[This Transcript is Unedited]
Department of Health and Human Services
National Committee on Vital and Health Statistics
Subcommittee on Quality
September 22, 2011
Embassy Row Hotel
2015 Massachusetts Avenue, Northwest
CASET Associates, Ltd.
Fairfax, Virginia 22030
P R O C E E D I N G S (8:30 a.m.)
Agenda Item: Welcome
DR. TANG: With that official bell, good morning everybody, welcome to the Quality Subcommittee breakout.
MR. QUINN: I’m Matt Quinn.
DR. COHEN: Bruce Cohen.
DR. HORNBROOK: Mark Hornbrook.
MS. JACKSON: Debbie Jackson.
MS. KLOSS: Linda Kloss.
DR. TANG: Paul Tang.
DR. NICHOL: Glenn Nichols.
(Due to technical difficulties 12 minutes of overview of past work is omitted.)
MR. QUINN: The follow-up to that was, in a world of meaningful use, do we have meaningful measures. And so meaningful measurement of quality in the meaningful measure supply chain was the hearing on October 13 and 14 of 2009, and it sought to ask the bigger question of building meaningful measures but some of the sub-questions here. So what is the correct process for developing measures and does it address measure development for key national priorities and subpopulations, health reform being in mind, how do we incorporate new data sources, so not just administrative data, but clinical data, user-generated, et cetera. And how do we switch out what we’ve been using in the past for better measures? And how do we maintain and update measures and what are the health IT system implications?
This was a letter to the Secretary, and what was great was that we heard about a lot of really good and positive measurement programs, many of them having impact on small groups of populations, but what we did not hear was how they’re working together, and what we heard time and time again is that the proliferation of all of these programs is burdensome for doctors and health care organizations.
I really like the conciseness of our recommendations on this, in that there were three; is that we need to have a national coordination of quality and performance measure, and that if it’s a bottom up exercise that it will be a lot of stuff; measures, measures everywhere.
The next is establishment of a quality and performance reporting specifications library. This could be based on at the time it was done, the quality data set. And the idea that there’s some chunk of data, or data model, well-specified and publicly available, that could be included in each electronic health record to support some core set of quality measurement reporting consistently and then alignment of certification of quality reporting requirements is making it –.
MS. KLOSS: How would you judge any of the progress? Which just seem as relevant today as they did in 2009?
DR. TANG: I was highlighting this too, because I think we can come back and reinforce this. It was a letter. But this, you’re right, it’s just even more true, and now that we – this was in 2009, just as quote, HITECH was being started. Now we know it won’t, maybe next year implementing these things. And yes, they’re certified, and probably one of the biggest challenges, and one of the big steps that is in this quality reporting certification. So that could be, actually, very useful input.
MS. KLOSS: And it is, the national coordination continuing to be troubled with but –
DR. TANG: Well, and this is also pre-ACA. So the whole initiative, ACOs and stuff, and the need for normalized quality measures, is just so much more apparent. I think that’s our entrée to come back and say, hey.
DR. NICHOLS: Well in the national quality strategy document, which has now been, I guess, officially promulgated, it would be useful, it seems, to come back – how much of that — but that’s our entrée, I would agree.
MR. QUINN: It was also; recommendation one was based on 2006 IOM letter, I think, or 2005. This is an idea that is established, it just requires moving forward.
I thought that number two, we’ve talked about this a couple of times; if you’re going to specify some chunk; you know, you can have a strategy of saying you want to start here with a little bit and build big, or build it over time, or look for maximum opportunities for multiple uses of these data elements to support lots of different things. Or be bold and say we’re going to include these things that aren’t currently in administrative data so that we can do things we have done. I think a conversation around what that could look like would be interesting, and useful.
MS. JACKSON: And this is a great example of where the Committee, again, came out in the forefront and — before a lot of public pieces are in place that are here now and make more definitive statements and then kind of go –.
MR. QUINN: If the letter to the Secretary is available on line as well, and I think this was the first one where we took a what we heard and observations and recommendations approach to describing it, because we started out trying to describe all of what we heard and we spent – we tried to go through each of the 74 programs – not 74, but lots – we’re going to hear some commonality, so that would be next.
The next one was that fall, and this really built on, in addition, one of the things that we heard in the previous was that although lots of measurement stuff is going on, especially with regard to maintenance of certification and some of others were, the rubber really meets the road, what’s being used for internal measurement programs, or quality improvement programs, there might not be perfect alignment between what’s actually being required by external — needed for health reform moving forward as well as internal. And so this is another hearing where we heard from lots and lots of folks; the consumer perspective, folks like Judy Hibbard and Jean Nelson; provider organizations, the American Boards and then in professional organizations, regulators that are from the Joint Commission.
We heard from United Healthcare. We heard from Arnie Milstein, and the recommendations coming from this, and the letter is also available on line, is that we need to improve the relevance of measures to the various stakeholders, not the least of which is the measures that are meaningful to the consumers. Paul described it as not the average consumer, because none of us are average, but the information is specific, so that if I, as a person of my age and background and circumstance, want some information about which provider is right for me, or my health choices, that it’s specific to me, not an average person.
The next was a recommendation about funding research and development, improve assessments and value of health care based on measures of information about cost and quality, so again, relevant to all health care stakeholders.
Accountability and care coordination measures – we heard about those and actually AHRQ had a project that it published as a clearinghouse for care coordination measures. There’s still something missing, because I don’t think that any of them are really taking hold the way that we like, and it’s sort of core to a lot of these health reform-based strategies.
DR. HORNBROOK: The word value – was there anybody at that time who said something about preference health health-status as an operational measure variant?
DR. MIDDLETON: Well there was testimony from the lady in Washington about the patient activation, the PAM.
DR. HORNBROOK: Right. That’s Judy Hibbard. But that’s not the same thing as —
MR. MIDDLETON: Utilities and preferences did come up, but we really didn’t dwell there well, sort of anticipation, from where it might come, from Phase 2, Phase 3, and given the difficulty of some of the science in that area, it wasn’t really highlighted.
DR. HORNBROOK: Because it gets down to the battle between the SF-36 and health utility — just a question of how are we going to operationalize value in a practical way, and that is one way, that’s one way to do it.
MR. QUINN: The last recommendation here hearkened back to our previous letter, saying that we need to have a way, no matter what we do, it needs to be able to be supported in our electronic health record base health data infrastructure. And so thinking about development of quality measures using standard metadata names and definitions, so that it isn’t a giant burden on providers and patients.
MR. NICHOLS: To me, this is extremely relevant to what is going on, what is supposed to be going on, and states thinking about, what are they going to require plans, and ultimately providers, to providers report? As I understand it, this is one of the regs that has not yet been released on time from HHS, so states are going to do this on their own. They’re going to do 50 different minimum data sets, unless we get moving. I would just encourage us, not to tell them what to do, but to say a document that would pull together what the hell we think we know, I mean Mark, I don’t know who’s winning this war between SF36 people – I can guess, but I’d love to hear — these things matter, people makes choices, and once those choices get made, that is what will be reported and therefore that is what we focused on.
DR. MIDDLETON: So, this is terrific. I think you guys will bring insight and point the committee, and the letters, in the directions they really need to go.
DR. TANG: So given our time though, we only have another 40 minutes. I wonder – well I almost wonder whether – we’re sort of on a roll, and I think this really has been very helpful, to look at our past. We actually did some very good groundwork, got pointed in a direction that’s still relevant, and even had some recommendations that are still relevant but we need to fill in the gaps and perhaps put it in context. Somebody talked about, yesterday, the HIPAA letter saying it’s in HIPAA-speak, and how does that reach the policymakers and the general public? Maybe we’re doing the same thing with this set of activities; if we just talk quality-speak, it won’t get outside this circle, then we won’t put it in its relevant context. So maybe one of our exercises is take this body of work, extend it and figure out which direction to extend it, and a lot may have the Community Health Data Initiative direction, and bring it home, in a sense.
Part of it is one, where’s the context; the context and the timing, and I think the thing to probably bring it home is getting it in a timely way, because we’re either too early or too late, and it doesn’t actually get effective. We’ve done the pre-work; I think we need to bring it home in this next year or two.
MS. KLOSS: In terms of what’s most urgently needed, it seems to me that it’s the follow-on to the discussion on reform because like you said, we have to bake that.
DR. TANG: And one of the ways we have to affect that in terms of baking is the EHR certification. Because even, in regard to what the states or anyone would want to do, what will get done is what’s easy, and we can make something easier by baking in literally the means of capturing, but also the way of calculating the results, because that’s what certification is supposed to do. So if we can have some reason to wave of effecting certification of what get calculated and how, that bakes it right in for actually all the states at the same time.
MR. COOPER: I’ve very naive about issues related to quality measurement. When I think of health care reform, I know the focus is increasing access to services. The piece that got neglected or is, I think, neglected, is understanding the outcomes of that access. So linking quality measurement to health outcomes seems to be, to me, the key of understanding the importance of measuring quality. I don’t even know whether – certainly Mark’s implication, how do we link whatever quality measurement and requirements are to understanding what difference it makes?
DR. NICHOLS: And see, what’s relatively little known is that the exchange is required to specify a set of things that plans have to report in order to be qualified to sell and sell the exchange. And one of them is specifically, what is the plan doing with its cost and cost sharing to improve the value of health care? Now what the hell does that mean to a plan in Kansas, I don’t know, but that’s what we get to – so that is the point. Fifty states are thinking about those words, and the HHS reg hasn’t come out yet, so plans are going to do what they can do easily, and the hospitals are going to say don’t look at things, so anyway, this issue is on the table, even though it got almost no attention.
PARTICIPANT: The other HIE, Health Insurance Exchanges, did we get the semantics here?
DR. MIDDLETON: Can we get the semantics here –
DR. NICHOLS: You know what, what we did in Virginia, we called one where you sell insurance health benefits exchange, you make it HBE and the other one is HIE, and you solve all your problems.
MR. QUINN: There’s – I read an article that some states are leaning forward on this, are ready to have something and have something useful. Other states, for a variety of reasons, are not, and are going to have to rely on a Federal –
DR. NICHOLS: Well let’s put it this way; it’s highly likely that the Feds will be involved. Depends on a couple of elections.
The quality reporting that’s in the law, whatever part of the law survives, will be there; those ten states, roughly, that have already passed legislation that says they will create exchanges, they’re now staring down the paths; holy cow, look at all these things we’ve got to do; here’s the Quality Measurement task force right now. And next year they’re going to make some choices.
MR. QUINN: So maybe that’s a good tie in.
DR. NICHOLS: It’s a perfect tie-in with what we’re doing here.
DR. TANG: So the other thing is what Jim said yesterday morning, which is they’re coming up with measures in these ten domains, and by the way, we either are or are going to circulate that, so you can send something in, and as he said, there are 50 measures. So one of the things that the government, or at least the Federal government, has to do, is pick on incentives-endorsed standards, and NQF is that voluntary consensus body. They are allowed to, in the absence of something else, make something up, but that’s infrequent.
So it goes back to which measures, and which domain of measures, do we need to move forward? Do we need to advise the Secretary to try to have a contractor or another way to gain stakeholders, to move quality measures in the direction that we need? How can we move that quality measurement development process along in time to get it into EHR, which currently focuses only stage three because of the lead time.
DR. NICHOLS: Well and see Paul, I would say everything you just said makes me want to suggest what we should think about is not so much specifying a vector of measures, but a way of thinking about allowing those measures to evolve in time to reflect what the private sector can indeed produce, if we get the standards right. Because on January 1, 2014, we’re not going to have enough EHRs in this country to make that – but what we should be moving towards is a world in which the focus of the exchange people is on the ability to capture the right things that we can help them to overcome. Our job is to look forward, and if we build in – bake in the specs now, then five years from now, the EHRs will be able to deliver what we want.
DR. TANG: Well it’s just like you’re saying, so the HIEs and the HBEs are coming on board. They don’t know yet that the only way that they’re going to be able to get this data affordably and in a comparable way will be if they get baked in in the data capture system. So that’s a forward look.
So the states are going to have to do something, but they’re going to figure out that it’s really hard to get data from everybody the same way unless you bake it in up front. So where this committee comes in, let’s go figure out how to bake it in up front with measures that matter.
DR. HORNBROOK: So our view is that in conjunction with electronic medical records, a consumer’s participation in that system is direct input of functional health data on a routine basis. You know, when you start doing enough research you realize that key functional attributes are really essential among the disabled and the elderly, the frail, whether or not they need help balancing their checkbook or help managing their meds. It’s a very strong discrimination between high users and low users.
What I’m trying to say, in some sense, what we’ve electronified a lot better at home, we’re still leaving the consumer patient out; we’ve got to bring them in in a very direct, connected way.
MR. QUINN: Those exact sort of attributes, and preferences, are what’s going to make one health insurance choice, health insurance carrier choice, or another health insurance carrier choice, that much more important. If I know that I’m going to get – one company does a lot of handholding, for a little bit more money and has health coaches and this and that and another one doesn’t and it costs less, that sort of information, and the ability to ask, to report preferences and to get choices based on those preferences versus alphabetically, would be really, really good.
DR. MIDDLETON: So we are putting our fingers on a real nexus of opportunity, in a way, Paul, which I hadn’t really seen before. In a way, we could actually make something intelligent, or point the arrow toward the destination where HBE, HIE, EHR and EMR, are sort of all recognizing their role in an integrated view of the quality data, management, assessment and capture, with PHR/EMR being really the sources of primary data capture from provider systems and the environment, as well as the consumer, and HIE/HBE, being both data generators, but also secondary users of those data for quality management and value. Does that make sense?
Can I just say one other thing – I just thought of what if we want to draft in sort of the Community Health Data Initiative language, or is that really just another input, maybe we want to put it in health reform language.
MR. QUINN: We could put it in health reform language.
MS. KLOSS: I think the model that Justine gave us yesterday.
DR. HORNBROOK: And then that, Absolutely.
PARTICIPANT: It is very interesting, if you are playing the insurance game, and I as the actuary had access to function health data into BMI and to certain history of lab tests values for your population, you could really start playing risk game. So I would rather have that in the consumer’s hands, not just the actuary hands.
MR. COOPER: And Leslie would say, that the risk of these data are decisions by the providers and insurers that are not consumer friendly.
DR. NICHOLS: Which is exactly why you want it to be at your 2014 so you can guarantee that issue survives. I think that’s right. It’s going to change the game. Guaranteed issue of insurance. Discrimination against a patient will theoretically, no longer be profitable.
DR. MIDDLETON: When the law comes to be –
DR. NICHOLS: With the law saying they’ll take all comers, and then risk adjustment becomes, in actual fact, like it is in the Netherlands, where they’re competing to get diabetics as opposed to shedding them.
MR. QUINN: It would be interesting to think of health benefit exchange as not just as the aggregation systems, but because they do touch consumers, a way of collecting information.
DR. NICHOLS: So they are going to be a way of collecting; that’s my point. I’m scared to death what they’re going to collect. I should tell you, this could make your day, is that they are required to rank, I’m not making this up, rank health plans by price and quality.
MR. QUINN: For the average person?
DR. NICHOLS: At that point they can choose.
DR. HORNBROOK: So the citizen for the status that the risk people want?
DR. NICHOLS: Yes.
DR. MIDDLETON: Your point, that we don’t know yet, nor have we had guidance, really, regulatory-wise, on how to assess the value and how they’re represented to the consumer. So the consumer is still really exposed, still at risk.
DR. NICHOLS: And maybe 15 states know what NQS stands for. Those are very good states – not the whole country.
DR. HORNBROOK: So the consumers often want to get the drugs that are being advertised on TV, as opposed to looking at the health plan.
DR. NICHOLS: Is my doc in there – got to get one of those scooters for free.
Just as a brief aside, I once saw the scariest presentation in the history of my career – it was a consumer demographics firm, and they not only knew what television shows we all watch, they knew what our politics were and what kind of stuff we bought, so they knew which ones go to Target, which ones go to Wal-Mart, which ones go to – it’s scary.
DR. MIDDLETON: So what happens in the Netherlands?
DR. NICHOLS: Risk adjustment mechanism to reward people who took the diabetes. So instead of having an effective value of zero, we still have the incentive to avoid them, plus 2, so if you could manage them.
DR. MIDDLETON: It is a win/win. Okay simple.
DR. NICHOLS: So it made Kaiser better off, Kaiser of the Netherlands.
MR. QUINN: To jump ahead to one of the ideas that we had in our road map, that need to assess quality and data use for quality reporting for individuals. Interested statistical adjustment method needed to use for new sources of data, risk et cetera. There’s a whole discussion that came out of our meaningful measures, around preferences by different clinician groups, the difference between proceduralists and general practitioners, around what kind of risk adjustment methodologies are acceptable, the use of those, and especially in the context of maintenance of certification and payment for quality and all of this, attribution of risk, and all of this, that could be another avenue.
MS. KLOSS: What was the genesis of the road map?
DR. MIDDLETON: Well in our last hearings for the last subcommittee meeting, actually, we had a whole bunch of thoughts, and I took notes, trying to reflect the sentiment.
DR. TANG: Well if you look at the intersection of this, the last page, the intersection of what the subgroup last talked about, and look at its intersection with the HHS and strategic goals, the intersection is around transforming health care and advancing the health, safety and well-being of our patient. And the Community Health Data Initiative and ten domains – I think that’s where the biggest overlap intersection is, and maybe that’s where we focus more attention, in the context of reform of the HIE and the HBE.
DR. MIDDLETON: The only thing, Paul, I might add, is goal two, advancing knowledge and innovation. If we actually get to the point of measures, repository and kind of address the measurement life cycle and technology and integration issues, blah, blah blah, it’s not what I think they thought this should be referring to in terms of scientific discovery and blah, blah, blah, but from an HIT or informatics point of view, it’s going to be innovative; that we could advance technology.
DR. TANG: The only thing is I don’t know how easy it is to translate that into human speak.
MR. QUINN: The hook, I think, the thing I feel – – the use of this broader need for infrastructure and standardization of quality measurement stuff is widespread, community health data, HIE and EHR quality measurement, but I think that the short-term hook could be the HBE specifications; that’s the thing that I think, number one, nobody is talking about, and number two, is urgently needed.
DR. MIDDLETON: So welcome Justine, and by way of quick recap, we kind of reviewed the Quality Subcommittee and the NCVHS Committee quality-related output over the last five years, from 2008, and we arrived at some thoughts around integrating, sort of the quality measurement perspectives across HBE, Health Benefits Exchange, to distinguish it from HIE, Health information Exchange. And then consider the potential role of EHR and PHR for primary data capture from providers and the patient, respectively.
Our goal is to kind of map it to your grid. Think of one, two, three key things we really want to make statements on, and then kind of map it to the grid to allow us to reflect the finished work against the HHS goals and priorities. Does that make sense?
DR. CARR: It’s the Secretary’s grid. I think you definitely want to stay in that space, but that also align with what the rest of the committee is doing. We had talked after Jim Scanlon’s presentation yesterday, so is that part this?
DR. TANG: Yes, so we are trying to figure out how, we noticed the meaningful measures, sort of letter for the three recommendations, is just as relevant, if not more relevant, now, and fits in with how do we make sure, and then talk about the state’s going ahead with their health insurance exchange and needing to have some standardized quality measures to track the performance. And it all seemed to dovetail with what Jim was talking about; in the ten domains, the quality measures, the HCL measures, all of these things are coming to even a greater focus than it was even in 2009, which is pre-ACA.
So we’re just saying, you know what, it’s just all about not only content, but timing, and our timing was a little bit ahead. If we bring it back into focus, and make it very relevant for policy and public point of view, that’s sort of my comment. The public can’t consume the Informatics view, but they can understand, what do I really care about? I want to know whether I walk, not whether seven days after my joint replacement I don’t have an infection, but I want to know whether this surgeon delivers people who can walk again.
They can get engaged, and if the public can get engaged, then certainly the policymakers and politicians can get engaged. So that’s sort of the how do we make work that we’ve done before, appear relevant now, put in different context and address the consumer and the ten domains?
DR. CARR: So the action then, what action?
DR. MIDDLETON: We are just there now. So let’s define some action.
DR. TANG: It’s a refocusing really. So the three recommendations were the national coordination of quality measurement development. We’d like to have a repository of data elements and measures, which we talked about yesterday with Tim, sort of a QDS/QDM thing, and we would like to have EHR certification that supports that.
MS. KLOSS: And those measures would be more for the patient –
DR. TANG: More from the consumer’s perspective.
DR. CARR: So would we be calling for that action, or would we be – I mean, what, are we at the 15,000 foot or the 2,000 foot level in terms of those measures?
DR. TANG: Well there’s activity going on already at the state level, at the CMS level, at the ONC level, to do this, so if we try to do some actual work and get some actual measurements out there, it will take us way too long and we’ll miss the boat. If we try to reinforce why it’s important and why are some of the recommendations, why is the coordination important and why is getting it in certified EHR specs important for 2015, at least? Then we ought to come out with it within the year.
DR. NICHOLS: To me it’s really about informing, to me the target audience, at least one of them, are the people who are putting together the quality metrics inside the exchanges are required to by law, at the moment have no guidance. And we can, I believe, help them think dynamically, as Paul convinced me. If we get standards baked into EHR certification, then three years from now, that quality data can be way better than it can be in 2014, and they need to be taught to think dynamically. Now they’re going to just go do what’s easy.
Speaking of doing what’s easy, it occurred to me, when you think about what’s relevant to consumers, why are all those countries waiting for guidance to come from HHS, they are out there doing stuff. For example, the alternative quality contract in Massachusetts, Blue Cross in Minnesota – I talked to the Blue Cross CEO one day and it was kind of interesting; he said you know, we took the 65 things that are in the ACO reg; we took them to our providers – the said the hell with that, we will do 12. They said fine, as long as you’re committed to being responsible for those 12.
So I think we should look at what those twelve are. A, they’re do-able right now. B, they are real. And you can use that as an example of how to think dynamically.
DR. CARR: You bring up a very good point, I mean, as a participant in the AQC, what they are are the inpatient core measures, patient experience of care, a couple of outcome measures on the inpatient side, and HEDIS measure on the outpatient side. So it seems to me that the Core measures and the HCAPS and now growing the PSI and some of the complication measures, they are kind of populating everything.
What’s challenging about the ACO 65 is that it brings in a whole other array of things that no one’s been using before. It’s a little bit about, I guess, the physician quality reporting thing, and it brings in also some administrative, untested things; that if you have diabetes and you have an admission, that’s a bad thing; if you have any chronic condition and you had an admission that’s a bad thing. I mean, that’s administrative data that’s there to measure.
So what I’m trying to think about, with all these things, so the core measures march through everything, HEDIS marches through everything – what is it that – and so we’re talking about two other things, a new space of measures and also a new perspective of those measures. So what is it that we would do?
Is that the focus that we’re talking about, the patient perspective and some alternative measures to Core and HEDIS, and if we are going to move that forward, how granular are we going to be, or how do we interest them?
DR. TANG: Well I think the second is the important one that we haven’t talked about yet, which is, it’s there, but that’s like measuring organizations delivery systems on measurements from the past. So it’s a little bit – I did this DOQ measurement about a decade ago, and what spurred interest was gosh, if you had the — what measures could you report on? So they took people with EHRs, because they gave the old measure definition from — So we don’t want to be in that situation because HEDIS is enough. So inpatient, I think is a little closer to what’s sort of important.
The outpatient is really, I think, poor in the sense of measuring what is either real, that doctors would believe in, or of interest to consumers. I think there’s probably more work in new directions on the latter, on the health patient’s side, on the HEDIS. I don’t think HEDIS measures do a good job. But that may be one of the things that we want to comment on.
DR. MIDDLETON: I mean and I think your story is very illustrative; maybe the third thing I’d add to the list, beyond the new perspective, is really connecting the dots. We’re in a stimulus mode, but if the stimulus and certification therefore would actually kind of derive the agenda on the primary capture of these data, as you say, way upstream, point of care, consumer supplied, et cetera, then their downstream use in all these ways can be just much more effective. And the providers can be brought in, the consumers can be brought in.
I wonder, I think that’s one of your main points, Paul, is to sort of tie this back to the overarching HIT agenda, and how it drives this and this drives it. Does that make sense?
MS. KLOSS: How do you shape that so we’re not so rigidly locked into measures that are inflexible? And I say this because I think so many of the measures now are useful for accountability, public accountability, where you tease out all the variability in populations, then you can measure sometimes, real patients who have multiple complications.
So we need to help people see that, we are at a learning curve, and ultimately we’re going to have to get to the point where we’ve got enough understanding on how to look at this population data and create our own subpopulations, and through the kind of thinking that will be required to manage a population.
DR. COOPER: I’m thinking from a perspective – I’ve just been – my TSA is high – what do I do about it? Where can I go and find information about what’s next for me and what my options are, where I live and how to pursue that? Somehow we have to link it to that perspective; the other is, I’m working with my community coalition and I know obesity is an enormous issue in my community. What’s out there in information that will help me plan to reduce obesity from the perspective of what’s available in terms of the information about what providers are offering?
To me those are long-term goals, but we need to keep our eyes on those in term of how we develop the measures here.
DR. TANG: The biggest learning point I got from the consumer was the whole speak to me, the patient, and I’m not average; actually there aren’t risk-adjusted patients out there. You basically get two line and then you don’t know where you fit. So in a sense, do you want to know where the stratified group of PSA in this range or A1c in this range – tell me which group I should go to, who does a really good job, and then give the two plus reward; that’s a brilliant notion. But that’s what you want.
And so that’s another insight we brought to the letter. But if we re-introduce that, we could talk about ACOs, and go along the lines of the Netherlands, saying okay, we’re not going to risk adjust every –- all information out of our data. We’re going to tell you who does see these kinds of patients, how did they do with these kinds of patients. That will be much more informative and put the incentive on well, look, you’re in an area where we get a lot of high risk – well, how do we do that? And reward them for doing well when you’re facing such a thing.
DR. CARR: So I really like what Bruce said, because also just having filled out the Pioneer Grant thing, there was one question that was three-quarters of a page long, and I’m allowed to give approximately three-quarters of a page, with language lifted from our letter on patient empowerment, and the answer could only be one page long. And it was like, what do you do for – tell us about your evidence-based medicine and your outcomes, your this, your that, and how it empowers the patient and how the patient is engaged in the decision – it’s like all this stuff.
And it was mind-blowing. First of all, you could write a book about it, and secondly, it was presuming an integration that exists in very high end organizations, but not yet. I like what you’re saying, because it ties together. If we have a PSA, okay, that’s one thing. The next A1C, right? And what do you do with that? So we have it, we’re going to empower the consumer because they’re going to be able to go somewhere and do something with it, and it ties in with the Community Data Initiative, because you’re making the community better.
And maybe that’s a great sort of horizontal way, because what I find now, with all these measures now, in the lived experience, it’s overwhelming; doctors that just learned how to type a few years ago, that have given up their faxes, now you’re asking all these complexities –and it’s overwhelming.
DR. TANG: It is not productive either.
DR. CARR: I like what you are saying because it does have the patient piece. It does take what we have today and it makes it effective. So somebody got better.
DR. MIDDLETON: SO here’s a thought. And I am just mindful of the time. In the next ten minutes we are going to produce an action agenda. It strikes me that we talk about the vision a lot, over and over and over again, and maybe what we should do is restate the vision. Really, just communicate the vision of what a patient-centered measured health care experience is and how that then drives value across the entire system. That is the opening.
Then we have some very concrete recommendations about how to actualize it that goes beyond higher letter language in terms of where we can help with the standards issues or postroid(?) measures issue, the preferences, you know, all those kinds of things.
DR. CARR: So I would say we have the vision, but tier one, here’s what we are going to do tier one, and it says place to go for the PSA. Maybe we come up with ten things. Tier two, you have more of an integrative thing and maybe if you are a Mayo you are already there, and tier three. But I just have this overwhelming sense of powerlessness when I read the very lofty end game. I am not there.
So if you tier it and you begin to feel successful, and then it also plays to all your different communities, some of which are very sophisticated, some of which are in the early stages, but everybody wants to be successful.
DR. TANG: So how do we prioritize, and ATPs(?) are already starting to, so they just picked a Million Hearts, right? Let’s go up to that and figure out how do you tier by Hearts? Because there are plenty of quality measures in-patient and outpatient. There are lots of things that let’s just follow the priorities that are being set, because they are obviously looking at the priorities of partnership. They decide, a Million Hearts –
SPEAKER: And the PSA they have the same concerns.
PARTICIPANT: Only because we have gotten so much better at cardiac care.
DR. HORNBROOK: And when you improve PSAs, then once you have the PSA you have got them with a standard family history for cardiac disease. Is this person a surgical risk? And then you want to know their urinary function and sexual function, because you want to see what they were before the operation and track it after the operation. If you want to talk about quality of aftercare, survivorship care, you have got to stay with that patient for their activation, their activities, their sexual function, their urinary function, and their degree of happiness with their lives.
One of the things we have seen is in function indicators is that it picks up people who are more vigorous than their clinical data would suggest. SO you get vigorous people who displace their A1C are really functioning high. They also get the people who are functioning low before the clinical markers show it. SO you can pick up patients who are rejecting their transplants before the rejection stuff. There’s a need for a couple of examples of why a physician-patient is a partnership, and I would say you do that generic health status and you could then look at people generically across the whole population. You can also believe the health status because if you have prostate things and there are things you want to ask that patient specifically about that wouldn’t be relevant to anybody else.
DR. TANG: So one of the things you are tracking – we talked about a supply chain for measurement. You are talking about a life cycle for a health condition. We did PSA’s limiting it to one segment of the population like mammograms.
DR. CARR: Mammography – same idea.
MR. COOPER: My sister is 43 years old. I told her to get a mammography or not.
DR. CARR: You are absolutely right. When you say the HEDIS measures are so random, but if you created a life cycle, when you get a mammogram where do you go, what do you do with it, what are your choices? What happens with your resources? I really think that adds value that patients can experience. It is a building block. It is not every condition, but let’s get a couple.
MR. COOPER: The use case approach to understanding quality. What has to be downstream to be upstream for the use cases that we encounter every day?
SPEAKER: This is sort of a random observation but it resonant with me, this idea of a life cycle for healthy patients. It really ties in to what is going on at the United Nations this week, this whole focus on non-communicable diseases. Not only can the US, but around the world, more and more people are living with these chronic conditions.
DR. HORNBROOK: And we communicated it through western lifestyle – through our diet and our lack of activity.
DR. CARR: The concept of coordinating care.
MR. QUINN: I just want to go back for a priming thing and how we look forward to a potential hearing in the spring where our next activity could be. There is real power – what we have talked about in different ways is a core set of data, well specified, that could be re-used in many ways for many things, whether it be in health information exchange, whether it be in benefit exchange, quality measurements internally for ACOs, whether it be used for population health, the more that we can figure our what that core set of granular data elements is for the domains that we have, and that they can support both HHS achievement of its goals, but also all of these other initiatives, then specification of those now so they can be specified in all these different regs is going to be extremely powerful.
This goes back to our recommendation from the meaningful measures that says what is that chunk of coordinated elements, core data models chunk, that are well specified that can be used. Is it big, is it small, is it patient, is it doctor? I think that is going to be a benefit, the catch for actually making this work.
DR. NICHOLS: If this was your operational but I would just say a lot of the vision start, because the vision gives us a chance to put the patient front and center, and to say that frankly, all of these measures are commentary unless the –
MR. QUINN: And to identify how, if you have that core set, how many ways you could use it? If you solve this problem, then here is the benefit in many different ways.
DR. CARR: I feel like that is what we have been trying to do, that everybody has been trying to do. There are many, many minds working on this. And I think with our new lines of community data initiative and being fashionable and coordinated and patient–centered, I would stop trying to make that compendium of all things measureable, but go with what we have. If we have a PSA, what do we do with it? We have mammograms. What can we do with them? You put tremendous effort, all these AQC and community things, they’ve got those results. That have the LBOs, they have all that data, but what are they doing with it? All they are doing is reporting in to see if they get their quality dollars.
DR. TANG: And it is a slice. SO I really like the model of Bruce – I am Joe at this stage, what do I do? Who do I turn to? We could paint those two scenarios. It is Joe and Mary.
I think we would get on the radar if we followed a Million Hearts.
SPEAKER: You could link into something –
DR. TANG: What Mark said is before I declare myself as a heart patient, and after I am treated, that is the story. It is not just how many deaths? Do we have less of them now? Winner. That’s not it. How did I feel before I got diagnosed? How do I feel during treatment? And how do I feel after having the heart attack?
DR. MIDDLETON: That is a new view on quality.
DR. TANG: It is a new view. It is a life cycle not of quality.
DR. MIDDLETON: It is what the navigator or the patient needs to navigate.
DR. CARR: It really is population health. It is sort of that intersection where you take a data element and now you give it some impact.
Agenda Item: Summary and Next Steps
DR. MIDDLETON: SO we have five minutes to be concrete.
MR. QUINN: So we were looking at what the next meeting was. WE have a moment of opportunity before Standards.
DR. CARR: Is that in the spring?
MR. QUINN: February.
DR. TANG: Let’s work backwards from either the ACO timeline or the meaningful use, because we need this stuff in the EHR.
Stage 3 is 2015. Right now, in fact, October 5th we are having hearings on Stage 3 strategy. For which if we had this letter it would be perfect.
DR. CARR: Well, let’s just write it.
DR. TANG: If we can get input so that when we come out with our Stage 3 recommendations it incorporates this. So the calendar we are trying to beat is it takes at least two years to get new measures. They have to develop, it has to go through the cycle, so we have to beat that cycle in time to influence the shift. Of course you know the end paren(?) for all of these CMS initiatives are being written right now. SO that is why the timing is so important. We cannot wait until the spring hearing. This is September – so if we can get it within the next three to four months and then take only three months, or two months, to get the darn letter in front of us – so we have the draft letter for March, and then what is it, June? So June should be our drop dead time. We can’t go later than June. So we will try to go for March – or December.
DR. HORNBROOK: If you look at prevention, if you really want to – you need to prevent the disease.
PARTICIPANT: What does that mean?
DR. HORNBROOK: That means you need to deal with what we eat and how much activity we have. So at the frontier, Intel has got an innovative thing where they put accelerometers on your wrists and ankles and then it gets uploaded automatically to the web and they synthesize all that information. They get measures of pulse as well as physical activity.
Then the other thing is how to figure out how to change somebody’s eating habits. What do you have to change.
DR. MIDDLETON: Now you have to change the school lunches.
DR. HORNBROOK: So then you get to the point of the intersection between the lived environment and your medical care system. Now you are making medical care take care of the person’s whole life. Medical care understands the risk factors of your diet.
DR. MIDDLETON: I’m attracted to this line of thinking because I think there needs to be a dramatic expansion of how we think about quality in managed health care. What are we going to do in the next six months?
DR. HORNBROOK: I was thinking two ways is get from people who are right out there on the frontier a web tool, that helps us manage these behavior problems that physicians just struggle with in primary care over and over again. They still don’t know how to deal with them other than they repeat the words.
So what is it in terms of behavior theory and in terms of engaging people in their own self help regime to get them to change their behaviors? Bring the frontier into the medical office.
Then the other thing is the power of the data. You get that data on population-based BMI you have data on how big baby is and how big mom is, and you start from there. And you have a tremendous amount of risk data during pregnancy. If you had population-based data on everybody you could really find something. We are letting the quality of the data go down and we need to improve the quality of the data to understand what is going on in pregnancy and in the birth process.
MR. QUINN: Are there any drop dead dates around the HBE specifications stuff that we have to be cognizant of?
MR. NICHOLS: Summer of 2012. January ’13 the Secretary has to say go/no-go.
DR. TANG: So summer of ’12 –
MR. NICHOLS: The ones that are going to make on their own will have decided that and then they will then be going through the list of what it is going to take to be certified by the Secretary to avoid federal takeover. The X that will decide to do that will be doing it in the summer.
PARTICIPANT: So those are the ones who will be working out these quality measures, choices they are going to have to make.
DR. TANG: so that a final rule would come out summer of ’12.
DR. NICHOLS: The final rule will probably come out – I am not going to guess – but I would say it should have come out already between now and March, but the rule that is going to be proposed, and the state is going to make a bunch of choices, then we are going to have an election and then we are going to negotiate it. But states will be making choices about quality in the summer of ’12.
DR. TANG: The trouble is to influence we would have to come out –
MS. KLOSS: But then it would be in the proposal.
DR. TANG: You said they have to decide by 13 January.
DR. NICHOLS: The Secretary has to certify they are halfway to be operational by the 24th.
DR. MIDDLETON: Just a page showing all these things moving together would be very helpful.
DR. TANG: Who can put that together?
DR. NICHOLS: You and I together probably could.
DR. TANG: That would be good, and then we need sort of a CMS input.
DR. MIDDLETON: So let’s do this. I apologize. We are going to have to break and reconvene in one minute next door.
So we will generate some minutes and circulate those, ask for your review, and in the minuets we will have a proposed plan for the upcoming activities of the Quality Subcommittee. We will review that with all of you and the Executive Committee, and then probably pretty quickly, if we are going to have some hearings, we are going to get right to it.
MR. QUINN: So in addition to trying to capture the notes of what we have here, I am going to take it back and try to summarize what we want for the hearing, questions and goals.
DR. TANG: So you might think about what’s the desired outcome of the March letter and then work backwards. So if you know what you need to say, what you want to say about it, then you figure out what the hearing has to be and when and what does the next letter say.
SPEAKER: Do you have a writer?
DR. TANG: It should be somebody with fairly deep knowledge of the topic we are talking about.
DR. MIDDLETON: The Booz Allen folks that are at this stage – Christine Martine.
DR. TANG: Christine has to be involved directly.
DR. MIDDLETON: Okay, we are out of time. Thanks everybody.
(Whereupon, the meeting was adjourned.)