The conundrum of Quality Metrics

Much of the discussion around how to “certify” an EHR in the new era is focused on reporting health quality data. It is also about collecting and sharing data in a standardized fashion, so that EHRs can readily display information from multiple sources about a patient’s status in a “dashboard.” But a lot of it is focused on reporting health quality metrics. Meaningful Use (the criteria set developed by the ONC’s HIT Policy Committee), which is intended to serve as a basis for HHS Certification metrics, contains a number of health quality metrics that are felt to be important.

Keeping track of health quality metrics, according to the National Quality Forum, helps reduce unnecessary and inappropriate care, reduces cost and improves patient outcomes – the current HIT policy direction puts the onus on EHR developers (appropriately) to collect and display health quality data to physicians (and other care providers) at the point of care. Prompting physicians at the time of a clinical encounter (“Mrs. Hernandez is due for her diabetes lab tests” when she presents for an unrelated matter, like the flu), as well as providing lists of patients who are “due” for certain interventions (“here is a list of all your patients due for a screening mammogram”) is the hope of EHRs. The EHR sector is a ways from getting there, but that is the direction – for HHS Certification (i.e., able to report on Meaningful Use metrics, as specified in the matrix), there must be the capacity to report on certain, specific quality metrics.

The process of defining exactly which metrics should be the “minimum threshold” for HHS Certification is reminiscent of other health quality metrics programs that have been in place for several years. For Medicare pay-for-performance (P4P) incentives, the PQRI metrics set has been implemented. For commercial HMO P4P, the HEDIS data set has been used. In California, where medical groups and IPAs are often delegated to assume risk for HMO patients, and manage the delivery of care, the Integrated Healthcare Association (IHA) has standardized the measure set used for group-level P4P (so that every health plan is using the same “report card” measures) and is based on HEDIS as well as some additional domains.How much overlap is there between all these data sets? There is a fair amount of overlap (diabetes management, cardiovascular management, immunization and wellness screenings), but there are also differences. What should be the “minimum” reporting data set for HHS Certification? That question is still in-evolution. The ONC’s HIT Standards Committee has tried to reconcile the Meaningful Use criteria set with the much larger and more aggressive HITEP data set developed by the National Quality Forum (NQF) and has published a detailed mapping grid. It is uncertain whether this approach from the Standards Committee will help answer the question – their efforts have been criticized as being inadequately responsive to evolution within the market, and stiffly asking everyone to “speak a language” that no one is currently using.

As the ONC develops its recommendations more fully over the next several months, the question of “what standard” of data (current Meaningful Use vs. PQRI vs. HEDIS vs. HITEP) is the “driver” of healthcare should become clearer. Our hope is that requiring EHR developers to simply build sufficiently-flexible systems that can report on any such standards will suffice for HHS Certification – physicians can then report on Meaningful Use criteria to get their HITECH bonus payments; on PRQI criteria to get Medicare P4P payments; on HEDIS measures to get HMO P4P payments, etc.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.