Quality Reporting

Quality Reporting is one of the key components for Meaningful Use included in the ARRA portion of the economic stimulus package. A requirement for EMRs to report various quality measures is sure to be incorporated in the rule-making regulations now being refined for publication later this year. The standards and technology needed to facilitate interoperable electronic submission and reception of quality reports are evolving. Some are still being developed and tested. Others are relatively immature and have not been widely incorporated into EMRs. Meeting the timelines determined by ARRA will be a challenge for many of the involved stakeholders.

Models for quality reporting are CMS' Core Measures for hospital care and the Physician Quality Reporting Initiative (PQRI) for outpatient services. Quality measurement development organizations are too numerous to mention but include the Joint Commission, National Quality Forum (NQF), National Committee for Quality Assurance (NCQA), and Agency for Healthcare Research and Quality (AHRQ.) There are probably over 600 quality measures that have been developed. There are a number of problems with quality measurement and reporting. There are too many quality measures already. The organizations that develop quality measures rarely coordinate their efforts. Validation of the existing measures has not been extensive, thorough, or scientific in many cases. The number of organizations demanding quality reports is excessive, ever growing, and represents an increasing drain on precious health care resources. The mechanisms for collecting, aggregating, transmitting, and analyzing these reports are poorly defined, lack necessary standards and vocabulary, and, in many cases, the infrastructure for handling electronically do not exist.

The Meaningful Use (MU) regulations for quality reporting will not be published until late this year and early next. Discussions within the two health information technology FACA committees (HIT Policy Committee and HIT Standards Committee) that report to the Office of the National Coordinator for Health Information Technology seem to indicate that the requirements for 2011 will mostly be based on self-attestation, either paper-based or electronic, with entirely electronic reporting by 2015. The quality workgroup of the HIT Standards Committee has recommended 29 preliminary measures. Eventually decisions will need to be made about whether EMRs will be able to collect/calculate all of these measures internally or whether intermediaries will be needed. Also, government agencies tasked with collecting the reports and assessing MU will need to rapidly ramp up their capabilities to manage and promulgate this information electronically. For example, I have heard reports that CMS was not prepared to accept PQRI data from providers when that program was first initiated. Furthermore, transport mechanisms, to include privacy and security, need to be defined. Will the systems support just send/receive transactions or will query/respond transactions also be utilized (these will almost certainly be required.)

On the near horizon: HL7 and IHE have helped develop the QRDA (Quality Reporting Data Architecture) and the Performance Quality Report profile. QRDA provides a framework for reporting patient level quality data across disparate systems. Reports are published in XML to provide human and machine readable. It will be interesting to watch for standard vocabulary development and trial implementations.

September 14, 2009

Reconciliation-an unmet challenge

There is little doubt that in the near future, more electronic clinical information will be shared between providers using established standards and various methods of information exchange. The goal is to provide the most accurate, up-to-date information to the clinician, when it is needed. An associated benefit for patients is that they will not have to fill out redundant forms. However, a new problem is about to be created. Multiple sources of information will be available to clinicians. The data will need to be collected, sorted, aggregated, de-duplicated and reformatted to serve as the source of truth for patient care. Clinicians will want this process to be automated, as much as possible. They will not want to have to click through multiple screens and scroll through pages of data. The final report will need to be reviewed with patients to verify accuracy whenever possible.
What types of information will need to be reconciled? As one starts thinking about this question, the list of possible answers seems to grow. Examples include: medications, laboratory reports, CCD documents, and administrative information. Consumer preferences for information release and advanced directives will be areas that it will be especially important to keep up to date. They have been mentioned as priorities by the Office of the National Coordinator for Health IT.
There will be multiple steps in the process. Location(s) where data is stored will need to be identified. Next the data must be imported (via a push or pull transport mechanism) and stored. Then the sorting process will occur that harmonizes all the data that is available. Finally, a report of the most accurate, up-to-date data will be presented to the clinician to review with the patient. Ideally, this would be a one click activity. All the decision rules would need to be incorporated into software to automate the process. (The banking world has developed a similar capability but their data does not have the variety of data elements that is seen in health care.)
In the inpatient setting, this would be used with every transfer of care between providers in the hospital. The transition from inpatient care to ambulatory care is an especially important area when reconciliation of electronic medical records must occur. Finally, in the ambulatory setting, reconciliation will be necessary when patients travel from one provider to another.
A good question is whether a potent, general type of software might be used to process all the different types of data- "the reconciliator" or whether multiple varieties of specialized software will be needed for each type of message/document. I suspect that the latter will need to be the choice. A special case may be the reconciliation of CCD documents. Here, if the software is designed around all the CCD sections, the data types and vocabularies will be standardized so complete CCDs and their summaries might easily be reconciled by one piece of software. It is imperative for EMR vendors and their engineers to address this important emerging EMR capability.

Online Education

September 10, 2009

Online Learning

I recently graduated from an online graduate degree program offered by Northwestern University. There are several reasons why online programs are growing in popularity. Many working students have an opportunity to obtain advanced training that otherwise would not be available; most classes are held at night, after work. Parents with child-raising responsibilities can attend classes from home while still taking care of the kids. Employers who contribute to an employee's education strengthen their workforce while being able to retain valued workers. Colleges with online programs have the chance to expand their student base. The schools do not need to support the high overhead of bricks and mortar classrooms even while charging regular tuition rates. Faculties often are enriched by instructors with practical experience in their fields, even if they are somewhat less academically oriented. This is an excellent forum to put technology to work for educational outreach and could serve as a model for other types of educational activities needed by universities and corporations to develop the technologically advanced workforce that will be required in coming decades. Finally, there is a lot of latitude to apply innovative ideas to the process of education.
The application process is similar to on campus programs. Some graduate programs do not require completion of the GRE. Mine did not when I applied two years ago although transcripts from previous schools were required. Interest in online education has been strong so schools have their choice of highly qualified candidates. Most programs are accredited, but there are a variety or organizations offering accreditation so prospective students should be careful to evaluate the programs that interest them.
Online classes may be conducted synchronously (real-time) or asynchronously. Many use a combination of the two methods. Synchronous teaching sessions use web-based teleconferencing with or without a telephone bridge for audio. Students need access to a broadband Internet connection. Technical issues arise frequently but they are usually easy to solve. Asynchronous solutions do not require such robust Internet connections but they have functional limitations and restrict interaction of students with each other and with faculty. Most educational programs utilize course management software such as Blackboard© to communicate weekly assignments, supplemental educational material, discussion boards, homework submission, and to post grades. A critical element of almost every class at Northwestern University was a group project. We had to learn to effectively collaborate and be productive in the face of demanding work schedules with students that lived in different time zones that spanned the country.
Online education poses challenges for students. Foremost is a commitment to continued learning and self-discipline to study and work hard. In my program, each class demanded ten to twenty hours of work per week to keep up with homework, class sessions, group projects, tests, and discussion board participation. There were eleven required classes. We operated on the quarter system with just short breaks between quarters. The program I participated in was technology-oriented. Students needed to learn new software packages for many classes. For example, I used MS Word, PowerPoint, Access, Excel, Visio, SQL, SPSS, TreeAge, WebEx, Adobe Connect Pro, EndNote, and Blackboard. Most classes had a final exam that required one to visit a proctored test site. One of the biggest challenges was managing the dynamics of working in groups where the members never met in person, never even saw each other, lived in different time zones, had different clinical or technical expertise and sometimes came to online meetings carrying the burdens of their personal lives, home, and work.
I think online education is the wave of the future in adult education. Many workers change careers during their lifetimes and need retraining. Also, a major way of advancing ones career is to learn new skills. Online education is a realistic way to meet each of these requirements.