National Quality Strategy Webinar Using Measurement for Quality Improvement September 17, 2014

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Agenda Welcome Heather Plochman, Facilitator Introduction to the National Quality Strategy Nancy Wilson, Executive Lead National Quality Strategy Centers for Medicare & Medicaid Services Kate Goodrich, Director, Quality Measurement and Health Assessment Group Office of the National Coordinator for Health Information Technology Kevin Larsen, Medical Director, Meaningful Use Questions and Answers Presenters

The National Quality Strategy: Using Measurement for Quality Improvement Nancy Wilson, B.S.N., M.D., M.P.H.

Here is a high-level look at how the National Quality Strategy works Here is a high-level look at how the National Quality Strategy works. I’m going take you through it step by step. Our ultimate goal is the three aims of the National Quality Strategy, which are better care, better health, and lower costs. I’ll take you through this graphic from left to right.

Quality Can Be Measured and Improved at Multiple Levels Community Population-based denominator Multiple ways to define denominator (e.g., county, HRR) Applicable to all providers Practice setting Denominator based on practice setting (e.g., hospital, group practice) Increasing commonality among providers Increasing individual accountability Individual physician We’re here to talk about one of the most important levers for achieving the National Quality Strategy: quality measurement There are three levels of measurement critical to achieving three aims of National Quality Strategy: the community, the practice setting, and individual physician Measure concepts should “roll up” to align quality improvement objectives at all levels Patient-centric, outcomes-oriented measures is preferred at all three levels The six priorities can be measured and improved at each of the three levels And yet, despite quality measurement’s many virtues there is also work that needs to be done in harmonizing and aligning the measures we use Denominator bound by patients cared for Applies to all physicians Greatest component of a physician’s total performance 6

Rationale for Addressing Measure Proliferation Proliferation of measures used by HHS Agencies for numerous programs and initiatives Redundancies and overlaps leading to provider/data collector burden, conflicting results, inefficient use of HHS resources, and lost opportunities to drive improvement through reinforcing program use of key measures No formal systematic mechanism to align, coordinate, and approve development, maintenance, implementation, and retirement of measures across HHS programs Precedent work done by Million Hearts™, Partnership for Patients, internal CMS Quality Measures Task Force, and MU2 Quality measurement began in earnest in the 1970s with the HMO movement and standardization of Medicaid and Medicare professional standard review organizations, and increased in importance and number into the 1990s. At the turn of the millennium, a pair of landmark studies showed us that the right care was only being delivered half the time, and was even doing harm in far too many cases. Meanwhile, health care costs continued to rise at several points above inflation every year. Providers, purchasers, payers, and policymakers alike demanded improvement, and you can only improve what gets measured. We’ve seen tremendous improvement across the country in the interim, but without a formal system for alignment we’ve also seen the number of quality measures rose to their extraordinary number today: 2,082 documented in the National Quality Measures Clearinghouse as of this morning. To begin to address this issue within HHS, we came together as a group to form the Measurement Policy Council

HHS Measurement Policy Council (MPC) Assembled in spring 2012 with membership representative across HHS Agencies Establishes and operationalizes policies for HHS-wide measure development and implementation Work to date has focused on: Reviewing publicly available HHS Measures Inventory and tackling topics around nine measure areas Developing a coordination plan for future measure development Piloting rules for categorizing measures across the Federal Government and multi-stakeholder groups The HHS Measurement Policy Council was assembled in spring 2012 with representative membership across HHS agencies The Council is responsible for coordinating HHS-wide measure development and implementation policies The work to date includes: Creation of 9 harmonized core measure sets A Measure Development Coordination Plan Rules for Categorizing Measures According to Care Setting and NQS Priorities 8

MPC Guiding Principles Focus on measures and policies that maximize quality improvement, minimize provider burden, and allow for assessment of the health of populations Deliberately align with National Quality and Prevention Strategies (and others when relevant) Leverage lessons learned from related HHS and external activities Develop consensus on standard definitions for data components of measures as well as measures themselves Maintain a portfolio of easily accessed artifacts from MPC deliberations Recognize alignment may not always be appropriate, but document justification when this occurs Use Measure Applications Partnership (MAP) to measure selection criteria The MPC guiding principles center around: Aligning measures where appropriate, both inside and outside HHS Focusing on measures that matter, finding the optimal sets of measures that will be of the most benefit at least cost Developing standard definitions, data dictionaries, and other guidelines

MPC Scope of Work: Short-Term To date, the Measurement Policy Council has reviewed and prioritized measures in nine major areas: Hypertension Depression Smoking Cessation Hospital-Acquired Conditions Care Coordination (closing the referral loop) Patient Experience of Care HIV/AIDS Perinatal Obesity/BMI We’ve been busy on the Council, creating core measure sets for nine topics to date (with several more on the way). You can access the core measure sets at the Working for Quality Web site. These topics span the six NQS priorities, and represent some of the highest-importance topic areas. Up next will be diabetes, cardiovascular disease, patient-reported outcomes, among others. 10

MPC Scope of Work: Long-Term Measure alignment Develop criteria on when it is appropriate/not appropriate to align measures within HHS Develop consensus on the measure aspects on which to align (concepts, specifications, data sources, etc.) New measure development and implementation Implement strategic direction for future measurement priorities Coordinate measure submissions to the MAP Coordinate measure development contracts Measurement policy/management Manage measure domains Identify measure selection, removal, and retirement criteria Create core sets of measures The long term scope of work for the MPC is laid out here. In the interest of person-centeredness, we’d love to hear from you on areas where the MPC could help you – topics that need alignment, measure gaps, areas requiring standardization, or areas requiring innovation. You can email your comments to NQStrategy@ahrq.hhs.gov I’d now like to turn the floor over to my colleague, Dr. Kate Goodrich, Director of the Quality Measurement and Health Assessment Group at the Centers for Medicare & Medicaid Services and co-chair of the HHS Measurement Policy Council.

Centers for Medicare & Medicaid Services Kate Goodrich, M.D., M.H.S. Director, Quality Measurement and Health Assessment Group Centers for Medicare & Medicaid Services

Objectives & Desired Outcomes Performance Measures and Targets Strategy Logic Strategic Altitude Mission Vision Goals Objectives & Desired Outcomes Performance Measures and Targets Initiatives Activities What do we exist to do? 30,000 ft. What is our picture of the future? What are our main focus areas for improvement? What results are needed to satisfy stakeholders? What continuous improvements are needed to get results? How will we know if we are achieving desired results? 15,000 ft. What actions could contribute to the desired results? What will support the initiatives? Ground Level

The Strategy is to Concurrently Pursue Three Aims Better Care Improve overall quality by making health care more patient-centered, reliable, accessible, and safe Improve population health by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care Healthy People / Healthy Communities Affordable Care Reduce the cost of quality health care for individuals, families, employers, and government 14

CMS Framework for Measurement Maps to the Six National Quality Strategy Priorities Care Coordination Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Population / Community Health Clinical Quality of Care Measures should be patient- centered and outcome-oriented whenever possible Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Health Behaviors Access Physical and Social environment Health Status Efficiency and Cost Reduction Person- and Caregiver- Centered Experience and Outcomes Cost Efficiency Appropriateness Patient experience Caregiver experience Preference- and goal-oriented care Safety All-cause harm HACs HAIs Unnecessary care Medication safety 15 15

Reduce inappropriate and unnecessary care Make Care Safer Objectives Reduce inappropriate and unnecessary care Prevent or minimize harm in all settings Improve support for a culture of safety Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Goal 6

Promote Effective Prevention and Treatment Objectives Increase appropriate use of screening and prevention services Strengthen interventions to prevent heart attacks and strokes Improve quality of care for patients with multiple chronic conditions Improve behavioral health access and quality care Improve perinatal outcomes Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Goal 6

CMS’ Vision for Quality Measurement Align measures with the National Quality Strategy and six measure domains/priorities Implement measures that fill critical gaps within the six domains, particularly patient experience and patient-reported outcomes Align measures across CMS programs whenever possible Promote parsimonious and core sets of measures Remove measures that are no longer appropriate (e.g., topped out) Align measures with external stakeholders, including private payers, boards, and specialty societies Improve measures over time (a major aim) 18

Landscape of Quality Measurement Historically a silo approach to quality measurement Different measures within each quality program Different reporting criteria for each quality program No clear measure development strategy Typically disease-specific measures Confusing and burdensome to stakeholders Burdensome to CMS, with stovepipe solutions to quality measurement 19

The Future of Quality Measurement for Improvement and Accountability Transition meaningful quality measures away from setting-specific, narrow snapshots Reorient and align measures around patient-centered outcomes that span across settings Base measures on patient-centered episodes of care Capture measurement at three main levels (individual clinician, group/facility, population/community) Why do we measure? Improvement Source: Conway PH, Mostashari F, Clancy C. The Future of Quality Measurement for Improvement and Accountability. JAMA 2013 June 5; Vol 309, No. 21 2215–2216.

CMS Activities on Patient-Reported Outcome Measures (PROMs) In 2012, CMS funded the NQF to develop guidance on development of PROMs CMS currently uses a number of PROMs in our clinician reporting programs (e.g., depression, functional status) CMS and HHS are working to identify existing PROMs that can be rapidly incorporated into our quality reporting programs, including the ACO program and CMMI models CMS and ONC are currently developing PROMs for the hospital and outpatient setting Disease-specific functional status General functional status CMS now includes patients in all measure development work in order to understand the outcomes that are most important to patients and families NQF workshop: Two white papers developed and a 2 day multi-stakeholder meeting held to identify methodologic issues with development of PROMs and guidance on overcoming barriers, and identified topics for PROM development in the near term. 21

Kevin Larsen, M.D., FACP Medical Director, Meaningful Use Office of the National Coordinator for Health Information Technology

Health Information Exchange

“I am the expert about me.” Patient-Reported Outcomes SF homeless outreach Geisinger patients doing med rec from home Open notes Nurses in hospitals able to fill care gaps Sandy Blue button 24

INTEROPERABILITY

Common Data Elements: The Future A terminology based metadata solution frees data consumers from data interpretation

HIV Cascade Source: CDC, July 2012 27

HHS Measurement Alignment MU, PQRS, IQR, ACO, VBP, HRSA, CDC Current Unified Outcome Measures EHR as primary reporting platform, with secondary reporting from registry, claims CMS’ commitment to alignment includes finalizing the same CQMs used in multiple quality reporting programs for reporting beginning in 2014 Other programs include Hospital IQR Program, PQRS, CHIPRA, and Medicare SSP and Pioneer ACOs Full alignment by 2020?

Only those who provide care can improve care

Car With No Dashboard

Clinical Decision Support: CDS 5 Rights To improve targeted health care decisions/outcomes, information interventions (CDS) must provide: The right information To the right people Via the right channels In the right formats At the right times Optimize information flow: what, who, where, when, how

popHealth Test Patient Data

“Small Data is our short term focus” —Dr. Joe Kimura “Small Data is our short term focus” Provider/Care Team Level Analytics – The action is happening at the microsystem level so business intelligence and analytic systems need to support work at the care team/individual physician level. BI systems need to easily and seamlessly telescope metrics up and down all levels of the organization and align metrics across cost to quality to patient experience domains. Robust physician-level analytics will require new analytic methods since methods developed for large populations can be glaringly problematic. For example, episode groupers offer significant conceptual appeal when aiming to understand clinician practice pattern variation driving expense differences for similar quality outcomes. However, at the individual PCP or specialist level, the methodological problems are magnified ,and limits validity and provider acceptance. 33

The Learning Health System

Future State: HIT-Enabled QI Toolkit Stakeholders Unambiguous human readable Value Set Authority Center Public Domain Unambiguous machine readable EHR Certification Tools Population Health Tool Electronic Health Records Clinical Registries Clinical Decision Support CMS Quality Reporting Other HIT Tools

How to Find More Tools and Resources http://www.ahrq.gov/workingforquality/ Working for Quality Web Site CMS Quality Strategy Meaningful Use

Questions and Answers Presenters

Questions and Answers For users of the audio broadcast, submit questions via chat For those who dialed into the meeting, dial 14 to enter the question queue

Thanks for attending today’s event The presentation archive will be available at www.ahrq.gov/workingforquality within 2 weeks