[This Transcript is Unedited]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
SUBCOMMITTEE ON QUALITY
November 20, 2009
National Center for Health Statistics
3311 Toledo Road
Hyattsville, Maryland
Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030
P R O C E E D I N G S (8:00 a.m.)
DR. CARR: This is the NCVHS Subcommittee on Quality. I am Justine Carr, Caritas Christi Healthcare, no conflicts.
DR. TANG: Paul Tang, Palo Alto Medical Foundation, no conflicts.
DR. W. SCANLON: Bill Scanlon, National Policy Forum, no conflicts.
MR. QUINN: Matt Quinn, Agency for Healthcare Research and Quality.
MR. RODGERS: Tony Rodgers, Health Management Associates, no conflicts.
DR. MIDDLETON: Blackford Middleton, Brigham Women’s Hospital, Partners Healthcare, no conflicts.
MR. HEFFERNAN: Henry Heffernan, NIH.
DR. CARR: Okay, so our immediate task is to get this letter in shape for the Full Committee vote today. So we heard a lot of good discussion yesterday, and as Paul pointed out, I think that making this sort of a iterative hybrid, it lacked a certain cohesiveness. Matt took a first pass at filling some of the specific changes yesterday, and then also balancing a bit more in terms of observations and recommendations. Paul took that and did some further revisions and then actually we have Mark Hornbrook, and we have some recommendations from him as well.
We will have copies momentarily. I think that actually the changes were so substantive that we are just going to start with a clean copy of the letter and we can refer back to the one we had yesterday.
So while we are waiting for the copy do you want to mention the concerns that we just heard – sort of big picture concerns?
DR. TANG: From yesterday, about sources of data – that was one of the big things. We need to come up with a phrase that doesn’t say EHR software. Mark and I were tossing around either we call it Electronic Health Records Data or Data in an EHR. In fact, the latter might call out the distinction better. The Data In an EHR – and then we can explain it somewhere. Then we would have to refer to it from then on to data in an EHR.
Then there was the notion of is the new thing either a new organization or new designation, the primary or the subsequent? I think we came in a little bit yesterday saying, okay, I see what you are saying, one, two three. After we reread it, it still seems like certainly the whole IOM committee felt that was – that was there number one. I don’t know that that has changed.
DR. CARR: Didn’t we leave it in?
DR. TANG: We did. But does this group agree and we have to defend that because we clearly heard multiple messages.
DR. CARR: What if we just read through the letter now, so we have a clean copy because basically every single word was changed from yesterday.
DR. MIDDLETON: There are a few more I am sending in unfortunately – they are minor.
DR. CARR: Let us just work from this copy and then we will add them as we go through.
DR. MIDDLETON: I will do that.
DR. CARR: So I will just do that. So the first paragraph, Matt helped take some of the words out. So we state that “NCVHS IS THE Department of Health and Human Service’s statutory public advisory body on health data, statistics, and national health information policy. A key focus is to monitor the nation’s health data needs and current approaches to meeting those needs. A second focus is to identify strategies and opportunities for evolution from a single purpose, narrowly focused health data collection strategies to more multi-purpose integrated shared data collection strategies.”
Are we good with that? That paragraph is okay?
Okay, next paragraph. “The National Committee recognizes that the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”) is a major initiative intended to accelerate the adoption and meaningful use of electronic health records, including their use to measure and improve health care processes and health outcomes. In order to effectively produce comparable quality data, EHRs must be designed with quality reporting requirements in mind. For example, EHRs must be designed to capture relevant clinical data according to standardized data definitions and quality measure definitions. Reporting on health care quality measures is a prerequisite for earning HITECH incentives.”
DR. TANG: Let me just make sure since I changed some of the words because the use to improve health outcomes addresses the population issue that was raised. The difference between healthcare and population health. There was another sentence or run-on that had that but I just reduced it from dealing with the process and dealing with the outcome.
DR. CARR: The part you deleted said in new ways that can contribute to improve population health and higher quality health care. I have no objections. Anybody else?
DR. SCANLON: I think we have got to be realistic. We may do things that are potentially beneficial but we can’t always count on the outcome.
DR. TANG: But that is why outcome.
DR. SCANLON: But we can’t always count on the outcome happening. Are we going to take the money away if the outcome doesn’t occur. We want them to improve these things but it is not guaranteed.
Population health is fine, I am just telling you you could get some more – population health – should be pushing harder.
I have a question about the last sentence. I think there is this issue that I am not sure we are all in agreement. If EHR in terms of measures versus measurements, and the ability of an EHR to report measures, to me is more complicated undertaking and also subject to whole lot more revision over time – makes it much more complicated. Whereas, our recommendations from respect to elements in some respects, in an attempt to reduce the burden, not just on vendors but also on providers, is kind of like I have EHR and I am going to get used to it and it is going to keep supporting the measurement process over time. The measurements are going to get more sophisticated but they are going to use the same elements.
If we say that each EHR has to be able to produce current measures –
DR. TANG: It says, reporting on health care measures is a prerequisite for earning – okay, so the emphasis – so reporting is a prerequisite.
DR. SCANLON: It is like supporting – to me it is the issue of I am not reporting the measures I am reporting the elements.
DR. TANG: So the actual report may be generated in a different environment.
DR. SCANLON: Right.
DR. CARR: That is true. So if we get to the first sentence, “The National Committee recognizes the HITECH Act is a major initiative intended to accelerate the adoption and meaningful use of electronic health records.
DR. SCANLON: In that sentence – or you could include “including the use to measure and improve”. It is like they are part of the tool but not the entire tool. So that sentence is fine.
DR. TANG: Can you even say, reporting on quality measures using data from an EHR.
DR. SCANLON: No, see the prerequisite part for HITECH incentive –
DR. TANG: Is reporting.
DR. SCANLON: But that is the prerequisite for the provider.
DR. TANG: Yes.
DR. SCANLON: So they are not doing the measures. Say the sentence again – it did not seem like it worked.
DR. TANG: Reporting on health quality measures – it is a functional –
MR. RODGERS: The actor should be the provider. Provider using the EHR is the reporter.
Either you are providing the data from which reports are compiled outside of the EHR system or you are actually reporting off the EHR system. Which one are we talking about?
DR. TANG: Let me rewrite it. Using data from an EHR to report on quality measures is a prerequisite for earning the incentive.
DR. SCANLON: I think that is bringing the report back to EHR.
DR. TANG: So when I say using data in the EHR – that is not reporting out of EHR and “using” is the emphasis.
DR. SCANLON: Using is the measure – the measure compiler is the user. But that is not a prerequisite. The HITECH money is contingent upon the EHR owner being able to report to this measure developer.
DR. TANG: Yes, so the last sentence should say, they should be using data from an EHR. I thought that meant exactly what we were trying to say.
MR. QUINN: Because that is part of the meaningful use.
DR. SCANLON: The last sentence is about the provider.
DR. TANG: Yes, so the provider is using data from an EHR to report on quality measures is a prerequisite –
MR. QUINN: In order to earn HITECH incentives, providers must report on health care quality measures using EHRs.
DR. SCANLON: That makes the measures the provider’s responsibility.
DR. MIDDLETON: To supply data for reporting – which may be done by elsewhere.
DR. TANG: I’m not getting the point. The provider is the one who is the meaningful user. The provider is the one who can earn the thing. That they have to use data out of an EHR.
DR. MIDDLETON: But they are not making the report necessarily.
DR. SCANLON: They supply data out of EHR for measures –
DR. TANG: But why is that –
DR. SCANLON: Because it is the data versus the measures. This is the confusion that is going on a lot, which is that the measures themselves may not come out of a single EHR. They may come out of a compilation of information that is available somewhere. Part of my thinking as to why this is important is we can get bad measures out of a single EHR because the information is going to be too limited. We don’t want that to sort of under mind measurement because that is what it would do. It is like people would start saying, if you don’t risk adjust properly, you don’t capture sort of enough of –
DR. MIDDLETON: While this Pandora box is open, I have a suggestion about it. I think our language never anywhere ever, sort of addresses this fundamental point of one way to mitigate this exposure somewhere that could be subtle. Just to say, is a major initiative intended to accelerate the adoption and meaningful use of electronic health records systems – only in a small office environment is a single application – everywhere else it is a system of systems. Anyway, and that also addresses Bill’s point.
DR. TANG: Would you be happy with that?
DR. SCANLON: Right, but that is not this last sentence.
MR. QUINN: Reporting the data either to create reports.
DR. TANG: But if we said data from EHR systems – would that be okay?
DR. CARR: Using data in EHR systems to develop reports on health care quality is a prerequisite.
DR. MIDDLETON: At the first use, electronic health record systems – and forever after, EHRs could actually be referring to that. Then the last sentence – we are very close. Saying it is the actor using the record to create the data, which then makes –
DR. TANG: Who is doing this?
DR. SCANLON: What about reporting data to support how – supporting data to support the construction of health quality measures as a prerequisite for earning HITECH incentives.
DR. TANG: So you don’t construct measures you-
DR. SCANLON: You just report data.
MR. HEFFERNAN: May I suggest that there is a missing context to the discussion that has to do with the process by which the health care improvements or quality health care, is accomplished. So you have got an issue within the institution, primary use of that data. You have got the use within the state programs because states work on improving – they are a primary responsibility to people. Then you have got the federal level.
I think there is a context there and my perception is you are attempting in one sentence to sort of include all of that some how or another.
DR. CARR: I think we have it in observation two, where we say “Clinical quality is evaluated through measures, which are composed of data elements. Standardized data elements are the critical building blocks of current and future measures. Then we go onto say, “A common data framework would help align –”. But should we take sentence and move it up?
DR. MIDDLETON: In the preamble area – I don’t think so. It works well there. I think we are actually close.
DR. TANG: Let us go back to the latest. There are two sentences. One has to do with –
DR. MIDDLETON: If you go from the beginning of the text, what I propose is just saying in the second paragraph, first sentence, “to accelerate the adoption and meaningful use of electronic health records systems,” and then the rest is the same until the last sentence which we are currently working on.
Matt, your construction was something like “in order to receive –
MR. QUINN: In order to earn HITECH incentives, providers must report quality measures using EHR data.
DR. MIDDLETON: The actually report quality data.
DR. CARR: So the last sentence begins “in order –
MR. QUINN: “In order to earn HITECH incentives, providers must report EHR data – quality data, using EHR –
DR. TANG: That is not exactly true.
DR. SCANLON: First of all there is not any requirement for –
MR. QUINN: He is working on it.
MR. RODGERS: Was there an assumption that providers would produce reports right off of their EHR systems?
DR. TANG: No, using data out of their EHR. So there is a compilation, an irrigation process that we are not describing. So we have to put that in there.
MR. QUINN: The main emphasis of our thinking here too, is that the bottom pieces, those data elements, need to be well specified and standardized at some level or else –
DR. TANG: How about “They have to produce quality reports using data”.
DR. MIDDLETON: To Tony’s point, they may or may not actually produce the report.
DR. TANG: But they have to cause it to be reported.
DR. CARR: It might be a list.
DR. MIDDLETON: To produce the quality data – I think is the simplest thing to say.
MR. QUINN: The paradigm with core measures for JAHCO, as you said, is an aggregate of data –
DR. SCANLON: What did you say?
MR. RODGERS: The EHRs are producing the data to build the quality reports. They are not making a judgment on where that quality report goes.
DR. MIDDLETON: Separate the two.
DR. TANG: But CMS should be receiving scores from quality measures.
DR. SCANLON: From what data? Let me just say – being very closely connected to the Medicare program, I want the data. I want the data because I want to be able –
DR. TANG: — have a need to know.
(Laughter)
DR. SCANLON: I want the data because I want to combine it with other data.
DR. MIDDLETON: I thought that was the intent, too.
DR. SCANLON: The graphic example is rehospitalization. I don’t want to hear from a hospital what their average rehospitalization is. I want to be able to break that down. I want to know who has been rehospitalized. I want to be able to protect vulnerable patients that are poor, sort of don’t have useful sources of care, et cetera. You can’t do that out of a single hospital EHR. That is why we have got to have the raw data.
MR. RODGERS: They may not be rehospitalized at the same hospital.
DR. SCANLON: Right, so I need to build this.
DR. TANG: In the new world where you do not have to put it together, we can put it together. We, the providers.
DR. SCANLON: Who is the “we”? But, no, Tony’s point, what if the rehospitalization is in another place.
DR. TANG: We would know about it because of the NHIN.
DR. CARR: Let me read what we have. I will read the second to the last sentence. “For example, EHRs must be designed to capture relevant clinical data according to standardized data definitions and quality measure definitions. In order to earn HITECH incentives providers must produce data to build the quality reports.”
DR. SCANLON: Let me put in sort of a technical issue on the table. If this is not a requirement yet, can we say that?
DR. TANG: That is true and also to be honest, that is not what we were thinking.
DR. SCANLON: I know.
MR. RODGERS: Do we want to take out the assumption that incentives are based on?
DR. TANG: The reason is the act of doing this activity should come back and make people improve the outcome. If I just hand out data –
DR. MIDDLETON: — it doesn’t say you won’t make your own reports.
DR. TANG: But people won’t.
DR. MIDDLETON: When they are being measured on it they will.
DR. CARR: “In order to earn HITECH incentives providers must produce data to build quality reports.”
(Simultaneous comments)
DR. SCANLON: The rest of the letter is about “should”. We are making recommendations about what meaningful use should be and this presumes that meaningful use is out there.
DR. CARR: Providers should produce data.
DR. MIDDLETON: There is a bit of redundancy in that sentence. Read it one more time.
DR. CARR: “In order to earn HITECH incentives providers must produce data to build quality reports.”
DR. TANG: That is probably fair.
DR. MIDDLETON: You took it out – good.
DR. SCANLON: I think we are making an implicit recommendation “should”.
DR. CARR: So do we put the recommendation is the second paragraph? Are we going to change the word from “must” to “should”?
MR. RODGERS: Yes.
DR. CARR: I am going to change the word from “must” to “should”. Now to the next paragraph.
The next paragraph, “In order to better understand the landscape of quality measurement” – this is just – I am not going to repeat it. What is new about this – “NCVHS held a hearing on October 13 and 14, entitled “meaningful Measurement.” We heard from a number of experts including experts in quality measurement, including AMA” Is there anybody that came that we do not have here?
MR. QUINN: SGS –
DR. CARR: No, we had American College of Surgeons. We have that on there.
DR. TANG: I thought “to better understand” is a split infinitive.
DR. CARR: So make a suggestion.
DR. TANG: I put “to understand better.”
DR. GREEN: It is proper grammar, you are right.
DR. TANG: I am right – because somebody uncorrected it.
DR. CARR: Are we offending anybody by the inclusion or exclusion, by identifying these particular inclusions or exclusions?
DR. MIDDLEFORD: I did not check but if you don’t list everybody someone will be offended. If they came and they were not listed, they would be offended.
DR. TANG: How did Brookings get in there?
DR. GREEN: Because they presented.
DR. SCANLON: We had CMS, too.
DR. CARR: Should we just have an attachment with the presenters?
DR. MIDDLETON: List of presenters, yes.
DR. GREEN: The point of having this in there is that it was a broadly based hearing; public and private sectors were there. That is the point we were trying to make. I think we ought to go ahead and list them right there.
DR. CARR: Matt, do you have that with you?
DR. TANG: I almost have the opposite in another sense, why would I want to be lumped with what the AMA thinks? If you say the broad based, and we attach our agenda.
DR. CARR: “Number of experts in quality measurement”
DR. GREEN: Say, public and private sectors.
DR. CARR: “in quality measurement, both public and private sectors. See attached.”
MR. QUINN: I put in a sentence yesterday about recognizing the multiplicity of public and private – there is a lot going on, et cetera. I did that just to sort of frame it. Does that make sense or no, because it is not here.
DR. CARR: Let me see if I can find it.
MR. HEFFERNAN: One of the observations is that there is a lot of independent work that is not coordinated. So that was a fundamental observation.
DR. GREEN: This is a good point, in my view.
DR. CARR: Is there a recommendation – I am sorry I did not hear it.
MR. QUINN: The version from yesterday, I put in a sentence that “recognizing the multiplicity of public and private quality measurement and reporting initiatives, pressing requirements of HITECH, and the need to incorporate data from EHRs and other new and emerging sources into measure development, endorsement and adoption process, NCVHS held a hearing on October 13 and 14.”
DR. CARR: Okay, I have that here.
MR. QUINN: I did that basically to say, why did we do this? I think those are the reasons.
DR. CARR: Okay, Paul, I think you took it out. Back to what Matt initially, yesterday said, “Recognizing the multiplicity of public and private quality measurement and reporting initiatives, the pressing requirements in HITECH and the need to incorporate data from EHRs and other new and emerging sources into measured development, endorsement and adoption, NCVHS held a hearing on October 13 and 14.”
DR. TANG: For one, it was extraordinarily long. Then I thought the concepts were – some of them you had to recognize the multiplicity – well, what does multiplicity mean? Is that duplicity? There are so many things that would have to be reworded and it was long.
DR. MIDDLETON: The key concept that I liked from Matt’s sentence was the emerging new data sources.
MR. QUINN: — go wider than just HITECH. Part of it is that we see lots of measurements.
DR. MIDDLETON: How about this? “In order to better understand the landscape of quality measurement development from current and emerging data sources and their use, —
DR. CARR: “In order to understand better the landscape of quality measurement development from current and emerging uses, NCVHS held –
DR. GREEN: Matt’s point is that it is a broader array – both of you said stuff that made sense to me a minute ago. What did you say again?
MR. QUINN: I was trying to frame – so what my concern was, was that we talked about the first is who is NCVHS? The second is talking about HITECH. The third sentence is why did we have the hearing? I thought that it needed a framing sentence to say why did we need the hearing. It thought it was real important to have it on the first page because I was scared it was going to get lost in the observations and recommendations on the second page.
DR. CARR: So what we have so far is “to better understand the landscape of quality measurement development from current and emerging uses”
DR. MIDDLETON: Current and emerging data sources.
DR. CARR: What Matt also had was “and the pressing requirements of HITECH and the need to incorporate EHRs”.
DR. MIDDLETON: I would suggest that it is already addressed in the prior paragraph.
DR. CARR: So what we have is “in order to understand better the landscape of quality measurement development from current and emerging data sources” and we have “and their uses”.
MR. RODGERS: Do you want to use an adjective?
DR. MIDDLETON: And their use of quality assessment. Either you have to finish the verb or not.
DR. GREEN: I have a suggestion. Your comment was you are seeking simplification and clarity, right? How about just doing this – “In order to better understand the increasingly complex landscape” and just keep going. Just put the words “increasingly complex”. It says it is complex and it is getting worse.
MR. QUINN: We should talk about the complexity of measurement initiatives?
DR. CARR: Quality measurement development.
DR. GREEN: The sentence that is distributed here “In order to better understand the landscape of quality development and use”. That is a clear statement to me. I am happy with that statement. From this point in, can we do it if we just put in front of it the modifiers, “increasingly complex” in front of landscape.
DR. CARR: So “In order to understand better the increasingly complex landscape of quality measurement development and use, NCVHS held a hearing”.
It doesn’t have the emerging.
DR. TANG: It does in the question, though. The number three question –
DR. CARR: That is true. So if we do that then “In order to better understand the increasingly complex landscape of quality measurement, development and use, NCVHS held a hearing on October 13 and 14, entitled “Meaningful Measurement. We heard from a number of experts in quality measurement, both public and private sectors.” See attached.
Do you want to use assessment? We have measurement here quite a few times.
MR. QUINN: In quality measurement development, endorsement and adoption.
DR. CARR: Again, questions get into that. So “a number of experts in quality assessment”.
DR. GREEN: It is pretty clear the way it was.
DR. TANG: We talked about the landscape –
DR. CARR: So it says, “we heard from a number of experts in quality measurement, both public and private sectors.” See attached. “Testimony focused on four questions:”. “We heard questions on a wide array of efforts of develop and use health quality measures, largely occurring independently of each other.”
MR. RODGERS: Can I ask a question? You use the term “initiatives”, which means that these are ongoing activities. Where you heard the number of experts – would you use the term “in quality of measurement initiatives”. Is that what they were reporting on or were they just reporting measurements?
DR. TANG: Like the registry, for example.
MR. RODGERS: Do we want to put initiatives there? I wasn’t there so you are hearing from experts on quality measurement. Do you want to add the word “initiatives”?
DR. CARR: Which paragraph?
MR. RODGERS: This is on paragraph three, where we are talking about the experts that – do you want to specify that it was about their initiatives?
MR. QUINN: In quality measurements and their initiatives.
DR. GREEN: I would say on the bases of the hearing, no, because some of them did not have initiatives they just had a dataset and they just knew something about it that they wanted to talk about. They had no initiative.
MR. RODGERS: The only reason I say that is did people present initiatives?
DR. CARR: Some. NCQA presented episodes of care and the different data points that they would envision.
MR. QUINN: Kathy McDonald from Stanford, just presented on a –
MR. RODGERS: We don’t say on initiatives – I don’t think, unless it is someplace else.
DR. GREEN: The broad terms encompasses both.
DR. CARR: Both current and proposed – we heard from a number of experts in quality measurement, both public and private sectors, on —
MR. RODGERS: I was just going to add it there to keep it simple. “We heard from a number of experts on quality measurement and initiatives or quality measurements –
DR. CARR: And development.
DR. MIDDLETON: This is where measurement may be a little too narrow.
DR. CARR: How about quality assessment?
DR. MIDDLETON: I know it is landscape earlier, but we also talked about decision support.
DR. CARR: So propose a word.
DR. MIDDLETON: It is just a letter. I think “assessment” – it also maybe helps the readability but it is tough without adding a whole set of issues. I like the focus and punchiness of it.
DR. CARR: So, we had a hearing and it was called “Meaningful Measurement”. We heard from experts in quality measurement. Do you like that?
DR. MIDDLETON: As opposed to quality support or quality improvement or clinical care in quality management.
DR. SCANLON: Lets go to recommendations and kind of leave that aside.
DR. CARR: We can come back to it.
DR. SCANLON: There is this issue about internal to an organization – what should be going on. Leave it aside, and then I think we would have to have a discussion about what is the government’s role in that.
DR. MIDDLETON: Kind of like co-morbidity, the longer we dwell on any one paragraph the more things we will –
DR. CARR: Yes. So we were on the paragraph that begins “We heard testimony on a wide array of efforts to develop and use quality measures, largely occurring independently of each other.” Let’s go sentence by sentence. Are we good with that?
“As a consequence, the burden on providers of complying with these multiple requests for quality reports and quality data is significant.”
DR. TANG: That is a consequence from yesterday’s discussion to put burden way up there.
DR. CARR: We heard testimony on a wide array – largely occurring independently. It is a leap to get to burden.
DR. TANG: Because there are all these independent requests.
DR. CARR: Okay.
DR. TANG: Is says, multiple requests.
DR. GREEN: If you want to fix that you can say, “As a consequence, providers who burden to compliant –
DR. CARR: Providers are burdened by –
DR. GREEN: Multiple requests for quality reports –
(Simultaneous discussion)
MR. QUINN: Do we need to mention any where in there because it is not just the measures that need to be aligned in the data, but also the EHR systems that have disparate data models.
DR. TANG: This is a build up.
MR. RODGERS: The data architecture has to be standardized.
MR. QUINN: This is before our three observations. Are observations are coordination, one is around the data –
MR. RODGERS: Did that come out of the testimony that you are talking about? What came out of the testimony here?
MR. QUINN: The EHR systems that we have are not what we need to have because each one has its own data model.
DR. MIDDLETON: Can’t we put that in observation three? That is where it goes. First paragraph, beginning on page two, did we finish that sentence? Or the second sentence, third paragraph?
DR. TANG: We heard testimony –
DR. MIDDLETON: – as a consequence.
DR. CARR: “We heard testimony on a wide array of efforts to develop and use health quality measures, largely occurring independent of each other. As a consequence, providers are burdened by the multiple non-aligned requests for quality reports –
DR. GREEN: And quality data.
DR. CARR: Why don’t you take the next sentence while I fix this?
DR. TANG: “NCVHS believes that the incentives represent an excellent opportunity to accelerate the development and utilization of quality measures derived from clinical data in EHRs and other clinical data sources.” To better – to leverage clinical data in EHRs and other clinical sources for quality measures.
MR. RODGERS: You haven’t addressed the issue that you are raising in the previous sentence – the burden.
DR. SCANLON: I was thinking you could take that sentence as is and then add while alleviating the burden for providers by reducing – one of those two phrases.
DR. TANG: Fortunately, the sentence stands as is and then add one more sentence.
DR. SCANLON: We had to phrase again, “while alleviating the burden for providers.”
DR. CARR: So NCVHS believe that –
DR. SCANLON: While alleviating, reducing, minimizing, the burden for providers.
DR. CARR: I will say “mitigating”.
DR. TANG: I don’t think we accelerate utilization. We accelerate the development –
DR. MIDDLETON: I am okay with that.
DR. TANG: But you are accelerating utilization?
DR. GREEN: Would you feel better if it were adoption instead of utilization?
DR. MIDDLETON: You are talking about utilization of quality measures.
DR. TANG: Yes. You utilize the measures.
DR. GREEN: Yes.
DR. TANG: Using and utilize are two different words.
MR. RODGERS: We did not use the word standardize in this sentence – isn’t that the way you are going to reduce the burden is to standardize? Aren’t we just saying that the burden is caused by the lack of standardization?
DR. SCANLON: We are going to standardize the elements but the measures can still remain variable.
MR. RODGERS: But you have not said you are going to do that.
DR. SCANLON: I think it is the issue that the HITECH derives this opportunity. We have not told you the trick – it is like a magic trick.
MR. RODGERS: Okay.
DR. HEFFERNEN: The reality is that this burden is creating a political backlash against the program as w whole. From a political perspective addressing that burden and in a sense, making it simpler for hospitals that are thinking about getting in that are complying with this, relieving that burden is a big political plus. I think the need to develop your logic is to relieve the burden and not only accelerate data acquisition, but accelerate a more smooth transition into this whole electronic era that hospitals are being pushed into.
DR. SCANLON: I think that hopefully that sentence will not communicate when we add this phrase about “while minimizing the burden”.
MR. RODGERS: That just tells you what the result is it doesn’t tell you how.
DR. SCANLON: No, we have not told you the how but I think the objective is there. You get to the “how” in the recommendation.
DR. CARR: “NCVHS believes that the incentives in HITECH represent an excellent opportunity to accelerate the development and utilization of quality measures derived from clinical data in EHRs and other clinical data sources, while mitigating the provider burden.
MR. QUINN: Development and standardization? HITECH is an opportunity to take from many –
DR. SCANLON: We are trying to limit what the government’s role here is to the elements. The government is going to have its measures, private sector is going to have its measures, but that is the reality. We are not trying to say that we are going to standardize all the measures because –
DR. MIDDLETON: I think we are.
DR. SCANLON: See – I don’t see how we can. This is kind of this issue that you lose support –
DR. MIDDLETON: At least the measures for HITECH.
DR. SCANLON: But the question is if I give the elements to Medicare – is that the end of my obligation under HITECH?
DR. MIDDLETON: I am confused now. Who are we talking about? On the providers side with EHRs I give you data. I may use the data report myself and I give you data.
DR. SCANLON: And you are done.
DR. MIDDLETON: I want to make sure that the data are used to get my incentive.
DR. SCANLON: No, you giving me the data gets you your incentive.
DR. MIDDLETON: Correct.
DR. SCANLON: I’m in Medicare and today I calculate these measures, tomorrow I calculate different ones because I have new data sources that I can match in or people have done research and showed me that this measure is more important.
DR. MIDDLETON: This we are going to have to get more for now.
DR. SCANLON: Right. I think we should because I think once we start to talk about the standardization measures, the question is under what sort of rubric of where they are going to be applied.
DR. TANG: One thing about measures is – so the NQF endorsement criteria says that you should look at existing measures and only propose a new measure if – we should only approve the new measure if it contributes something or is better.
DR. SCANLON: Right, and that is being applied – and Medicare is using that, CMS is using that, they are using NQF as part of the process.
DR. TANG: Correct.
DR. SCANLON: So that part is fine. But we talked about this on the phone, if I am AETNA, HUMANA, or something like that, how do I relate to NQF?
DR. TANG: I hope they use the same NQF endorsed measures.
MR. RODGERS: Otherwise it is going to be a greater burden on the provider.
DR. SCANLON: No, no, no, not if they are all built upon the data elements that have been reported. If it is a standardized set of data elements that are being reported –
MR. RODGERS: Are you talking about the difference in the timing of a quality measure or the characteristics of a quality measure?
DR. SCANLON: Let’s go with the hemoglobin A1C example. If I decide that nine is my critical point and it is plus or minus, above or below nine, that is a measure I can calculate if I have got the values. If Plan B decides it is going to be plus or minus eight or below eight, they can calculate that too. That is the issue.
DR. MIDDLETON: Here is the deal. You are right Bill, but actually that is still part of the problem. Where we recommend there needs to be this national coordinating entity, the AETNA measure and the CMS measure should be the same.
DR. SCANLON: There can be a national coordinating entity that sets out or endorses measures. But that would be very different than saying that these could be the only measures. That is where I think we would have to have a discussion about.
DR. MIDDLETON: We have three minutes – let’s do it right now because it should be all the same measures.
MR. RODGERS: Yes, if it is not – think of the doctor’s practice – he has got to know that AETNA’s range is different than the CMS range or the Blue Cross range, et cetera.
DR. MIDDLETON: That is not the way we practice.
MR. RODGERS: The measure has to be generally accepted by everyone.
DR. MIDDLETON: Your point is well taken, but let us agree that in fact we do want to go for common measures and that national quality measurement coordination is going to help us move that way; standard data, standard measures, implementation with –
DR. SCANLON: I don’t know how you bring this down to the practice level because I think in the practice level, it seems to me, is what you have got to do is you have got to optimize in terms of the knowledge that you have and not in terms of necessarily what the measure is.
The reason I think you distinguish between – it is not AETNA versus HUMANA – between eight versus nine on hemoglobin A1C – and I am totally sort of speaking out of my hat here because I have no clinical knowledge. There is this question of okay, people with certain co-morbidities – sort of what is the right value that I should be worried about for them. If I am trying to evaluate a provider – what about socioeconomic status? How do I take that into account?
These are the kinds of things that I think about from a measurement perspective as a plan and do it correctly. I don’t know how that translates into a practice.
DR. TANG: But you don’t have to worry about how it translates. You could like give this to all, measure the same thing. We could figure out how we are public reported. How we get our folks to perform is our problem. NQF, by the way, their measures are for public reporting, in fact, if it is only proposed for QI it is rejected, that is the theory.
MR. RODGERS: I thought it was public reporting and incentives?
DR. TANG: It is public reporting. It can be used for –
MR. RODGERS: Okay.
DR. TANG: We have to have one score sheet.
MR. QUINN: I think to frame this though, we see HITECH as an opportunity to move the process of standardizing things along. This is something that has emerged, we are going to touch every provider in the country with these new systems and help them use them. This is a catalyst or a driver or something, where we see it as a way to disrupt the status quo to go from everything everywhere to here is a way or normalizing.
DR. CARR: Let me speak to Bill’s point. In the equation of burden, there are two parts. One part is the collecting in a certain way. The other part is the assembling in a certain way. I think Bill’s point is we can reduce that burden by the collecting in a certain way, but the reporting of the measures of who wants what, may be a whole other level of complexity that once you have those data elements, you can mix and match, aggregate, bring in factors or not.
I am saying this correctly – that the burden reduction that we are talking about is going to be in making sure that the information is captured in a standardized way.
DR. TANG: Both Blackford and I, we want the end goal, which is to improve the outcomes. What we are seeing is there are three pieces. There is the how you collect? How you report, but also what you report? The what you report is what affects the culture of the people trying to produce the output. To us, burden is trying to explain that we have 50 goals and not five.
I need to go and explain the five goals, then we all get it and we can rally. How we get to the five goals is still our problem. But we get five report cards.
DR. CARR: My suggestion is that we come back to this because we have to get through the recommendations.
DR. SCANLON: I will give on standardization but I am going to – recommendation three, we had an earlier discussion about measures, I will put my efforts into recommendation three.
DR. TANG: I’m giving on that one.
DR. SCANLON: We can put standardization here because actually your coordination issue in recommendation one, may accomplish what you are talking about because there is a big difference between a government seal of approval and a government requirement. That is what I think we have to be careful about. Which is people may be willing to say I am going to accept this government seal of approval – in fact from the public’s perspective, you operate at your peril if you ignore it, versus, and this is the kind of the thing that I am reacting to, all of the policy discussions about why is government micro-managing? What does government know about clinical practice of medicine? Going back to ’65, Medicare will not interfere with the practice of medicine. It is those kinds of things that I don’t want to kind of set us up and have that kind of attack against us.
DR. TANG: They want all our data.
(Laughter)
DR. CARR: Okay. “NCVHS believes that the incentives in HITECH represent an excellent opportunity to accelerate the development standardization and utilization of quality measures.” Is that what we are saying? “derived from the clinical data in EHRs and other clinical data sources while mitigating the provider burden.”
Why do we have to say that?
DR. GREEN: Why don’t we just – I prefer to get rid of while we mitigate provider burden here, because we are coming up on observation 1 where we come right back to that.
DR. CARR: And we have already said that “as a consequence, providers are burdened by multiple non-aligned reporting request. NCVHS believes that the incentives in HITECH represent an excellent opportunity to accelerate” – we could say mitigate this burden by accelerating the development of standardization and utilization of quality measures derived from clinical data in EHRs.
DR. GREEN: You had it right the first time. What you read just a minute ago.
DR. SCANLON: I guess you said earlier that you wanted a punch line in here about burden, and I think I do too. Maybe we can just make it a second sentence.
DR. GREEN: Let’s just make it a new sentence, it also can mitigate provider burden.
MR. QUINN: I think you reduce burden and mitigate risk.
DR. CARR: How about “NCVHS believes that the burden can be reduced through HITECH. HITECH represents an excellent opportunity to accelerate the development dah, dah, dah.”
MR. QUINN: Done wrong HITECH could add to the burden.
DR. SCANLON: No question.
DR. CARR: NCVHS believes that the burdens can be reduced through HITECH incentives?
Then what?
MR. RODGERS: It has got to be standardization.
(simultaneous suggestions)
DR CARR: So that is a fact that it can be reduced. NCVHS believes that the burden can be reduced through standardization. HITECH incentives –
DR. TANG: You had it right before. Incentives from HITECH represent excellent opportunity. That was right.
DR. CARR: “Incentives in HITECH represent an excellent opportunity to accelerate the development standardization utilization quality measures derived from clinical data in EHRs and other clinical sources.”
DR. MIDDLETON: Period.
DR. GREEN: Do you have the sentence that you want to put in there about burden?
DR. CARR: We said it. We have the sentence that says, “NCVHS believes that burdens can be reduced through standardization. Incentives in HITECH represent an excellent opportunity to accelerate the development of standardization …”
DR. TANG: Very good.
DR. GREEN: Observation 1.
DR. CARR: There is another sentence. “We believe the aggressions timeline of meaningful use requires that this strategy be developed quickly. In order to accomplish these goals in a timely way, we recommend that HHS take the following action.”
DR. TANG: That is why we are writing.
DR. HEFFERNAN: Would you like to add to that – and thereby reduce the burden on implementers of systems?
DR. CARR: Let’s hold that thought. You are right, we are talking about – well, we are saying providers are burdened by – we are talking about providers are burdened by non-aligned reporting requests.
You are saying, are we only talking about providers? Are we talking about implementers?
DR. HEFFERNAN: Both.
DR. TANG: I think we have it down in observations, right?
DR. CARR: Hold that thought, and if we don’t have it then let us come back to it.
Observation 1: “Based on testimony, it was clear that there are numerous measurement initiatives underway. While there has been significant progress in the development and application of quality measures, testifiers highlighted an array of challenges and barriers to achieving robust and comprehensive quality measurement. In particular, the initiatives discussed were independently designed and described, without a consistent connection to national goals for health care quality improvement. This situation not only impedes creation and adoption of valid and comparable measures, it increases the burden on providers who must report different quality measures to different agencies and health plans.”
DR. TANG: That is very redundant, redundant.
DR. CARR: It is.
DR. TANG: Can we take the first sentence away completely.
DR. MIDDLETON: Unless you make it a little more powerful by saying, numerous disjoint measurement initiatives.
DR. TANG: Lets combine it with another one – the whole independently designed.
DR. CARR: Testimony revealed that – how about that?
DR. MIDDLETON: Yes, just the facts, ma’am.
DR. TANG: In particular – instead of in particular – we can move that sentence so it would say, the numerous independent initiatives –
DR. CARR: How about, testimony demonstrated that while there has been significant progress in development and application and measures?
DR. MIDDLETON: Right.
DR. CARR: “testimony demonstrated that while there has been significant progress in development and application of quality measures –
DR. TANG: Coma, without a consistent connection to national goals for – something like that.
DR. CARR: That while there has been significant progress in the development –
DR. TANG: The lack of a national strategy or lack of coordination in a national framework for these initiatives –
DR. MIDDLETON: I like it. It sets up the recommendation.
DR. CARR: “demonstrated that while there has been significant progress in the development in application quality measures. The lack of coordination national framework for –
Is it national coordination and framework or coordination and national framework?
DR. TANG: It is coordination and national framework.
DR. CARR: Has undermined –
DR. TANG: Its effectiveness. Those are some of the concepts. We know that there is a lot going on, there is progress. Without a framework in coordination we have ineffective results and burden.
DR. CARR: Everybody listen to me. “Testimony demonstrated that while there has been significant progress in the development and application of quality measures, the lack of coordination and national framework has undermined effectiveness.”
DR. GREEN: Good sentence.
DR. TANG: I would actually swap the framework and coordination. You need a framework, then you need to coordinate the effort.
DR. MIDDLETON: I think the framework allows us to refer to our prior use of the word framework – a framework for quality measurement.
DR. CARR: So, the lack of national framework coordination –
DR. TANG: A national framework and coordination of efforts –
DR. GREEN: It was better the first time. The first time you said it, it was clear and simple. Now you are trying to explain it too much.
DR. CARR: “Testimony has demonstrated that while there has been significant progress in the development and application of quality measures, the lack of a coordination –
DR. TANG: The absence of a national framework has undermined its effectiveness.
DR. CARR: Right. “Testimony demonstrated that while there has been significant progress in the development and application of quality measures, the absence of a national framework has undermined effectiveness.”
Let me read the next sentence. “Testifiers highlighted an array of challenges and barriers to achieving robust and comprehensive quality measurement. In particular, the initiatives presented were independently designed and described, without a consistent connection to national goals for health care quality improvement. This situation not only impedes creation and adoption of valid and comparable measures, it increases the burden on providers who must report different quality measures to different agencies and health plans.”
DR. TANG: That is a nice paragraph.
MR. QUINN: The other thing that it does too, is that it adds uncertainty to the requirements of the EHR vendors so they don’t know what to build. We address that in three, but should the coordination framework –
DR. CARR: Let us go down to that and see if we should come back. We have got to make sure that we put that thread through there, but let’s just try and get through the recommendation.
The recommendation is “national quality measure coordination, HHS should develop a national quality measurement strategy and designate or establish an oversight structure to coordinate and align existing initiatives in the national strategy. The Institute of Medicine –
DR. TANG: Lets stop at that because that is the sentence. The attributes are that HHS should develop or cause to develop, a national strategy. Then it should designate or establish some way to coordinate the efforts in alignment with that strategy.
MR. RODGERS: Only within the public sector –
DR. TANG: You could say that.
MR. RODGERS: But you could say, align existing initiatives in the public and private sector.
DR. TANG: You don’t necessarily have to do that.
MR. RODGERS: What about in the national strategy?
DR. TANG: The national strategy, just like we have national report card –
DR. SCANLON: It could be a voluntary effort type of thing.
DR. GREEN: What is wrong with the sentence? I mean the sentence is just fine.
MR. RODGERS: But you are not going to reduce the burden of private sector.
DR. SCANLON: We are going to try and get through that with the recommendation about the elements. The idea would be you really would have to put pressure on the private sector to say, these elements are fine because all the EHRs have been funded through public funds establish it.
(Simultaneous discussion)
DR. CARR: So we have that first sentence. “The Institute of Medicine’s Pathways to Quality Health Care series recommended a national strategy for quality measurement development, maintenance and effective use in performance reporting.”
DR. MIDDLETON: We are just alluding to it. Don’t we want to say, this builds upon?
DR. TANG: I think that is a better approach.
DR. CARR: This could build upon –
DR. TANG: This builds upon –
DR. GREEN: This recommendation is consistent with –
DR. TANG: That is even better.
DR. CARR: My only question is the whole series was Pathways to Quality Health Care. This specific recommendation was in the performance measurement.
DR. TANG: Just get the one.
DR. CARR: Okay. So it would be in the performance measurement.
DR. TANG: I am not sure you want to call out the – didn’t you call out the institute?
DR. SCANLON: I was going to say I think we need to drop, not necessarily the whole sentence, but reexamining the obstacles to implementation of the IOM’s 2006 recommendation would be timely. Keep it generic because I think tying it – I don’t know what obstacles there were then.
DR. TANG: Exactly, we might go down with that ship.
DR. CARR: “HHS should develop a national quality measurement strategy and designate or establish an oversight structure to coordinate and align existing initiatives in the national strategy. The recommendation is consistent with the IOM’s performance measurement – report, which recommended a national strategy for quality measurement development, maintenance, and effective use in performance reporting.
DR. TANG: Or just say, consistent with that report.
DR. MIDDLETON: You spelling it out Justine, I thought sounded good.
DR. GREEN: I agree.
DR. CARR: Okay, observation two. “Testimony revealed a lack of standardization in measure definitions among reporting initiatives as well as a lack of standardization in the underlying data elements composing these measures.”
DR. TANG: I think Bill, you need to leave the room about now.
(Laughter)
DR. CARR: First of all, this sentence does not make sense to me. “Testimony revealed a lack of standardization in measure definition-“. Do we need “among reporting initiatives”? We do? It is just so confusing.
How about a lack of standardization in measured definitions, as well as a lack of standardization in the underlying data elements –
DR. TANG: A lack of standard definitions among reporting initiatives. I think you are stumbling on just the amount of words.
DR. GREEN: I like Paul’s suggestion. The lack of standard measures –
DR. TANG: A lack of standard definition among reporting initiatives across reporting initiatives.
MR. RODGERS: Can you just bring in the data elements there?
DR. TANG: Standard measured definitions and standard data elements.
MR. RODGERS: Standardization in measurement definitions and underlying data. Right.
DR. SCANLON: Actually, I like that.
DR. CARR: Let me just say, I am going to give everybody three things that they are allowed to do. When they have gotten to their three, you are done.
(Laughter)
Bill, you may be on two.
“Testimony revealed the lack of standard definitions and underlying data elements.”
DR. MIDDLETON: Standard measure definitions.
DR. CARR: “Testimony revealed the lack of standard definitions and underlying data elements” does not make sense.
DR. MIDDLETON: What are we defining? The measures.
MR. RODGERS: Yes, there is measure definition and then the underlying data.
DR. CARR: Lack of standard definitions of measures and data elements.
DR. TANG: Lack of standard definitions and their underlying data element. Then you at least refer back to the measure definition without restating it.
DR. CARR: Underlying data elements among reporting initiatives. What is reporting initiatives? Okay.
“Testimony revealed a lack of standardization in measures and their underlying data elements among the reporting initiatives.” You say strike this sentence. “Clinical quality is evaluated through measures, which are composed of data elements.”
DR. MIDDLETON: Right.
DR. CARR: “Standardized data elements are the critical building blocks of current and future measures.”
DR. MIDDLETON: Because standardized data elements are the critical building blocks of current and future measures, a common data framework would help align the efforts and output of the quality and performance measurement field.
DR. CARR: “Because standardized data elements are the critical building blocks of current and future measures, a common data framework would help align the efforts and output of the quality and performance measurement field. An example of such a framework is the work of the AHRQ-funded National Quality Forum’s Health Information Technology Expert Panel, which created a Quality Data Set of NQF-endorsed quality measures and their component data elements.”
DR. TANG: You could say, example such framework exists in the quality data set, which was developed by NQF’s HITECH. You have this compound adjective that we do not know.
DR. CARR: An example of such a framework is the quality data set –
DR. TANG: Developed by –
DR. CARR: Do we have to say, funded by?
MR. QUINN: Developed with AHRQ funding.
DR. CARR: AHRQ funding by the National Quality Forum HITEP. We can shrink that down. Next sentence.
“Through this initiative, NQF decomposed its current portfolio of more than 500 quality measures into data elements that have been standardized and can be made accessible to all the stakeholders in the quality measures supply chain, including developers of clinical trials, clinical guidelines, EHR clinical decision support rules, and quality reports.”
DR. MIDDLETON: Why “can be made” as opposed to “are accessible”?
MR. RODGERS: Well, I understand the quality measurement supply chain, but you have not defined it in any place else in the document.
DR. TANG: You set her up – now you are going to get the figure.
DR. CARR: Oh, are we going to have the figure?
DR. GREEN: I will spend one of mine in getting the figure in. I think the figure is a good idea.
DR. CARR: “An example of such a framework is the QDS developed with AHRQ funding by the National Qualify Forum’s HITEP. Through this initiative NQF decomposed its current portfolio of more than 500 quality measures into data elements that have been standardized and are accessible to all the stakeholders in the quality measure supply chain.”
Could we say – this includes? This sentence is six lines. So could we – do we have to say, including developers of clinical trials? Also, what about vendors?
DR. MIDDLETON: How about calling the “measures supply chain period.” See figure.
DR. CARR: Okay. And take out all this – it is obvious who would want to look at this.
Okay, so we are done with that observation. “Recommendation 2: Establish a Quality Reporting Specifications Library. HHS should fund creation of a library of essential EHR data elements and their specifications. These elements would be the building blocks for quality measures and risk adjustors.” Everybody good with that?
MR. RODGERS: Okay, if everyone knows what risk adjustors is. You have not brought that up before, I don’t think.
DR. SCANLON: The Secretary does.
DR. CARR: We did not have a problem with it until you got here.
(Laughter)
MR. RODGERS: I was just looking at it from a payers point of view.
DR. CARR: I am just saying we were very much into all of the presentations and risk adjustment for outcomes. I am just spicing it up.
MR. RODGERS: Is that what the context was for a suggestion for outcomes?
DR. CARR: Yes. Should we say, quality measure and outcome risk adjustors? How about that?
DR. GREEN: No.
DR. CARR: “These data elements need to use precise standardized definitions and terminology and must be assigned codes (e.g. LOINC, RxNorm, SNOMED, NCPDP, ICD, etc.)”
Do we want ICD in there as well, even though that would imply administrative data?
DR. GREEN: Yes.
DR. CARR: “To ensure they can be unambiguously identified. The set of data elements also needs to be sufficiently robust to support the computation of current quality measures and to support research on future measures. The NQF’s Quality Data Set may serve as the initial basis for this library of data elements. A strategy should also be developed to maintain, expand, support and make this framework publically available.”
MR. RODGERS: Any co-star(?) pays mum-base system, is going to have a problem with this unless they translate the information onto a separate data base. This tends to focus on EHR and the library –
MR. QUINN: That is the number three set of observation.
DR. MIDDLETON: It is coming, Tony.
DR. CARR: Leaving that for the moment and moving to Observation 3. “Multiple testifiers commented that existing EHR systems, including those certified by CCHIT, are not designated to produce easily the quality reports required by the various public and private reporting initiatives. As one testifier remarked, “There exists no F7 key –
DR. TANG: Get rid of that.
DR. CARR: That is Carolyn. “Disparate data models underlying certified EHR systems further complicate data capture and reporting by providers.”
DR. MIDDLETON: I am not sure it is worthy of debate. You don’t actually need a standardized data model to get the data. So, standard specification and translation —
DR. CARR: What modification are you suggesting?
DR. TANG: So we can eliminate the last two sentences and perhaps go back into the standard data.
MR. RODGERS: The issue is do people believe they are generating reports off of an EHR versus that you have to have a third party application that transmits the data into a reportable format. That is my question. If that is understood, fine. The question is who is going to pay for that.
DR. CARR: Right, we did have discussion about the need for an aggregator. I think that we need to make sure that that comes out.
DR. TANG: We did not say that you need to have an aggregator. There is an aggregation function that occurs.
DR. CARR: Right, right, the aggregation function. Would you like to make a recommendation for any change here?
DR. GREEN: I just went back and read this about four times again. Having that phrase, “as one testifier remarked”, goes back to our formatting issues for letters where we keep tying this back to testimony. I think near the end of it using this again in testimony with a phrase like that is not a bad thing. That example, pulled out, whoever did it, captures – that really communicates about –
DR. TANG: You have to interpret. It is a logical statement not a physical statement. I don’t think that Carolyn meant that you actually put the F7 key. She means that you should be able to extract data as a byproduct of the care – collecting data during the care process.
DR. GREEN: There is no simple way –
DR. SCANLON: We have two strains of it. We have pressing the F7 key to produce the quality report and we have pressing it to produce data elements that will be used by others.
DR. GREEN: My point is not about F7, it is anchoring it back in testimony near the end of the letter.
DR. CARR: Let’s leave that for a second because we have six minutes and counting. Let’s just do the recommendation.
“Align EHR certification with quality reporting requirements. CMS should require as part of the EHR system certification for meaningful use that EHR vendors use standard data elements from the library to support reporting of quality measures. Further, as part of the continued certification, that EHRs have the capability of timely update or addition of data elements once they are identified. Initially this could be the NQF QDS.
DR. MIDDLETON: I have a proposal. Standard data elements and standard data exchange methods, which are critical for reporting. My proposal is to use standard data elements and data exchange methods – data elements from the library, and data exchange methods to support reported quality measures.
DR. SCANLON: Is the issue of EHR reporting the quality measure or element?
DR. TANG: It looks like this works for you.
DR. SCANLON: I have “will support the computation of quality measures”, not the reporting of quality measures.
DR. CARR: Alright, we can live with that. “Support the computation of quality measures.”
MR. QUINN: We also said that somewhere here we were going to talk about “today there exists uncertainty as to what the requirements are.”
DR. GREEN: And you asked them to say that so you have to pay attention to it.
MR. QUINN: Today there exists uncertainty among EHR vendors as to what sort of requirements that they should support in their products. Do they hard code in –
DR. CARR: “CMS should require as part of the EHR system certification for meaningful use that EHR vendors use standard data elements from the library and data exchange to support the computation of quality measures.”
MR. RODGERS: But you have not told them to create the library.
DR. MIDDLETON: Wait. Now we are going back to the EHR computing –
DR. CARR: To support the computation internal or external. Should we state internal or external, or does that make a difference?
MR. QUINN: Today, a customer of an EHR vendor goes to their vendor and says, I have this new reporting initiative that I am involved in. Here are the requirements for it – can you do this for me?
DR. GREEN: And they say, why sure but it will cost you $85,000.
MR. QUINN: Yes, and it is slightly than the other two customers that requested exactly the same thing.
DR. GREEN: Which suits the vendor because he gets three times $85,000 and makes a quarter of a million dollars off of that.
DR. SCANLON: And we are trying to totally eliminate that.
DR. CARR: Have we addressed your concern?
DR. HEFFERNAN: My fundamental observation is that when the proposed rule goes out there is going to be a huge reply, a huge reply, and the HIPAA experience indicated because this affects people much more than HIPAA did actually. With that huge reply you can anticipate that the rule may have to be modified and go out for the second time. Now that is a big timeframe, and that is why I think anything that can indicate in this that you are going to be able to reduce that volume. In other words, simplifying and coordinating – I think that is really what you want to get at here so that when this is read in the Secretary’s office, they say this will help to alleviate the shear burden of processing all these objections that will come in or questions for clarification.
In other words, you will be able to say that we have got an answer — these 500 questions all boil down to there not being an existence of library – here is the solution – boom.
DR. SCANLON: I agree. I know we are very late in the written process, but I think we should talk about having this letter shared in draft form with CMS and the Secretary’s office right after this meeting. I don’t think they could really change anything but I think –
MR. RODGERS: When is the earliest they are going to actually start requiring reporting – 2013, 2014?
DR. GREEN: 2011.
MR. RODGERS: Really.
(Simultaneous conversations)
DR. CARR: Blackford is changing the final sentence of Observation 3.
DR. MIDDLETON: Disparate data definitions and capture methods complicate data capture and reporting by providers.
DR. TANG: Okay.
DR. MIDDLETON: I took out the data models.
MR. QUINN: Did we find something in there to talk about clarifying things and sorting through the confusion for vendors?
DR. CARR: Let us not even say “reporting”. Let’s say “data aggregation and reporting” because we don’t know who the aggregator is.
DR. MIDDLETON: That is good.
MR. QUINN: Justine, is there something in there about reducing and burden on the vendors?
DR. MIDDLETON: And clarifies functional requirements for vendors.
DR. CARR: Does that work?
DR. GREEN: Just say, “clarify requirements”.
(Finalizing letter to present in the Full Committee that follows.)
DR. CARR: Meeting adjourned.
(Whereupon, the subcommittee adjourned at 9:35 a.m.)