1. HIT Policy Committee TIGER TEAM RECOMMENDATIONS: Framework and Overlap Areas Christine Bechtel National Partnership for Women and Families October 28, 2010

2. Measure Concept Criteria and Rating Scheme State of readiness—State of measure development and pipeline/endorsement status HIT-sensitive—Evidence that measures built into EHR-systems with implementation of relevant HIT functions (e.g., clinical decision support) result in improved outcomes and/or clinical performance Promotes parsimony—Measures applicable across multiple types of providers, care settings and conditions Preventable burden—Evidence that measurement could support potential improvements in population health and reduce burden of illness Supports health risk status and outcomes assessment—Supports assessment of patient health risks that can be used for risk adjusting other measures and assessing change in outcomes, including general cross-cutting measures of risk status and functional status and condition- specific measures Enables longitudinal measurement—Enables assessment of a longitudinal condition-specific patient-focused episode of care 2

3. Areas of Overlap Across Domains: Efficiency 3 SourcePriority Measure ConceptsCare Coord P&F Engagement Patient Safety Pop/Public HealthEfficiency All cause readmissions and length of stay EfficiencyAmbulatory care sensitive preventable admissions EfficiencyPreventable ED visits Efficiency Appropriate use of diagnostic imaging procedures, with measures for redundancy, cumulative exposure, and appropriateness EfficiencyAppropriate use of invasive testing Efficiency The number of adverse effects caused by a chronic condition Efficiency Patients with a treatment plan for a chronic condition and whether that treatment plan has been followed across care settings/multiple specialists Efficiency Combined quality and cost measures at each level and site of care reflecting potential defects in care Efficiency Appropriate medication treatments, including overuse and/or underuse EfficiencyUsage rates for generic vs. brand name medications EfficiencyHospital acquired conditions/infections EfficiencyMedication use linked to outcomes EfficiencyAppropriate cardiac treatments EfficiencyAppropriate cancer treatments Efficiency Use/availability of services that promote healthy lifestyles (smoking cessation, body mass index management, patient health literacy)

4. Areas of Overlap Across Domains: Patient Safety & Population Health 4 SourcePriority Measure Concepts Care Coord P/F Engagement Patient Safety Pop/Public HealthEfficiency Patient Safety Reporting Adverse Drug Events Patient Safety Medication error prevention Patient Safety Hospital Associated Infection prevention Patient Safety VTE prevention Patient Safety Falls prevention Patient Safety Patient Identification Patient Safety EHR safety (defined as mechanism to report EHR related errors, delays in care, etc. to improve EHRs and maximize patient safety in the context of EHR use) Pop Health Smoking cessation focused specifically on quit rate for patients within a reporting period. Pop Health Body Mass Index focused specifically on tracking longitudinal change to determine patient outcome. Pop Health Screening for alcohol use using a validated tool. Pop Health Blood pressure focused specifically on tracking longitudinal change to determine patient outcome. Pop Health Glucose monitoring focused specifically on tracking longitudinal change to determine patient outcome. Pop Health Mental health screening using a validated instrument. Pop Health Health equity focused on measures with no discrepancy when comparing rates among those within priority populations

5. Areas of Overlap Across Domains: Patient/Family Engagement 5 SourcePriority Measure Concepts Care Coord P/F Engagement Patient Safety Pop/Public HealthEfficiency Pt and Fam Engagement Self Management Pt and Fam Engagement Patient Activation Pt and Fam Engagement Shared Decision Making focused on measuring a patient’s knowledge and confidence about their care process and measuring a patient’s preferences and values. Pt and Fam Engagement Patient Preferences Pt and Fam Engagement Patient Experience of Care Pt and Fam Engagement Disease/Disability Status (Patient Health Outcomes) Pt and Fam Engagement Health Risk Status (Patient Health Outcomes) Pt and Fam Engagement Functional Health Status (Patient Health Outcomes) Pt and Fam Engagement Community Resources Coordination/Connection (Patient Health Outcomes)

6. Areas of Overlap Across Domains: Care Coordination 6 SourcePriority Measure Concepts Care Coord P/F Engagement Patient Safety Pop/Public HealthEfficiency Care Coordination Receipt by patient of a self management plan for patients with conditions where a self management plan might reasonably be considered to benefit them Care Coordination Presence of a comprehensive clinical summary in the EHR with an up to date problem list Care Coordination Advance Care Plan- Availability of a completed advanced care plan and health care proxy in EHR Care Coordination Assessment of timeliness of provider and appropriate response to clinical information, including lab and diagnostic results* Care Coordination Measure of reconciliation of all medications when receiving a patient from different provider Care Coordination Measure of receipt by patient and care team members of a comprehensive clinical summary after any care transition Care Coordination Measure of patient and family experience of care coordination across a care transition Care Coordination Assessment of duplicative test orders (lab and imaging)

7. HIT Policy Committee PATIENT AND FAMILY ENGAGEMENT Tiger Team Summary Christine Bechtel National Partnership for Women and Families David Lansky Pacific Business Group on Health October 28, 2010

8. Patient and Family Engagement Tiger Team Members Christine Bechtel (co-chairperson) David Lansky (co-chairperson) Michael Barry Susan Edgman-Levitan Judy Hibbard Lew Kazis Eugene Nelson Dana Safran Joshua Seidman Paul Tang Kalahn Taylor-Clark Paul Wallace James Weinstein 8

9. We have Identified Four Patient and Family Engagement Sub-Domains 1.Self-Management/Activation—Measures that show that the patient understands what his/her role is in his/her own care process and has the knowledge, skills, and confidence to move forward in this role, including resources and support for self-management 2.Honoring Patient Preferences and Shared Decision Making— Measures that demonstrate that the patient has the knowledge, resources, and confidence to make informed decisions or an informed choice about his/her care. Also includes the quality of decision making, connecting patients to resources, assessing patients’ preferences and whether the care that was delivered is in accordance with the patient's preferences and values 3.Patient Health Outcomes—Measures that focus on optimizing three States (Disease/disability, Health Risk, and Functioning Health) at the individual patient level and/or population level 4.Community Resources Coordination/Connection—Measures that show if a patient was connected to community resources 9

10. Measure Concept Recommendations 1. Self-Management/Activation Self-Management Patient Activation 10

11. Measure Concept Recommendations 2. Honoring Patient Preferences and Shared Decision Making Patient Preferences Patient Experience of Care 11

12. Measure Concept Recommendations 3. Patient Health Outcomes Disease/Disability Status Health Risk Status Functional Health Status 12

13. Measure Concept Recommendations 4. Community Resources Coordination/Connection Improving health outcomes, including functional status, often requires other non-health institution resources (e.g., support groups, transportation, etc.) Patients can benefit from having a social support system within their community, and from resources in the community for health promotion and disease management and care 13

14. Methodological Issues Two approaches to collect data from surveys: “Add on” and “Design in” to the current system Determine the timing of when the survey is administered Assess the strengths and limitations of the different modes of administering the survey (examples, phone, paper, email, etc.) Decide who should administer the survey Determine the sample size and who should be included in the sample of patients receiving surveys Assess measure computations Decide how the data collected can most effectively be used to support progress towards quality health care 14

15. Questions? 15

16. APPENDIX: Summary of Patient and Family Engagement Measure Concepts Patient Activation—patient’s ability to set goals and self-manage and engage in care effectively Outcome of Activation—once the patient is activated, what do they do? Include measuring health outcomes Provision of effective self-management resources and tools, in accordance with patients’ preferences Self-management of health risk behaviors and preventive care in general (not just chronic conditions) The feedback loop of the patient’s data to the clinician Patients’ engagement with their own data (e.g., displays) tools that help translate data into actions, etc Did shared decision making occur and was the clinician aware of the patient’s preferences? Efficacy of shared decision making—did the patient understand what he/she was making a decision about? Did shared decision making actually make a difference (is the patient comfortable with the decision) including concordance with patient’s preferences/values and service delivery? Connection to community resources for health promotion, complex chronic disease management and care, and social/other non-medical needs/ support, including online patient/caregiver communities 16

17. APPENDIX: Summary of Patient and Family Engagement Measure Concepts Functional Health Status—level of functional ability in physical, mental, and social domains Disease Status—patient self reports or diagnostic tests for specific health conditions, focus on patient-reported outcomes and how health information technology can enable this for the high-variation, high-volume, high-cost conditions with appropriate outcome tools Risk Status—two sources: report of health behaviors (eating, exercise, etc.) and biometric variables. Measures of avoidable risk of death that are based on both biometric variables and lifestyle variables Caregiver as a proxy for patient, in each of the sub-domains In situations where caregiver present, measurement of caregiver’s engagement, health status, communication preferences, etc. in each of the sub-domains Potential for technology to increase a family member/caregiver’s participation and decrease some of the family/caregiver burdens Facilitation of peer networks, enabled by health information technology that would provide a social support for caregivers/family members, as well as medical guidance Methods by which patients prefer to communicate (examples: phone, email, portal, paper, personal health record (PHR), etc.). Connecting to community resources for health promotion, complex chronic disease management and care, and social/other non-medical needs/support, including online patient/caregiver communities 17