[This Transcript is Unedited]
Department of Health and Human Services
National Committee on Vital and Health Statistics
Workgroup on Quality
March 4, 2005
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
CASET Associates, Ltd.
10201 Lee Highway, Suite 180
Fairfax, Virginia 22030
P R O C E E D I N G S [8:35 a.m.]
MR. HUNGATE: I’m Bob Hungate, I chair the Quality Workgroup, my professional activity is I’m really retired but I go under the label of Physician Patient Partnerships for Health as an advocate of the dyad of co-management of health. And on my left, no conflicts, excuse me, I forgot.
DR. STEINWACHS: Don Steinwachs, Johns Hopkins, I’ve always aspired to be a quality person so I knew this was the right group to be with, started quality measurement back 30 years ago, I don’t think I’ve transformed the American health care system yet. My only conflict is my self interest in having quality care out there.
DR. HUFF: Stan Huff, I’m a member of the main committee, just visiting today with Quality, I am interested in quality but not a member of the subcommittee. I’m with Intermountain Health Care in Salt Lake City.
MR. SCANLON: Bill Scanlon, I’m an economic by training, and I’ve been in qualitative health care research for I guess about 30 years, first as a researcher at the Urban Institute and then at Georgetown, and then I went to JAO(?) about 11 years ago for a year’s leave and ended up liking it and staying ten, and just recently left there and am now doing sort of a variety of different things including this, the Medicare Payment Advisory Commission and some consulting in various places.
My area of my research has involved payment policy for public programs and I think one of the major clear effects of those policies are that we’ve always ignored quality and everybody the same is sometimes push very hard to control costs, they won’t even talk about it, we’re not measuring quality but we ought to control costs, but we’ve ignored the quality dimension and I think we’re now fortunately reaching a point where the error of that has been recognized but we’re only making very small steps in the direction of trying to correct that. And I don’t have any conflicts other then Don’s.
DR. COHN: I’m Simon Cohn, chairman of the committee, I’m actually not a member of this workgroup but I felt that I should come in and talk a little bit about the future directions, I’ll probably not make it through the whole meeting, at least some though if I had known Stan was going to be here I probably let him take care of it.
MS. GRANTHON: Good morning everyone, my name is Miriam Granthon, special assistant to the director of the Office of Minority Health, and I’m actually a staffer for the Populations Subcommittee and Dr. Steinwachs mentioned this meeting yesterday and the idea of working of closer together, I’ve been in the department about nine years, I’ve worked on the Healthy People initiative, I worked at AHRQ in the Office of Priority Populations on Minority Health, and somewhat –. And I’m a former student of Dr. Steinwachs —
DR. FITZMAURICE: I’m Michael Fitzmaurice, senior science advisor for information technology in the Office of the Director at the Agency of Healthcare Research and Quality. Basically what I’ve been spending the last half of my life on is trying to get medical information more computerized, accurate, and uniform so that researchers can have access to better databases, I can turn out more robust findings under conditions of confidentiality, the access to data not the findings, and it dovetails in with quality, with cost of care, and with everything, if you can’t measure it it’s hard to describe what you’re buying.
MS. MCCALL: My name is Carol McCall, I’m with Humana, I have no known conflicts for today. A little bit about myself just to introduce you, give you a flavor for some of the things that I’ve done, I’m an actuary by training and have been with Humana, let me just say on and off over a number of years, I had an opportunity to do some other things as well that are not traditional actuary work and some of those things have been, I was four time chief information officer for Humana, not a technologist, more on the informatics, ran pharmacy management for Humana for about three years which took me into a lot of things related to Medicare and prescription drug coverage for Medicare, we had a very large and still do Medicare population. Did some work during the high tech or dot.com boom with a company that does electronic prescribing and electronic medical records. Returned to Humana when we created what’s called our Center for Health Metrics and that has a focus on, I actually have five or six areas that I’m responsible for now, so things like clinical metrics, all of our clinical programs, all the economic measures, outcomes measures, and operational measures, all of our pharmacy metrics, comparable types of things in there.
Responsibility for trend analysis, we do a lot of things that look at trends and emerging trends and those things involve new technologies as well as new types of reimbursement that will link into another responsibility which is around what I’ll just call provider analysis, both physician and hospital on efficiency and quality measures, we have some things going on there.
And last but not least I’m responsible for I guess what I would call business intelligence tools which we’ve built some things that involve some advanced analytic and predictive modeling techniques and some advanced visualization that we’ve found to be fairly powerful in understanding the relationships of one thing to say many other things. So that’s just a top on some of the things I’ve done and been responsible for.
MS. GREENBERG: Sorry I’m late, I was next door.
DR. EDINGER: I’m Stan Edinger, I work at AHRQ in the Center for Quality Improvement and Patient Safety — because I started out as a PhD physical chemist doing our conversation work which probably has very little to do with what I do now. I worked as a clinical chemist and one of the first things I had to do was basically implement the hospital based information lab system, which is over 35 years ago which the computer age was not quite going, problems are still the same though. There’s an article in JAMA today which reminded me of what we were doing 35 years ago, discovering the same things we discovered 35 years ago that if you put something in place you have problems.
I worked in the old Bureau of Quality Assurance in HRSA with Mike Grantz(?), I then worked at CMS for a number of years which some of your people are investigating some of the work we did. And then I got the pleasure of sitting on the other side, I belong to a Congressional committee where we ordered stuff that I got to look at instead of being investigated. I also worked on the Hill for about four years, I guess we’ve sat across on the table on one or two hearings. I worked in the White House Drug Program for a year and then I was on AHRQ in various places, I worked in the practice guidelines, we don’t call it practice guidelines any more. I worked with Mike in some of the information technology and now I work with some of the patient safety and other areas, so I guess I couldn’t hold a job because I had so many different kinds.
DR. HOLMES: I’m Julia Holmes and I work at the National Center for Health Statistics, and I’ve been there for about three years. Prior to that I worked at Blue Cross/Blue Shield of Michigan, I did quality studies in the Center for Health Care Quality and Evaluative Studies. At NCHS I work in the Division of Health Care Statistics, we run the provider based surveys, the National Hospital Discharge Survey, the National Ambulatory Care Surveys, and in my tenure at NCHS I’ve been kind of the point person for working with AHRQ on the National Health Care Quality and National Health Care Disparities Report, and we’ve worked quite closely with AHRQ and a lot, the majority of the measures that are in those reports come from NCHS/CDC systems.
DR. CARR: I’m Justine Carr, I’m a hematologist, I’m at Beth Israel Deaconess Medical Center and Harvard Medical School and I am director of health care quality, worked on safety outcomes, metrics, quality metrics, and clinical resource management.
MS. GREENBERG: Marjorie Greenberg, NCHS, CDC, executive secretary to the committee and very, I guess I’m interested in all of the obviously workgroups and subcommittee but I’ve been quite involved and hope to continue to be with this workgroup.
MS. MCCALL: I’m sorry, I wanted to add one thing very quickly that I forgot to mention, that I’m involved in, that Humana is involved in which is Humana recently won one of the awards for the chronic care improvement pilots for phase one and so I’ve been one of the architects of bringing together all the parties for that award so it’s another reason that I’m particularly interested in some of the things that are going on here, so that’s also a factor that may prove valuable as we move forward.
MR. HUNGATE: Very good. Let’s cover the wall over here —
MS. BURWELL: Audrey Burwell, Office of Minority Health, lead staff to the Populations Subcommittee.
MS. JONES: Katherine Jones, CDC, National Center for Health Statistics and staff to the committee.
MS. JACKSON: Debbie Jackson, staff to the committee.
MS. BOLYN(?): Sue Bolyn, American Health Information Management Association.
MS. CURRY(?): Courtney Curry, contractor.
MR. HUNGATE: Thank you.
MS. POKER: Sorry I’m late everybody, Anna Poker, staff lead to the Subcommittee on Quality, AHRQ.
MR. HUNGATE: Okay, I want to leap right into the future directions and I’d like to make a few preparatory comments and I think Simon would as well so let’s do that first and then get into the specific discussion and I hope Bill or Carol will not feel intimidated at all, there’s no reason to expect to change qualitative, because part of what I’ve learned in the two and a half years or so is a little bit about what works and doesn’t work in terms of whether you make a contribution to the game.
And there seem to me to be two kinds of contribution that occur, one of which is very topic specific and deals with decisions that kind of have to happen now and the letters exemplify that kind of thing where things are going on and you’re dealing with a content issue with a letter. There are other things that are longer term like the NHII report, the 21st Century report, where you’re not dealing with something that’s an action now, it’s a longer term kind of a choice. And you kind of need both in terms of what we’re doing.
Now I don’t think we as a workgroup have been clear on which of those we think is our best mode of operation, I inherited an agenda that had been going on for a long time and the institutional memory of the content of that wasn’t very good. When I read the transcripts, which I did, of all the hearings in detail, I couldn’t necessarily connect the transcripts to the report which disturbs me quite a bit and so my conclusion from that is that things that make sense have to be begun and completed by one unit of institutional memory and that unit is kind of a mix of the workgroup and the other subcommittees of the functioning organization, that what we can do effectively depends on the level of trust placed in us as individuals on the topic.
E-prescribing for instance, I don’t pretend to understand all the content that went into the letters that went forward but I have great confidence that the people that put the letter before me do. Now maybe that’s misguided, I see Simon making —
— so we have to convince the rest of the people of our own brilliance on the subject that we pick is part of what I’m trying to say and part of that relates to the constituencies that we have here, who we are, what we bring to the table, what we can do in terms of what our competencies are.
And the other and I think equally important is what we think we should do and what’s important for us to do. I am not one who’s wedded to my own views although they’re very strong, I’m always going to articulate my views and I’m not going to back off until somebody convinces me I’m wrong, which is kind of hard to do sometimes. But I’ve had a few years of accumulating confidence in my beliefs and so I push them and I expect others to do the same.
And I think from that we get a picture of what might work and I used to manage a sales force and I had the greatest trouble with people who refused to speak up because they held knowledge that I didn’t have and we needed in order to make progress and so we lost opportunities because people didn’t speak up. So that’s my input to the process.
Simon I think has some other additive thoughts to the same thing which should relate to our future directions.
DR. COHN: I apologize, as I commented to all of you, very early in the morning in California, I’m not usually quite as eloquent as I get to be later on in the day.
DR. COHN: The other thing is that clearly before our next meeting I’m going to have to look in the mirror and pay poker face, that I seem to be telegraphing into my face in terms of messages or otherwise —
DR. FITZMAURICE: But that’s a good sign of a leader.
DR. COHN: I actually Bob I agree with much of what you said and clearly the reason I’m here is to really talk about goals and work plan and really, what I see as really the key first step for this workgroup. Like Bob has commented that when Bob took over this workgroup there was sort of a legacy of information on work that had been done but nothing had ever been done with it, and at least from my perspective and I’m speaking now as a member as opposed to chair of the committee, but my sense had been for a couple of years that the workgroup had kind of been held hostage by the report, in a sense it couldn’t seem to get beyond it. I think there have been, as I’ve begun to see sort of the draft recommendations, the hearings, coming up with a couple of actionable recommendations, it makes me feel, I love to see things that have actionable recommendations on them.
But obviously I think it’s at this point that we need to begin talking about sort of moving beyond that report and doing things that are timely, relevant to this time as opposed to four or five years ago which has been many of, I’m not even sure they were hearings but maybe the sessions that clearly around the quality information, and to sort of rethink the agenda.
MR. HUNGATE: Well, one of the other aspects of the past was that a lot of the content was before the full committee as established and proposed by the Quality Workgroup.
DR. COHN: There are a whole set of things, and I don’t think we need to go over old ground on it but I do that, I guess I would worry if you spend the next year in this workgroup rehashing yet more of that same information which is from many years ago. And really what I, I mean there are probably going to be near term things that the workgroups needs to do but I really want to start off a deliberate process to really talk about goals and I want to see well articulated goals and to me a goal needs to be something that you can sort of talk about in a sentence or two, sort of an elevator speech type thing, it shouldn’t take two or three pages to articulate a single goal. And I think work plans need to be things that we’ll understand, these are all fundamental business concepts, we’ve all dealt with this before.
The other piece and Bob, I agree with you about some of these are longer term goals and shorter term goals, I would however posit that almost no matter what the workgroup decides to engage in you’ve got to have actionable recommendations and that’s the thing I’m almost most concerned about. You’ve done a good job with some of the specific recommendations on the creation but I always get concerned when I see the reports coming out of the committee and at the end of the reports there are sort of high level recommendations that if you’re not careful then the Secretary or the staff have to spend a year figuring out what to do on it.
And I think the mark of this committee, really the mark of our relevance, is that we have thought through the recommendations, have talked enough to the industry or whoever it is we’re dealing with for these recommendations, that when we give some recommendations to the Secretary it’s not just our recommendations but they’ve been vetted enough by everyone else that we can say, geez, this is representing the views of a lot of the industry, you’re not going to get consensus in a lot of cases, we obviously need to note that as the case may be but if you can move the industry along with it, and move the environment, then I think we’ve really done things that are really valuable. And obviously we give the Secretary confidence that they can actually move forward with the recommendations. So I think that’s sort of a model.
Now as I say all of this I don’t, I’m still talking to people, I can’t tell you what it is you ought to be doing next, you’re all experts, you have views on all of this stuff, I think that’s really part of the workgroup process to figure this one out. I do think it might be useful as part of that deliberative process to actually potentially hold a hearing at some point later on this year with the right people, to have them come in and talk a little bit about what the agenda ought to be, in other words asking the customer what would be valuable if we worked on these areas. Obviously that’s not a blue sky, just grabbing some people, you need a framework so that you can ask the right questions. But I think that once again that becomes sort of a very useful piece because at the end of the day we have customers that are interested in the information and are willing to do something with it. There’s nothing more frustrating, and we’ve seen this from time to time in the committee, but generally our recommendations and letters are eagerly awaited or taken and things happen with them. And then other times we have a recommendation or a report, we sort of wondering six months later well, the Secretary hasn’t even responded to it —
MS. GREENBERG: Or a year and a half.
DR. COHN: A year and a half, and other times it’s a perfunctory letter and whatever. So hoping to establish the customer interest in the beginning is critical in all of this.
MS. GREENBERG: I just wanted to reflect a little bit, I mean I agree with what everybody has said and as Bob articulated is very much my kind of long view from having worked with the committee for a long time, that you do need certainly actionable recommendations and you don’t want recommendations that are dead on arrival or that nobody is going to do anything with. And if that were the sum total of the committee’s recommendations it would clearly be problematic but you also need these broader visions and I know Simon agrees with that, too, and that I feel like I’ve articulated this before but that if every recommendation feel on receptive ears the committee would not have met its mission because it needs to be kind of thinking ahead and kind of pushing the envelope and these are recommendations. So some balance there between kind of getting some ideas out there that may take a while to percolate and being kind of just in time as well with recommendations.
The thing that I think is so challenging here in this quality arena is the quality chasm, and I don’t mean the chasm, what the quality of care that people should receive and the care they do receive, which is one chasm that’s been well articulated by IOM, etc., but the chasm between the different stakeholders and I think we just heard that so clearly in the two hearings which I thought were very informative and valuable. And at the end of the day I don’t think the chasm is different objectives, I mean I think probably there’s a lot of agreement on what one would like to see as outcomes in our health care system. But the chasm between the people who want, purchasers and some of the other groups who just want all this information, they say don’t let the enemy be the perfect of the good, we have so little we need more, and we don’t want to pay for care without having this kind of information. And more on the provider side that says this is not going to be very good information, it’s going to be misused, we’re already providing you with more information then you know what to do with.
And there’s truth on both sides of this but it’s quite a chasm and where to, there are a lot of groups working in this area too and that’s been articulated, I feel there has to be a role for the committee in an area as important as this but I think we haven’t quite, we haven’t figured that out yet and it’s got to be some kind of new thinking and I’m so glad to have new members here as well to help us think through and meeting with others from the outside who aren’t on the committee, etc., as to how to bridge that chasm some way.
MR. HUNGATE: I agree, I’ve seen the same thing in repeated discussions over decades and we have made limited progress in diminishing the cacophony of that debate, at least that’s my perception. There is movement as Bill articulated in the pay for performance model but there’s a lot of crudeness in that as well, it’s not clear whether that’s going to, if I can lead to somebody else’s turn, the administration simplification, if you look at the health care system we have layers and layers of responses to others demands on the system where the information system hasn’t improved. A few years ago there was a little squib in the Wall Street Journal that gave the staffing levels in the hospital where my daughter was born and it was interesting to see the direct care staffing between 20 years before and then was about the same, but the administrative staff, the quality assurance staff, all the functions that are dealing with this content of information were vastly increased. And so we’ve increased cost at purchasers, at plans, at hospitals, at physician’s offices, all trying to comply with this information demand and I think it’s because we haven’t got a measurement system that’s working in the sense that you’re talking about. Don articulated measurement in his comments today and his first comments in the committee, metrics is your expertise. Simon?
DR. COHN: It’s an interesting conversation, as somebody whose been at times the measuree and the measurer, I’d much rather be the measurer then the measuree —
DR. STEINWACHS: Feels more powerful.
DR. COHN: — reorganizing something, you’d rather be the reorganizer —
So as I comment about that one I guess I can understand the whole size of this, I’m sure Justine has been in this position also. Clearly though what we’re describing is underlying sort of, well, it’s economic, it’s political, process used to power dynamics, I’m not an economist but obviously acknowledging the market and all this and this is obviously how it plays out. Although I think we could probably observe that if we are playing at that level we’re certain to lose and not get very far because, I mean that’s been GM and large medical and AHIP and CMS and all of that.
On the other hand there are, and once again I’m just pausing, this may or may not be anything that anyone wants to pursue, but obviously the fundamental data that would enable that political story to play out, be it measurees deciding to measure themselves or be measured by somebody else or wherever, and certainly I think there’s a great opportunity as we move forward into the NHII, I think we’ve seen enough now, I think Don has commented on it in Populations, that without some forethought there’s nothing intrinsic in any of these future systems that will allow us to do better then we do now. And look at the VA system where things are primarily free text, look at doing the more sophisticated systems, you don’t necessarily want to capture everything and subject to be evaluated and yet what’s your direction to improve on.
This may or may not be something that should be put on the table but there’s just a sort of thought of potentially were we fit as the national committee.
DR. EDINGER: Basically the origin of the Medicare program back in ’66, the whole concept was theoretically you were paying for performance, the certification of the facilities, whether you agree it did anything at least it was paying for the performance of the facilities, I mean in theory it never worked because basically everybody was a player, but I mean theoretically since 1966 the federal government has been paying both for some type of performance. Maybe the issue is not so much to get it to pay for performance and how to do that, which is probably a more political discussion, but what kinds of information can be provided to enhance the process of measuring performance.
MS. GREENBERG: And that’s what Cathy Colton started with the workgroup back in the mid-1990s or something, that was always the focus, not to resolve the political problems but what are the data that you really, that you need and that if you could just have some more data, as opposed to everything, what would be the key things. And that was kind of what you would hear but I think that always was the focus.
DR. EDINGER: And trying to go beyond that, well, I should say beyond the focus, but trying to get into the bigger political issue is probably going to be very difficult issue because in AHA and other places have already complained pay for performance because they don’t pay at all, you get into a whole series of other issues which have nothing to do with the measurement process but it’s a legitimate issue, it brings up the issue of how will the electronic health record and patient record play in measuring, in providing the measurement systems.
MR. SCANLON: I think ultimately we are going to be sort of part of the bigger debate because we really, I mean the reason I’m interested in this is because I think that we needed the transformation in terms of how we buy health care. And the reality now is that the marketplace is imbalanced in terms of the information that people have available and it’s in particular related to quality and the need for services and until we sort of try and achieve some sort of new balance in terms of information that consumers and payers have a better sense of what they’re getting we’re not going to get control over costs.
And this is maybe the cynicism, I’m an economists, but I think there is a fundamental difference in the objectives of the people supplying the service versus the people that are consuming and paying for them, the issue is that the way the market works well is when they both recognize that they have to sort of behave in a certain way that benefits both sides and right now it’s not the case, I mean right now, I’ve sort of said on occasion that we need to do is we need to stop it being possible for John Windberg(?) to repeat the same study and get the same results year after year. And we have, he’s been able to do it and we haven’t made some progress in those dimensions and I think we need to. I mean there’s all kinds of aspects of this which we could think about pursuing, I mean the issue is which do we do first because there are issues of what concepts should we be measuring, then there’s the question of sort of how do you go about getting the data to implement those concepts, and then there’s the issue of what do you do with them. I mean I could mention payment and pay for performance but how do you incorporate that into a pay for performance system because access is another issue that we worry about and we can’t sort of gut the kind of base payment in order to, and pay for performance and sort of end up not having access formally for individuals.
But then there’s the issue of sort of can we harness market forces and there’s a lot of interest in that sort of in the Congress right now, is information sort of the forest that will promote some better quality but what format does information need to be in before it actually is effective sort of in the marketplace and we could look into some of the things that are going on now with respect to trying to use comparative information and see sort of effective they are, how they could be improved. So there’s like for me I guess I’m sort of stymied in the sense that there’s this huge potential agenda, the question is where do we narrow our focus and pick something.
MS. MCCALL: Just to kind of leverage some things that have been said here so far, I agree with trying to leverage some of the market forces, I think it’s very difficult because I think that somebody had said earlier, P for P or pay for performance, it’s still fairly crude. And to leverage a market force I look through the charge of this particular workgroup and it says a lot about data, it says a lot about access information. Market forces are driven by things that drive your business every day and those take a while incoming, so I guess one of the things that I would say is that whatever it is that we do should probably start with transparency because we don’t know necessarily what the metrics are yet and to think that we’re going to go from not knowing the metrics all the way to and using it to have market forces, there’s a lot of things that have to happen along the way and the order in which those things happen will end up being very important.
So I would recommend that we start with transparency but then the question that begs is transparency around what, and a couple of thoughts that I wrote down, one is the first that when we talk about quality, and every time I hear the word I struggle with it because I want somebody to define it and I don’t think that we’ve done a good job of articulating what we mean by that. And so I would even say that there are probably domains of quality that we need to look at, that will be different for different constituencies and I will ask the question where’s the consumer, it needs to be about the consumer, it really does, the rest of us are stewards to that process.
You used the word earlier customer and I wanted to ask you then, so who’s a customer, in my opinion it is in fact the person who ultimately received that care, we’re stewards to.
So those are kind of some thoughts that are floating in and out but I always want to bring it back to what does all that mean with respect to what we do, what are we responsible for doing as a group and I agree with comments that if we have been, if we’ve had a say coefficient of drag because of a previous agenda now’s the time to redo that, I think there’s a great opportunity to do that because of some things happening in the full committee. I would love for this group to operate within the context of that full committee using for example the great work on e-prescribing as an again an example of how well that’s gone.
There are opportunities in there to leverage that because that’s what makes it actionable, you know what I mean, so if NHII is coming up big and we’re going to be talking about health records and medical records, electronic versions thereof, it will be important to run along side those initiatives and make whatever it is that we specifically recommend, synchronize with those very, very well so that our agenda is synchronized and so everything looks to be of a piece, I want to understand what the vision is overall, I want to leverage those specific opportunities that are gaining momentum, I want to talk about definitions of quality and then and only then do I want us to spend a lot of time talking about what seems to be in a lot of this document which is about a data element or how to do something and I really don’t think that that’s our problem to solve necessarily, is how to get a database built or something like that, our job at one level has to also be about recommending strategies or policies or whatever it is.
MR. HUNGATE: I could not relate the charge as it’s shown in the Workgroup on Quality from when I came into the group, I couldn’t relate it very well to what we were doing.
MS. GREENBERG: It can be tossed out, particularly, unlike walking into a situation where you’ve got a law or even a regulation these are man made, woman made, and these charges can be completely tossed with the agreement of the full committee and revised.
Carol makes a really interesting point and that’s why as I said last night at the dinner, as much as we mourn the loss of our colleagues who are going off the committee it’s such, the thing that’s so interesting and dynamic about this committee is that unlike in government and elsewhere that we get new blood and new people come in. But I mean it’s really an intriguing thought to not just forget everything else that’s been on the agenda, the Populations Subcommittee and the Quality Workgroup, but on the other hand to maybe align some of the work of both groups with this whole e-prescribing initiative because we know that a lot of, certainly in quality we know that a lot of the quality problems have to do with medications because we know that a lot of health care now is trying to keep people out of hospitals, being less interventionist, maybe that’s not the goal of surgeons but in any event.
Prescribing is not a marginal activity in the health care system and, that’s an understatement obviously, and you can hardly certainly find a person in the Medicare program who isn’t taking several drugs and probably hard to find anyone even around this room who isn’t taking at least one. But in any event, and so that would be so, there’s something very appealing about that because it is, it’s focused, it relates to the standards area, sort of like the year of the drug or something, I don’t know, but I do think that that’s a very intriguing, it works even better for quality then it does for populations but it’s a very intriguing proposal that I think could be considered.
MR. HUNGATE: We’ll keep that in mind. I’d like to get Justine and Don to input.
DR. CARR: I think the e-prescribing presentation is a model for what we want to do, I mean it began a year ago, in incredibly fast time came up with a very tangible workable value added process and I think what was good about it was it was clearly identifying here’s where consensus is, let’s take that, here’s where there’s disagreement, let’s study that, and here’s where we’d like to be but we won’t be this year. And I think that it felt like incremental I think the word was used and I think that was very helpful.
What I have done on this little grid is to try to put together what we learned from the two hearings because I do agree that it’s a new day in terms of what’s out there in quality, what the climate is and what the opportunities are with the electronic health record but I think we should build on, we heard a tremendous amount of very important information. And so just as I read through the testimony the other night I tried to just put it all in one place just according to how it fits in my head to sort of understand the construct and then to identify where the gaps are or where the opportunities for us to be actionable.
So the shaded column in the middle are the Institute of Medicine Dimensions of Care so when you talk about how do we quality, I find this works for everything, I think it was the most parsimonious and comprehensive statement of what care should be, the domains, so on the left side of the page are the kind of systems driven manifestations of these dimensions and on the right are the medical condition manifestations and this is kind of what we heard. So if we start with safety, you look to the left of the page, we heard from Ken Kizer on the NQF 27 safe practices and these are all about processes within the hospital, anticoagulation, central lines, infection control hand washing, they go across a system, they’re a systems issue. AHRQ has helped give definition to how would you know how you’re doing on that by some utilization of the administrative datasets, ICD-9 codes, it’s not perfect but it’s getting there. And so I think that is kind of the information we heard there.
I’m going to leave outpatient aside for a moment but if go to the right side of the page we also heard about all kinds of quality metrics and again I put them in this category, in terms of safety, mortality being a major one, when you think, we can think about these issues in terms of a clinical condition so we know about mortality, risk adjusted mortality in cardiac cases through the American College of Cardiology and Society of Thoracic Surgery Hospitals have databases that are manually collected but into a database and utilizable in large numbers. And we can learn about safety of particular conditions because of the volume and because of that infrastructure.
We don’t have that infrastructure in a lot of other conditions so you move then down to effective where we’ve gone with process measures, so we know, are we treating heart failure in an evidence based fashion, myocardial infarction pneumonia, this is also very, very valuable in terms of improving effectiveness. The challenge that we heard from the Hackensack Hospital person was that this is all dependent on chart review and every hospital is hiring scores of people to go page by page through this. So while I think we have enhanced effectiveness tremendously and reduced mortality really in terms of some of these things, that’s where that is.
Timely, another process measure, we’re getting that in timely meds and MI and pneumonia. Patient centered brings us back to functional status I think and this is something that’s been on the agenda of this workgroup for at least as far back of the minutes that I could find on the webpage and we’re not there yet, it came up at the hearings, it’s something that really of all these things is most patient centered of all the things we do, at the end of the day how do you function in life.
And then finally equitable ties in with race and ethnicity both as a systems and then also in the individual treatment of particular conditions, a lot of articles coming out recently about disparities. And then efficient, I think then that brings us a little bit back to the e-prescribing, when you think about e-prescribing it’s making our systems safer, timely, and efficient.
And then just to mention on the outpatient on the other side, we have the HEDIS and NQA measures. But this to me is what we heard that day and it was jumbled together because everybody was talking about everything and it really needs to be parsed out into what were talking about and who’s doing what. But the questions that it raised for me and the reason I put it in this format would be to say what are the gaps and we do have gaps in our functional status, race and ethnicity, and then the whole issue of automated reporting I think will have some taxonomy, administrative datasets, or even these datasets, we have an opportunity.
And so then that brings us to what is the role of the EHR and there was a lot of thought about the electronic health record will save us but it won’t if we don’t have a taxonomy, if we don’t have fields that are flexible for evolving data elements and if we need to learn from lessons of the VA. So my final thoughts were as we look at this, I think the role for us as Carol was saying is not define whether an A1C is a good metric to get or a blood pressure but rather to say what is the scope of the work that’s being done today and where are the gaps. And then working with AHRQ, CMS, JCAHO, what can this committee do to bring forward the things that need more attention.
MS. POKER: Can I just ask a question? Justine, that’s one role, do you think we could also take a step back, and this is a question, and look at for the new evolving NHII our role might be what we need to make that happen —
DR. CARR: Yeah, that’s the point, the taxonomy and the data fields, that we are not in isolation, we’re very much linked to that, e-prescribing is the first step and all of these things but I think we have to size it in a bite size fashion so that, I mean what we heard the other, Leapfrog wants every element for every thing and every moment in every day of everyone’s life, that’s a little big and as we look at it we see we are making things safer, faster through that, and we have to say what are the concrete things that a year from today we could bring forward and what are the longer term things, the electronic health record as we build it needs to be built in a way that will give us the kind of searching opportunity, the data fields will be comparable and measurable.
MS. MCCALL: I also think one of the mechanisms that may, is making e-prescribing as effective as it will be is that there was a compelling event, and that compelling event was essentially CMS saying guess what, guess what’s going to happen to the people and for the people for whom I pay, and you will be doing electronic prescribing in order to do that. So I would say with respect to NHII because I really think that there’s an opportunity now, I think that we need to look around for compelling events, they may not be of that order of magnitude but there has to be something that becomes an attractor for some synergy there. And so maybe we will have to create one or maybe we can do enough research and fact finding that we make a recommendation that somehow we create one.
And then I also back to Bill’s, some of Bill’s earlier comments and something Ed said yesterday in the subgroup, I would love for HHS to lead by example which is kind of like e-prescribing, I can’t tell everybody to do it for everybody else but for those people for whom I am steward you will do this, this is what we’re going to do. Are there opportunities elsewhere to lead by example, create some of those compelling events around bringing it into, I guess what I call the ecosystem, a business ecosystem, and to use some of these things. It’s not the perfect world and it’s not the Leapfrog everywhere all the time but there may be a few critical ones that can come in that would in fact begin to, I don’t know if they could affect reimbursement or not, I would love to look hard, very, very hard.
MR. HUNGATE: Don is up next.
DR. STEINWACHS: Bob is going to put me to work here. I think this conversation is superb because it seems to me it is trying to find the opportunity and so one thing we had talked before was also looking for the interface between this group and some of the other groups and so when we talked about administrative transactions, we talked about well, is there a way to think about the utility of something of a quality transaction, so within the HIPAA claims, and what would that be, would that be a kind of framework that would allow you if you wanted hemoglobin A1C to capture that so it was identical kind of transaction that was something that may be negotiated between the payer and so CMS could say we want this on for patients on certain kinds of drugs and so on, we want this quality transaction for certain kinds of information.
The other which I think is critical and Justine was talking about and probably more difficult and that is for the outcome transaction is functional status, how would you really think about that kind of capture. And one of the biggest limitations we have in the health care system is the only time we capture outcomes is either when you die in our hands or when you show up and you’re at a visit which is many times not very ideal for outcomes because usually when you show up at visits something is wrong, it’s not a random segment of where you are and a trajectory for chronic illness and so on. So it seems to me maybe one of the longer term areas to contribute is in the functional status and the outcomes, define it and to think about how can we capture it versus how would you like to capture it, what are those tradeoffs that sit out there of the practical versus, and what are some of the biases and limitations of doing that.
MR. SCANLON: Essentially I think we’ve got some opportunities here depending on the way the pay for performance proposals go because in terms of encouraging the use of electronic health record rather then having the army of people go through the chart the issue is will they recognize, and this is kind of changing the business climate, will they recognize that having the electronic record makes it so much easier to get this reward, to give the information that’s being required. So it’s key that the decisions about pay for performance are done in a way that makes that very obvious to the provider community.
The second sort of thing I think in terms of the functional status, I mean this is exactly sort of the kind of thing that’s been discussed, this issue that we really need to change what we’re doing in terms of measuring the service and the outcome of the service and we’ve got sort of a very good example of low hanging fruit in the nursing home where we’ve got a minimum dataset which is measuring status, the problem we have is that we don’t measure it at discharge. We measure it at arbitrary points in time for payment purposes but we don’t sort of ask okay, did that person three days later die, sort of walk out of this fully functioning or not and the recommendation was to change that so that there was at least some information captured at discharge so everybody knows the outcome of the services.
MS. POKER: There’s another problem with —
MR. SCANLON: Well beyond discharge that’s another, that’s carrying the concept even further which is the issue of who’s then responsible because this is, I mean we’re making providers nervous enough telling them we want to know what the status is at discharge and the issue of beyond discharge is opening up a new horizon.
MS. POKER: Bill, another issue is then is that it’s not captured accurately.
MR. SCANLON: That’s a whole other sort of dimensions that I think we could think about which is, I mean there’s this issue of information and there’s the issue of the quality of the information and how it’s going to be affected by the use of it is going to be applied.
MR. HUNGATE: Simon, I’d like to get your comment again if I may —
DR. COHN: Oh, I’m actually listening to the conversation. Obviously there’s four or five different directions obviously I’m hearing, I actually sort of like the bringing of what Justine was commenting but what I actually wanted to point out was not necessarily all this which is very good but her comment about near term improved, the sort of things that are evolutionary as well as long term and you probably need to think about that in terms of the framing —
MR. HUNGATE: I have a thought on framing, it’s my feeling that we should use the compilation of the hearings we’ve gotten to date to do the framing of where we’re going forward, that’s what you’ve started here I think, that to capture a fairly robust set of hearings in terms of representation from the field and to kind of put that down and say here’s where we are and use that to set kind of our work plan recognizing the other things.
DR. COHN: Are you talking about the future hearings or those last two hearings?
MR. HUNGATE: The three hearings, there were three altogether, two days of one, three days of hearings, three days and two days.
DR. COHN: And use that to tell you what you want to do?
MR. HUNGATE: Yes. We can draw some conclusions from that in terms —
DR. COHN: Well, let me make my comment because I think you’re jumping off into what you guys are going to do, and I was only commenting that whatever you guys decide, whatever pieces you decide to work on, framing those sorts of recommendations, what recommendations you have, I as I said would like you all to take, I mean I’m hearing very interesting ideas, obviously there’s the idea of thinking globally acting locally, it’s sort of like quality is everything and anything and well what is it, and obviously taking it down to business cases, especially business cases that people feel strongly about in e-prescribing, maybe functional status, maybe whatever, there’s a very interesting way of sort of framing it beginning to become actionable and specific. So as I said I’m going to stop here but I do think that rather then assuming you know a lot, and once again I almost after two or three days of hearings that you had, and maybe there’s more there then I thought there was because I wasn’t there for the third day, I guess once again I’m sort of saying whatever it is you think about I’d want to get some external validation that that is really the right thing to be working on and anybody cares before you embark it.
MR. HUNGATE: I think we could use a draft report to seek external validation.
DR. CARR: I do think we need to frame it because we heard just a kind of description of the landscape of today and I think that was part of with this, we kind of know that, I think it’s how we coordinate it and define the gaps. I mean following up on what Simon said, I think we need to think in terms of having a deliverable in six months, in 18 months, and in three years, that we have our long term thing, our immediate thing, and our something in between, and thinking of those timeframes work with what we have and cull it down so that we’re all working on the same thing to kind of get it done.
Getting back to e-prescribing, I think the advantages, their assignment came in an envelope very specifically written out, our challenge is getting those specific because it’s everything in quality but if we can discipline ourselves to come up with something that we can deliver in six to eight months say, that already narrows the field and then if we think about these longer term issues and partnering really very much with CMS and JCAHO because we don’t want to redo what they’re doing, that whole other, that’s all going on, that refining stuff is all going on by them, but how can we bring their agenda ahead, I think that would —
DR. EDINGER: I just want to mention that actually if you’re interested in the pay for performance there is a linkage because CMS is doing the pay for performance demonstration with Premier so there are some basis for doing something already, but they’re already doing something so that could be a hook into it, what are they doing, how are they doing it, where do they see it going, probably one of the few people who actually has hands on databases at that level experience, that might be a useful adjunct and one of the issues that Simon and I talked about and others of the discussion is even when you get into the electronic health record, how do you share data, not just the data elements but the legal issues that come up when you try and share information in an electronic health patient record —
DR. CARR: But I don’t think we need to do that, that’s already being done —
DR. EDINGER: That’s an issue that needs to be looked at probably more by the other groups but it’s something we should be aware of at least but not necessarily we shouldn’t do it ourselves. But I think you’re right though that CMS could —
DR. HOLMES: I have a question, I’m a little confused, is e-prescribing an end in and of itself of the work of this group or is it a vehicle through which quality data are —
MS. MCCALL: The answer is yes, the answer is yes, both, it is an end to itself and a vehicle and that’s the beauty of it.
DR. FITZMAURICE: If it doesn’t work we don’t get to the end.
DR. CARR: It will enhance quality in and of itself, it will become a data repository where you could query and get additional information, so it’s both.
DR. HOLMES: It’s just that in this committee traditionally my understanding has been that we have dealt with what are the data needs to support quality measurement and we’ve not focused so much on the vehicle through which the data are —
MS. MCCALL: And I’m not saying e-prescribing that we’re focusing on the vehicle, what I’m saying more that it is a vehicle that’s coming that if we acknowledge then we can leverage for purposes of defining recommendations around quality and recommendations, if we want to make specific recommendations around metrics or data or things like that, that it is now a thing that’s coming that has a lot of potential but we can leverage and unlock for the things that really are for a specific agenda.
MR. HUNGATE: It seemed to me that there was a distinct parallel in the e-prescribing between the mention of the need for HL7 prescribing information to be transferred to the NCPDP when it moved to the other domain, that was a critical decision made in e-prescribing to take advantage of what was there before. And there was testimony in our hearing that talked about the need to do a similar thing with regard to the clinical information for the HL7 domain and the X12 domain, to me those are parallel issues. And that was raised as a question in testimony as well —
DR. COHN: Was that a claims attachment discussion?
MR. HUNGATE: Yes, that’s what I was getting to —
DR. COHN: HL7 to, I mean that’s hard to do —
MS. GREENBERG: That’s what I was saying yesterday to Bob, yeah.
MR. HUNGATE: but it’s not clear whether the claims attachment takes care of all those issues.
MS. GREENBERG: It’s a vehicle also and that’s where you get into this idea of the quality transaction or the outcome transactions —
MR. HUNGATE: So I think there’s a question that we’ve opened but not dealt with there but I don’t know whether that’s a six month or a year deliverable in the context that you mentioned, Justine, but it seems to me that it’s a piece of this equation of what we’re talking about, where the claims attachment is coming up for rulemaking soon I understand —
MS. GREENBERG: One could hope.
MR. HUNGATE: Karen Trudel offered to share the content of that with this group at the next meeting and I think given the relevance of that discussion from our testimony and the timeliness of that activity we should take advantage of that. So that’s a specific that I think might help us move forward on the agenda in a content sense.
DR. COHN: Well, I’m still struggling, I mean I think what it is, once again I would encourage you not to decide right now what your six month, three year, five year plan is, but certainly that would be interesting information, but whatever it is you need to tether it to something that is tangible and actionable and recommendation to talk about HL7 information in the X12 format, I don’t think enough people understand it unless you had a specific use case, business case, use case, whatever, it’s one of the things that, I think Carol was sort of talking about e-prescribing, functional status, chronic care, I mean we just need to figure out what we all take this to because it’s amazing how suddenly everything becomes concrete and understandable when we’re talking about those things as opposed to the entire concepts which I have to admit I think people don’t understand, but that’s just me.
MR. HUNGATE: The issue we kind of have is that this committee formally meets four times a year, right? The full committee, and these meetings tend to be concurrent with that, they needn’t be but classically they are unless there’s a set of hearings that are occurring outside that or conference calls. So by the time you look at the calendar each time you move to the next meeting another three months has gone by and if you have a six month objective you can’t take very long to decide what that’s going to be or it’s already gone. And so I’m very conscious, you’re saying take your time to decide but there ain’t much time allowed for work on these things so there’s some tension on the other direction —
DR. COHN: Well, let me make a comment then because maybe we’re misunderstanding what we’re talking about here. I would be very happy if you guys all come up with a crisp set of goals and objectives in six months, I don’t think that you do decide that in two hours here, I also, just let me be honest, I mean first remember I come from, I chair the Standards and Security Subcommittee and they are, we now are meeting to beat the band, Marjorie knows this one, I mean to my view there’s, I mean meetings that happen during the full committee meeting like that are good for conversation, they’re good for if you have a letter and revising it, but there isn’t enough time between 8:30 and 9:50 to figure out a six month —
MS. MCCALL: So it’s not where the major amount of work is happening so what I’m hearing said is that between now and when we get together three months from now if we want to do what it is we’ve all talked about, we’re going to be spending some time together over the next three months.
MR. HUNGATE: We have to if we’re going to do anything.
DR. COHN: And I think certainly maybe hearing from some, I mean figuring out how to get some external in put on what the agenda ought to be would be a high priority thing, certainly you guys have come up with some very interesting ideas, I think maybe talking to CMS about, I mean once again I heard things that resonate with me and there may be different things that resonated with you but talking to CMS about e-prescribing, the quality discussion around that, might be a very interesting exploration, certainly it’s something they’ve got a lot of heat on right now, chronic care, I mean different people in CMS but the same agency. Functional status, obviously this is something that we’ve tried to deal with, Marjorie, I’ve only been around for eight years so maybe even before that, but we’ve certainly had —
DR. COHN: — I mean that’s obviously a thought.
DR. FITZMAURICE: To use Don’s word, this has been a really great conversation, I have a suggestion for an actionable item, since people have gone through and read the past hearings and reports, why don’t you make a list of the quality issues gleaned from those reports and then consider setting up a hearing whereby you say to the public here are some items that we think we want to study, we ask for your input, and then have the major players come in and tell you at this hearing this is what I think you ought to work on, this is where I would set my priorities, given your list here’s what I would do and I would add to that list. And I would do it before June so that in June you have your own deliberations, you have the results of a hearing, and you could report back saying here’s what’s been suggested to us, we’re compiling it, and we will have an action plan based upon these suggestions.
MS. MCCALL: To follow-up on that, because I agree, that’s a very important activity, before June would be great. You had mentioned something earlier, Bob, about the frame being the feedback from these earlier hearings which I obviously need to get and digest and all of that.
I actually would suggest a different frame, I think the frame or the lens or lenses through which we view this, one is I think this is a frame, the IOM for example is a frame through which we look at things, I think other important elements are environmental frames and those include our own environment of the committee, the whole committee and the activities, the environment of the compelling events that have happened, are going to be happening, they include pilot activities like pay for performance, knowledge of what those things are all of those things become the frame including input from previous hearings.
And I’d love it if this group could get together and actually create a consolidated view or strategy to say look, this is our best picture right now of what we think that we would want, here’s where the gaps are, structure future hearings around those gaps within a more fully developed framework, then have the hearings. It would be great if it could be before June, and then set a final agenda.
MS. GREENBERG: I think we could do the first part before June, it’d probably be hard to do the first part and a hearing before June given I know, I mean we’re trying to schedule one day of the executive subcommittee and it’s nearly impossible. But I think what we’re moving towards is a full day, minimum, a full day of this group with some additional people and we could bring in Susan Canaan who could, who’s really good at synthesizing all of this and she’s already told us that she would be happy to work with the workgroup so that, kind of what Margaret has done for you and she’s been involved, she was involved with the quality report so she can hit the ground running on at least knowing what you’re all talking about, and then bring in some people from CMS, strategically some other people, it’s going to be an open meeting so whoever you feel, and people can sit around the room if they want.
But really more of a, not a hearing but a really, really like a retreat, two days I mean would be ideal, at least let’s say a day and a half would be good. And if we could get that scheduled before the June meeting, which is the end of June, as I said it’s hard for me to be optimistic. Of course I selfishly want to be there and I already know what my schedule looks like but I think that would be a goal to try to do, not to have the hearing also, that’s impossible. And then from there you go to the hearing —
MR. HUNGATE: Fine, shall we try for the two weeks of May for that time? What’s the window —
MS. GREENBERG: That’s totally impossible for me but that’s another story. I think what we need to do is poll people —
MR. HUNGATE: Beginning with what date and ending with what date? What’s the window within which —
MS. GREENBERG: It could be early June too. I know that the Subcommittee on Privacy and Confidentiality is talking about having a meeting on June 6-7, I would say —
MR. HUNGATE: We don’t have to decide here but I just want to get a window —
MS. GREENBERG: We need to your schedule obviously as the chair, that’s usually how we start, and then we poll for dates. But I think if there’s a commitment to do that hopefully we can find, a day and a half would be good to work towards.
DR. EDINGER: I’ll just mention that 6-12 already there’s patient safety, HIP —
MS. POKER: Thanks for reminding me.
MS. GREENBERG: Is Marietta here? Oh, Courtney is here, Courtney you’re taking notes that we’re going to poll the group —
MR. HUNGATE: — we’re going to need some conference calls in between —
MS. POKER: It would have to be before that —
MS. GREENBERG: Before when?
MS. POKER: June 6 —
MS. MCCALL: I would suggest, one more suggestion is that preparation for such a retreat is one of the most vital steps to its success and so I would suggest a conference call or two to frame the agenda, get clear on what the important assignments are, could be just reading something but as a newbie —
MS. GREENBERG: [Off microphone.]
MS. MCCALL: I think that there’s a lot of things that we may want, I would want to refresh on so it may not be uniform across the board but preparation I think is critical so that I would agree there’s a couple of calls and some —
MR. HUNGATE: So probably an April phone call and probably a May phone call, an early June meeting —
MS. GREENBERG: Let’s try to zero in first on the last, where we’re going to which is that meeting, so get those dates squared away because those are more challenging, and then we’ll go back from that and poll for the conference calls.
MR. HUNGATE: The other comment I want to make relates to the linkage to Populations and the importance of that, that the more I think about Quality, I think Quality is inseparable from everything else, I view the Privacy discussions as critical to trust on the part of patients in the system and I attended the hearing they had last week, learned a lot, relates to e-prescribing as well. The synergy back and forth between the contents of the various workgroups is critical to the momentum that we can generate and I think getting the Populations synergy as strong as it can be, the difference between individual health and population health, I think we’re going to tend to focus more on the individual side, but I think meshing that information system is part of our challenge and so I think that ought to be in the back of everyone’s mind as we work on these things in terms of what we’d like to see happening in both places.
I think it would be nice for everybody to be able to get a cup of coffee so I think we’ve reached a reasonable stopping point, thank you all for good discussion, excellent content.
[Whereupon at 9:50 a.m. the breakout session was adjourned.]