Quality Reporting May Prove Challenging Under Meaningful Use

I think it's fair to say that healthcare executives and physicians would all agree that the sooner hospitals, health systems, and physicians start gathering and reporting on quality indicators, the sooner healthcare quality can be improved. So it's not surprising that quality metrics are central to the meaningful use requirements outlined in the Centers for Medicare & Medicaid Services interim final rule.

What did surprise healthcare leaders, however, was the number of quality measures that is required for 2011. According to the rule, hospitals must report on 35 quality measures to meet the 2011 meaningful use requirements, including metrics on:

• Emergency department throughput, such as admission decision time to ED departure time for admitted patients and median time from ED arrival to time of departure from the ED for patients discharged from the ED.
• Ischemic stroke, such as the number of patients who arrive within two hours of symptom onset who receive thrombolytic therapy, and the number of ischemic stroke patients with atrial fibrillation who are prescribed anticoagulation therapy at hospital discharge.
• Venous thromboembolism prophylaxis, such as the number of patients who receive VTE prophylaxis within 24 hours of arrival or have documentation on why it wasn't given, and the number of patients with confirmed VTE who received anticoagulation overlap therapy.
• Acute-myocardial infarction patients, such as the number of patients who are prescribed aspirin or beta blockers at discharge.
• Hospital specific 30-day risk-standardized readmission rate following acute myocardial infarction admission, heart failure admission, and pneumonia admission.
• The ventilator bundle, such as elevation of head of the bed, daily "sedation interruption" and assessment of readiness to extubate, and peptic ulcer disease and deep vein thrombosis prophylaxis.
• The central line bundle, such as hand hygiene, chlorhexidine skin antisepsis, and optimal catherter site selection.
• Urinary catheter-associated urinary tract infection for intensive care unit patients, central line catheter-associated blood stream infection rate for ICU and high-risk nursery patients.
• Overall inpatient 30-day hospital readmission rate.

Even though the initial reporting will be done through attestation to CMS because the Department of Health and Human Services won't have the capacity to electronically accept data on clinical quality measures from electronic health records for the 2011 payment year, hospitals and physicians must still provide data on the quality measures as a condition of demonstrating meaningful use. HHS plans to have the capacity to receive electronic information on clinical quality measures from EHRs by 2012.

Currently, "we, as an industry, are only tracking—at least in Medicare pay-for-performance programs—about nine of those," says Steve Hanson, executive vice president of system alignment and performance for Texas Health Resources. And while all 35 are important, Hanson says, he hopes that CMS and the Office of National Coordinator will take the opportunity to focus on the "truly critical criteria" for 2011.

Tripling the number of quality measures that Texas Health Resource's reports on in less than a year is going to be difficult, acknowledges Ed Marx, senior vice president and chief information officer. One of the challenges is the maturity of the technology to produce the types of reports required in just a few key strokes, Marx says.

"There are not many clinical applications out there today that are robust enough to produce the types of reports that we are talking about," he says. "So what we are doing is building a clinical business intelligence system that allows us to report on these measures in real time." THR already has an electronic medical record in all but two of its 13 hospitals and boasts an 80% to 90% utilization rate for CPOE, but it's just now starting to build the clinical business intelligence system, says Marx. "And we are ahead of many of our peers."

Physicians are going to be challenged to meet the quality reporting requirements, as well—perhaps more so than hospitals. Eligible professionals have quality measures broken down by specialty. For example, there are 10 quality measures for cardiology, eight for pulmonology, six for oncology, and 29 for primary care.

But many physicians—even those with EMRs—don't capture clinical data in a discrete format, says Chris Macmanus, partner and practice leader in the Healthcare Information Technology practice of Tatum LLC. For example, some physicians groups chose to upload lab reports as an image in their EMR rather than using a version that captures discrete data from lab findings, Macmanus explains. "Is their EMR fully electronic? Absolutely. Does it meet the need for discrete data for meaningful use? Absolutely not," he says, predicting there will be a lot of reinstallations or software upgrades to physician practice EMRs.

Some healthcare executives are also concerned about the focus of the quality measures. Members of the Health IT Policy Committee were critical that CMS didn't include the recommendation that physicians generate progress notes for each patient visit and document the recording of advanced directives for elderly patients, for example.

"We have been tethered to whatever data has been available, and that data typically has been claims and administrative data," said Paul Tang, MD, co-chairman of the committee's meaningful use work group and chief medical information officer of the Palo Alto Medical Foundation, during a committee meeting Jan. 13. "Most of the existing endorsed quality measures are based on that kind of data," he says. "The rationale from CMS was that it wouldn't contribute to care coordination, [but] there certainly is a lot of feeling that it may," he said.

Hanson is concerned that CMS appears to have focused more on the traditional way healthcare is delivered on a per-procedure basis in the requirements. "I'm not saying that we should add more to this, in fact, the reverse, but we need to be thoughtful as we look at a broader approach of care through accountable-care organizations or bundled payments with physicians and between hospitals and rehab and nursing facilities."

The issue of community and public health is one of the stated goals of meaningful use, says Hanson, "but my sense is this early stage is more focused on traditional medicine."