this problem of having to collect at every encounter. You would have at least from the enrollment data, you could update it periodically. If you wanted to collect it on the encounter, it was not at all possible on the UB92. It is possible on the UB02 in the area on the bottom that is called the code-to-code area that you can define yourself.
MS. MCCALL: First, it is a good summary. My one recommendation would be to put in a bluff, which is a bottom-line up front. So before you go into the here is one, two, and three actually have an executive conclusion, which sounds like it will be, we saw the need done. There has been progress, but there is still a need now. I do not know if we see it as small or big. I think that would help. The second is that, this is about the building blocks for quality. If quality is a sentence or a paragraph, than these are either the words or the alphabet. It is not that now it is informed by the priorities that we go after and are informed by what we think is needed to in fact down the road measure quality and those types of things. I am struck that. It is every single time. Then I go, that is fact. Is that a role? Yes or no? It also begs a meta issue. If we are doing it, do these not have a home? Where do these issues get resolved? Where do vocabularies get built and set and pushed through?
MS. GREENBERG: There is not a coordinated way that that happens.
MS. MCCALL: That seems to me to be the meta issue is that if there is so much happening here and more is coming rather than less that these things need a home.
DR. SCANLON: One of my reactions was that they have multiple homes. As we were going through this, the issue of should this be a single letter going to the secretary, or should this be multiple letters going to the secretary saying, about these things, go to your friend over here and do something about it. The second letter says, about these things you go over here because sampling versus administrative data – these are totally different domains. Getting a letter with a list that involves too much complexity is not necessarily going to make the move immediately.
MS. MCCALL: I have one more comment. The meta issue could be the big thing for us to address, which is to call out the fact that there is a need for much more emphasis. The reason I say that is it is a medical home for data. As data begins to flow, this issue is going to grow. It is going to grow not linearly. It is going to explode. That is what I would say is the time is now. Go back to the morning comment. What are the data needs in data stewardship when you start thinking about insurance reform? Insurance reform in the next couple of years starts to come out of line. The requirement around data – I see that taking a change. I believe it would be incumbent upon the secretary to be ready and have some of these over arching mechanisms in place. Right?
DR. STEINDEL: I have two comments. This was a little disconnected. First was in Bill’s comment about what we should do with this report. I thought we needed to discuss that later. I do not feel we should turn this into a report to the secretary. This is our notes. We can refine it and clean it, but I think the Quality Committee should use it as a guide to create a multiple specific letters because I think they will have a better reaction. The second, I thought Carol had a brilliant suggestion there with respect with data home. That is something to explore. This comes from a HITSP perspective. When we were working on the quality use case last year, one of the big issues that we had was how to define quality data sets. What we really found was there was no place to go to say, what should this data set look like? Is there some place we can go to and say create this data set or bless this data set? In the quality world, it was very fragmented. That is what we are dealing with in this particular report. To hone in on it, we are going to be dealing this year on population health case reporting. That has a home. There is an organization that exists for years that has handled that home.
MS. GREENBERG: It just sums up what the problem has been all these years. There is a lot of stuff in here, and it is all over the map. Some of it is related to the hybrid thing. Some of it is related to surveys. Some of it is related to privacy. The fact is that we keep coming back to it because there are a lot of important issues here. There is no real unifying place for this.
DR. CARR: What I would like to do is get through the next ten recommendations for feedback on where does this go or what is the overriding issue. Skipping the top of page four because that was simply summarizing things we had heard at one of the hearings. Now we are building data infrastructure to support quality improvement. Recommendation 14, adopt standard clinical terminologies including a crosswalk or met thesaurus of clinical synonyms that can be used to consistently identify and describe clinical conditions, procedures, treatments, and outcomes across administration transactions, patient and provider surveys, and – do you want to say a word about that?
MS. GREENBERG: This is something going on here. There is this foundations committee. There is the vocabulary committee. There are a lot of different groups working on this. This is what we are going to hear tomorrow partly from IHMIA. There is no real coordinated mechanism. I think you could raise this particular recommendation with them tomorrow and say, is this one of the things you were talking a bout?
DR. Carr: This is good just at the high level. Fifteen, promote the identification of synonyms for standard clinical terms that are easily comprehensible to patients of different cultures, educational, et cetera.
DR. STEINDEL: It is an area we haven’t made much progress in. It is open. There is some discussion and even at the time we wrote this about how much of a need is there for a vocabulary.
DR. CARR: Isn’t Google doing that?
DR. STEINDEL: In part because people who tend to get really interested in it learn the vocabulary.
DR. CARR: Sixteen, adopt ICD 10. I am not going to go there. Seventeen, create a mechanism for efficiently mapping procedure codes across current and proposed HIPAA standard coding systems to facilitate querying and aggregating procedural information across care settings.
Eighteen, standard functionality requirements for EHRs should include clinical decision support to facilitate planning and delivery of evidence based care. I think that is well in hand.
DR. STEINDEL: Actually, from what I gather, there is a lot of effort going on in this area. I think there are some things coming to printed stage relatively soon. When it does, one of the first things we are going to do is invite those people to report to us.
DR. CARR: Nineteen, EHRs should employ uniform data standards for core content data storage formats to facilitate population health, surveillance, and reporting functions.
DR. STEINDEL: I think this is started. I think that is best way to put it. NCHS is looking into that. CDC Atlanta just kicked off an effort yesterday to start doing this.
DR. CARR: Twenty, promote standards for interoperability of electronic clinical data systems and EHRs and adopt a core set of record formats to the EHR and should be capable of exporting and importing to support care coordination.
DR. STEIDEL: That is tied into the one above.
DR. CARR: Okay. HHS should recommend adoption of NPI that we should use it not only in administrative transactions, but also clinical data systems, EHR provider surveys. Does everybody have just one NPI? You actually can have more than one.
MS. GREENBERG: Institutions could depending on how they define them. The design of the system is such that individual clinicians are supposed to have only one NPI.
DR. CARR: Does this make sense then that NPI would be used as the way to identify – I didn’t know. Not allowed?
DR. STEINDEL: This is a problem. It was brought up when they were creating is because the physician is only supposed to have one NPI, a physician who provides care out of multiple locations, that care location is difficult to identify from the provider identity.
DR. CARR: So if you are a resident or an attending and you moonlight someone else, you might have your NPI when you are doing that?
DR. STEINDEL: As a human being, you should have one NPI. The common cases I think with radiologists and people like that who actually read wearing different hats in different locations.
MS. MCCALL: The same code does not need to do double duty.
DR. CARR: The question is, can NPI be used to identify physician performance?
MS. GREENBERG: There was an issue about whether an organization can compel somebody to provide his or her NPI.
MS. MCCALL: This is a great example of the kind of very detailed discussion that somebody who owns the NPI would say, CMS needs to describe what it can be used for.
DR. STEINDEL: They have. What came up were some of these questions about using NPI for purposes other than what they were requesting, which was strictly for billing purposes. It was clearly numerated that it could not. It had difficulty.
DR. CARR: I have enough information on this now. Twenty-two, patient identifier. We know the answer to that. Twenty-three, balancing patient’s interests – let me go back to that for a minute because in addition to patient identifiers the logic of matching patients to their records. We held hearings. Did we not write a letter on that?
DR. STEINDEL: We never finished.
MS. GREENBERG: This would have to be re-written for our own uses. The unique identifier was rejected by congress. WE do not want to talk about those hearings back years ago. There was a series of hearings on matching patients with their records. Still, if you cannot match patients with their records –
DR. CARR: Why did we not write that letter?
MS. GREENBERG: It got picked up into the NHIN letter. It was being done at the same time, and it didn’t seem like a good idea to produce both those letters at the same time because one could draw attention away from the other. I think some of the findings did get into that NHIN specifications letter.
DR. CARR: The last one, examine privacy protections under federal laws that inhibit access to and linkages of patient records across payers, providers, care setting, coordination management, revise and clarify current regulations to reduce obstacles while effectively balancing the best interest of patients in populations. Those are the twenty-three things. What I have heard is we need to break them down into smaller groups according to who would be the recipient of the letter.
MS. GREENBERG: I think what you want to do is clean this up as a background document for the quality group. Get this so it is accurate and what it says here is correct. Then decide whether you want to because it is so over the map that if there are particular topics you want to either do a recommendation on, maybe address in the medical home hearing, or what you want to do with them. We should clean it up as an overall document and then figure out what you want to address as you see fit.
DR. GREEN: This review could help me a great deal in thinking about the broader questions. This helps me conceptualize how the NCVHS might want to design the way it moves forward. With quality being a delightful unifier of the word instead of dividing ourselves up into pieces and try to put ourselves back together. When you go through this exercise, whether it was intentional or not, the Quality Work Group served as a home in a unifying focus for quite a spectrum of things. I think we aught to try to figure out a way to establish the work group as a permanent fixture in the NCVHS.
DR. STEINDEL: Larry, in the executive subcommittee meeting, this was discussed and the recommendation that it should be elevated to full committee status.
MS. GREENBERG: That was suggested. I do not think the executive subcommittee recommended that. It was on the table.
DR. STEINDEL: It is something to bring forward. One of the other things, and this will probably be discussed in May when we look at a new constitution for the committee, is that we think about changing the name and scope of the committee to expand beyond just quality into the whole rubric of data usage.
MS. GREENBERG: I think my response to any of those suggestions to reorganization is that if what everyone was going to do – you really need a clear mission statement as to what the group is going to do and then a work plan. If you can do that, and it something people buy onto, fine.
DR. CARR: This is why I said to Simon, we need to have a grid and then organize around them because this is the work of two full committees. I think it is why it has been so difficult even going back to 2004. It wasn’t just a work group thing. It was the whole landscape. I think we need some clarity tomorrow.
MS. MCCALL: If it were just a continuation of this agenda I certainly wouldn’t support a recommendation to keep the Quality Work Group going, let alone trying to turn the work group into a committee. I do not believe this kind of work belongs in the Quality Work Group of the NCVHS. It is spitting in the ocean. It is just too big. It is day jobs of many, many people on this earth. I would support maintaining the Quality Work Group if one of the main tasks was to have an opinion on recommendations about how to make it into people’s day jobs in a way that is delightfully agile and robust and all those things. That kind of work is not about quality. It is about data usages. Data stewardship begins at home. It is not data for quality. It is data that has quality in and of itself. That is what we are talking about here.
MS. GREENBERG: That is one of the things that Sondik raised at the Executive Subcommittee. What is your role in talking about the quality of data?
MS. MCCALL: Right. I would say that the quality of data is in fact – I would give it a different name and not put it under Quality Work Group because it would be confusing. I would also take people back to the vision for the 21st century because the health statistics vision talks a lot about this. It talks about mechanisms for many things. This being one of them. That goes back to a lot of data stewardship. Simply continuing here. No.
DR. CARR: We are at the end of our time. Thank you for this marathon trip. Let us maybe think about this tonight. We will have some summary tomorrow before our closing comments. Also aligning with Don’s plan to revisit the statistics for the 21st century, there may be a way to pull this together that brings through the themes that need to continue. So, I thank you for your time and your ideas.
[Whereupon, as of 5:47 pm, the Quality Work Group meeting was adjourned.]