AQA Invitational Meeting October 24, 2006 Contents Introduction Opening Remarks Review of AQA Governance Report of the Performance Measurement Workgroup Report of the Reporting Workgroup Report of the Data Sharing and Aggregation Workgroup Report on the Formation and Workplan of the Quality Alliance Steering Committee Final Remarks Introduction The AQA (formerly known as the Ambulatory Care Quality Alliance) was founded in the fall of 2004. Its mission is to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians, and other stakeholders in order to inform choices and improve outcomes. The AQA’s mission and goals focus on key areas that can help identify quality gaps, control skyrocketing cost trends, reduce confusion and burdens in the marketplace, and otherwise address the challenges of the current health care system. The timing of this stakeholder process has coincided with a growing interest in rewarding high-quality providers (through “pay for performance” or “p4p”) and clinicians’ burgeoning interest in adopting health information technology to enhance the quality, safety, and efficiency of care delivery. The October 24, 2006, AQA meeting was convened to review the activities of the AQA’s three workgroups (performance measurement, reporting, and data sharing and aggregation). Participants also discussed the formation of the new Quality Alliance Steering Committee, comprised of the AQA and the Hospital Quality Alliance. Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), chaired the meeting. Back to top Opening Remarks —Carolyn Clancy, AHRQ Carolyn Clancy opened the meeting by welcoming participants and noting that there were a record number of people (over 160 representing 100 stakeholders) in attendance. Clancy said that the increase was due in part to the fact that there were representatives present from the organizations involved in the pilot programs. Back to top Review of AQA Governance —John Tooker, American College of Physicians John Tooker provided an overview of the AQA. He stressed that the AQA employs a collaborative process that includes consumers, health insurance plans, physicians, purchasers, and other key stakeholders. He also reiterated that the quality improvement movement is voluntary, and that it involves a series of interlocking groups working together. Tooker briefly reviewed the AQA’s governance model, which he said has no formal structure and relies on the voluntary commitment and collaborative spirit of the multiple stakeholders. He noted that there have been at least three open meetings annually, and that the steering committee (made up of representatives from consumer groups, health insurance plans, physicians, and other participants) meets before every meeting and occasionally otherwise. Between meetings, each of the three workgroups meets regularly. The AQA uses a consensus process for getting work done, continued Tooker. At the same time, he emphasized that there was a balancing act between the need for urgency and the desire to take advantage of opportunities. On the latter subject, he pointed out that new challenges are constantly providing opportunities that the AQA needs to take advantage of in a timely manner. The AQA is really focused on implementation and adoption of measures in the field, said Tooker. As a result, there is a need to coordinate with organizations that are developing performance measures. Tooker added that the intent is to develop a robust series of measures for all areas—and then to  implement them in the field. In addition, he stressed that there needs to be an orderly process from development to implementation—and then the principles must be maintained. The principles must be workable in the field, stressed Tooker, and hence there are six pilot projects underway to  evaluate whether measures can be adopted in the field. Tooker also noted that it was clear that performance measures must be implemented in coordination with the work being done by the Hospital Quality Alliance (HQA). As a result, he said, an AQA/HQA Quality Alliance Steering Committee has been established in order to look at how to expand the pilot projects and how to establish a health quality network in the United States. Finally, Tooker took a minute to talk about the AQA’s communications philosophy. The AQA is a transparent process, he said, and all its meetings and agendas are posted on a public Web site. At the same time, because the AQA is not a formal entity the AQA Steering Committee has agreed that it is not appropriate for the AQA to provide formal public comment on its activities. Rather, the steering committee believes that it is more appropriate for individuals representing their own companies to do so. Following Tooker’s remarks, Carolyn Clancy reiterated that that the AQA process is highly transparent, and that the goal of the process is better health care. One participant said that she wanted the opportunity for all participants to at least listen in on workgroup activities, something that has not been done. Clancy responded that this was a very good point and promised that the AQA Steering Committee would discuss the matter. Kevin Weiss (who chairs the Workgroup on Performance Measurement) said the problem stemmed from the way the Cost-of-Care Subgroup had started. He and others learned from that process that it was important to bring more people into the room and into the conversation. There also was a question about the voting process. Clancy responded  that the AQA generally takes an up/down vote, although there have been times that an item has been sent back to a workgroup for further discussion. Finally, one participant expressed concern that the direction taken by a workgroup often depends on who is participating in any given conference call or meeting. He said that he was sometimes uncomfortable that the process was moving very fast without adequate representation from all parties. Back to top Report of the Performance Measurement Workgroup —Kevin Weiss, American College of Physicians Kevin Weiss opened his remarks with a comment about the workgroup’s process. He said that the workgroup tries to discuss a document or a concept until there is little left to discuss. As a result, when the workgroup votes on an item there are generally only a handful of abstentions (usually because of a conflict of interest, because a person did not have time to review the materials, or because a person was not comfortable speaking for his or her organization on the issue) and a handful of NO votes. He added that there are usually about 65-70 people on each call. Weiss thanked the members of his workgroup, and noted that they have accomplished much. These accomplishments include approval of the Ambulatory Care Starter Set (26 measures),  Cardiology and Cardiac Surgery measures,  and development and approval of a document on principles of efficiency measurement. In addition, he said the workgroup has held six cost-of-care physician education WebEx seminars and two meetings with specialty societies to review measure development activities. Next, Weiss outlined his workgroup’s meeting objectives: review and endorse the registry principles document review and endorse the Guide for the Selection of Performance Measures for Medical Subspecialty Care review and endorse the Surgery/Procedure Workgroup Mission and Principles review and endorse the quality metrics for dermatology, radiology/neurology, rheumatology/clinical endocrinology, ophthalmology, surgery, and orthopedic surgery review and endorse the CAHPS® Clinician and Group Survey, including composite measures review and endorse the candidate list of conditions for cost of care work review and discuss work in progress Finalizing Principles  and Guidance Documents Weiss started with Principles in the Use of Registries for Enhancing Quality of Care Through Performance Measurement. He noted that the document has been revised to clarify that the principles refer to registries that are created for the purpose of performance measurement. There was no discussion. Motion: To review and endorse the Principles in the Use of Registries for Enhancing Quality of Care through Performance Measurement. The motion was adopted. Next, Weiss turned to the Guide for the Selection of Performance Measures for Medical Subspecialty Care. The purpose of the document is to refine the general guidelines to reflect what should be included for subspecialty care.   A participant opened the discussion with a comment about adding language addressing the needs of consumers and purchasers. He also commented on guideline 4 (“Measures should consider the importance of good comprehensive care for a condition even if only one or two of the measures will ultimately be used for public reporting. The complete set will be useful for physician practice quality improvement efforts.”), saying that he believed language should be added that says the set “should be important and relevant to consumers and purchasers.” He also suggested adding language that says the “collection of measures should be feasible.” Weiss asked for the sense of the group about adding the proposed language to each of the proposed amendments. In each case, there was consensus on doing this (with only a few NO votes). One participant asked whether the amended phrases were redundant because  a broad, general principles document already exists. Another participant also referred to the broader principles document. Weiss said he would check the general principles document to see whether there was existing language to cover these points, and rework this document if necessary. A second participant noted that he did not really care if the language was redundant because it bears repeating that measures must be feasible and relevant to purchasers and consumers. One participant wondered whether the language in guideline 6 (“Measures of appropriateness of care should be utilized, whenever possible”) should be changed to say “whenever appropriate.” Another person said he was fine with the concept, but preferred to say “whenever relevant.” Another participant stressed that it is important to make sure from the outset to create measures that are relevant to consumers. In response, someone else suggested that the solution  is to identify for whom a measure is being developed. We need to create a roadmap for better health care, said one participant, and  the specialty society she represents has limited resources. She noted that if her organization has to prioritize between a measure that will make a big difference in quality of care for patients and a measure that will emphasize quality to the consumers, then it will opt in favor of the measure that physicians believe will improve quality of care. Carolyn Clancy said that the issue of capacity across all physician societies is one that the AQA Steering Committee has been discussing at length. She said that while there are clearly measures that physicians recognize as important to quality, it is important to recognize that what consumers understand is a fast-moving target. One participant stressed that involving consumer advocacy organizations in the process is very important. Another person suggested that the document under discussion and the AQA Surgery/Procedures Workgroup Mission and Principles should be harmonized. Referring to the latter document, he said that language should be added to principle 4 (“The measure must address one of the IOM’s six dimensions of quality care (safe, effective, patient-centered, timely, efficient, and equitable).”) to say that the measure “collectively should try to address all six elements.” Motion: To review and endorse the Guidelines for the Selection of Performance Measures for Medical Subspecialty Care, as amended [to address feasibility and relevance]. The motion was adopted. Next, a member of the workgroup discussed the Surgery/Procedure Workgroup Mission and Principles, and asked for discussion on whether to include language in principle 4 regarding “collectively try[ing] to address all six elements.” One participant noted that the overarching principles criteria include feasibility. Another person said that it is  important to acknowledge that there are two separate tracks that will need to be brought together at some point. A third person said that while the initial steps to provide measurement are useful, there is also pressure to produce measures that consumers and purchasers can use. He suggested that the health plans have expertise in this area and can help the AQA in this regard. The immediate concern is whether the measures being proposed are ones for which there is no way that  health plans can  collect the needed information (e.g., he said that it is not possible to capture whether or not someone receives an antibiotic after surgery). There has to be a way to move more quickly than we are moving with the current measure set, he concluded. One participant pointed to two critical elements that need to be considered: the feasibility (re. cost) of collecting and analyzing data, and the fact that the two tracks are not equally weighted and may or may not intersect. From a health care point of view, said the participant, we have to see what will be best for the consumer. He added that it was important to come to terms with an explicit bias in favor of consumers/patients, and improving health care for them. Another person noted that everything that comes before the AQA includes technical specifications, and said that he thought some of the concerns were, in fact, being addressed. We have given a lot of thought to implementation of these measures, said one participant. He said that there will have to be work done on the measures to add in a cost-of-care component, adding that there is a need to look at new Category Two codes. Another person said that it is necessary but not sufficient that codes be created and assigned to these measures. He also raised a related question: What is the path by which all physicians will use these codes, and how do we ensure that all payers will use them? This, he said, stands in the way of implementation. One participant stressed that health care is a vital part of the entire economy, affecting people and jobs. Business, he said, is looking to the AQA to bring forward a set of measures to drive efficiency and quality for purchasers and consumers of health care. Kevin Weiss noted that the proposed language says that the measure “collectively should try to address all six elements,” not that it must. We need to work to get where we want to be, he said, but, most importantly, we must keep moving as quickly as possible. Finally, a participant noted that some measures fully specify down to how to measure at an individual physician level with administrative data that we could use tomorrow, and some measures will be relatively feasible (and can be coded and reported). For others, however, it will take more time to get physicians to use other codes, and the path to implementation will be more difficult. Motion: To review and endorse the Surgery/Procedure Workgroup Mission and Principles. The motion was adopted. Proposed New Quality Measures for Adoption Kevin Weiss discussed new quality measures for: dermatology (from the American Academy of Dermatology/Physician Consortium for Performance Improvement) rheumatology/clinical endocrinology (from the American College of Rheumatology/ American Association of Clinical Endocrinology) radiology/neurology (from the American College of Radiology/American Academy of Neurology) ophthalmology (from the American Academy of Ophthalmology) perioperative surgery (from the American College of Surgeons, in collaboration with the Surgical Quality Alliance) orthopedic surgery (from the American Academy of Orthopaedic Surgeons) Weiss noted that some of the proposed measures are  very simple and others are far more complex. He said the differences reflected where different specialty societies are in terms of their ability to develop measures. The differences also reflect the recognition that there are some very real gaps in health care quality, he said. Weiss noted that while some of the measures are basic, they come from a sense that physicians are not getting something right and that this is unacceptable. He added that his workgroup had made it clear that basic measures are a good first step, but that they could not be a means of avoiding more difficult issues. The specialty societies understand this, he said. Dermatology A representative from the American Academy of Dermatology briefly outlined the three proposed measures for physicians caring for patients with a current diagnosis of melanoma or a history of cutaneous melanoma. This outline was followed by a discussion of whether or not the measures are too simple to be acceptable. One participant said he could not  support the first two measures (addressing patient history and the complete physical skin examination) because there should be a level of basic competency. He also argued that, from an equity point of view, there needs to be a level playing field regarding performance measurements. Another person, however, saw the matter differently. She said that it was tragic that the two measures were necessary, and it points  to the fact that the quality chasm is greater than the medical community has generally acknowledged. We must look at and close that chasm to get to better quality, she argued. She also urged participants to look at “always” events, and that having measures means that plans and networks can look at these and know they are being done. To presume these are being done is not fair to patients, she said. Another participant thanked the American Academy of Dermatology for bringing forward an issue of major concern and said there is an urgency to act. Another participant noted that it is important that the AQA see itself as improving the field of medicine and pushing the envelope. On the other hand, she said, she preferred to wait on approval until the American Academy of Dermatology can present a more comprehensive set of measures. One participant said that when the measures were first brought before the workgroup she thought they were too basic. However, she said, there is a documented gap in care, and we need to address it and improve patient care. She added that not all measures adopted have to be used for pay for performance; some, she said, may just reflect a basic level of care. A second participant echoed the previous comments, adding that she thought perhaps one solution is to label the measures as first phase, temporary, or provisional. This would signal that these are only a first step, she said, and send a message that this measure set is not commensurate with the other sets of measures that the AQA has endorsed. There also was discussion about the language “any physician,” and whether the measures are meant for dermatologists or physicians in general. The answer is dermatologists.  A question was raised about whether these measures have been coded (yes), and  about to whom they apply. The answer is that the measures apply to patients seen within a practice within a calendar year. Wrapping up the discussion, Weiss noted that the Performance Measurement Workgroup had held pretty much the same discussion. Ultimately, the workgroup voted with only one abstention to move the measures forward, he said, recognizing that they are very basic and that if we close this gap then we have done well for improving care. Motion: To approve the proposed dermatology measures. The motion was adopted. Weiss noted that he recognized that many voting YES were doing so on the understanding that these are very basic measures—and that the American Academy of Dermatology needs to move forward rapidly with additional measures. Rheumatology/Endocrinology   Next, Weiss turned to the measures for rheumatology/endocrinology. The five measures are  intended for physicians who are (1) treating patients aged 50 years and older with a hip, spine, or radial fracture or (2) managing the ongoing care of patients with a diagnosis of osteoporosis. There was no discussion. Motion: To approve proposed rheumatology measures 2-5. The motion was adopted. Neurology/Radiology Measures The neurology measures (1-6) are designed for any physician caring for patients with a diagnosis of stroke or transient ischemic attack in the hospital setting. The radiology measures (7-8) are designed for radiologists and other physicians reading the imaging studies of patients with a diagnosis of stroke or transient ischemic attack in the hospital setting. There was a question about coding.  The answer was that this has not happened yet but is in the works. Another participant noted that coding specifications were sent out during the public comment period. There was also a comment about the “any physician” language, seeking clarification that it refers to neurologists/radiologists and not to all physicians. Motion: To approve proposed neurology measures 1-6. The motion was adopted. Motion: To approve the proposed measurement set for radiologists (measures 7-8). The motion was adopted. Ophthalmology The eight measures proposed by the American Academy of Ophthalmology are intended for ophthalmologists caring for patients age 18 years and older with primary open-angle glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. Echoing the earlier comments on the dermatology standards, there was again a discussion about whether some of the measures are too basic. Like the earlier discussion, the comments revolved around whether the bar was set too low or whether it was important to address core competencies and documented gaps in care, no matter how basic. A couple of participants suggested that perhaps these measures should be labeled a starter set, and one participant summed up the discussion by noting that there is a large quantity  of data  suggesting that collecting data in and of itself improves performance. Thus even the most basic standards are important, he said, and he supports the proposed standards. In concluding  the discussion, Weiss proposed that a short synopsis of the discussion be placed on the AQA Web site along with  these measures in advance of a more formal AQA discussion on the matter. Motion: To approve the proposed measurement set for ophthalmology. The motion was adopted. Surgery (Perioperative) These measures  apply to physicians caring for patients undergoing a surgical procedure, as specified in each measure. There was a  suggestion to extend the use of prophylactic antibiotics to children.  The decision was no, because the use in children was quite different and needed a separate guideline. Motion: To approve the proposed starter set for surgery. The motion was adopted. Orthopedic Surgery The proposed measurement set applies to  all physicians treating patients age 50 years and older with a hip, spine or radial fracture or managing the ongoing care of patients diagnosed with osteoporosis. Motion: To approve orthopedic surgery measures 1 and 5. The motion was adopted. CAHPS® Clinical and Group Survey Next, Weiss discussed the proposed CAHPS® Clinical and Group Survey. He noted that the first step was to approve the measure as a whole. The next step, he said, was to figure out how to translate the items into composite measures. There was a question about the status of the assessment tool in the National Quality Forum (NQF). Weiss replied that a final recommendation from the NQF Steering Committee was due  the following  week, after which the measure would be put out for public comment. There was also a question from a participant about how  the CAHPS® Clinical and Group Survey was being presented to this forum. Was it being presented as a consumer, experience-of-care transparency tool?  In response, Weiss noted that it was meant for implementation in consumer and physician reporting environments. Motion: To adopt the CAHPS ambulatory composite measures that can be used with the survey. The measures were adopted. Cost of Care Measurement Turning to the candidate list of 20 conditions as a starter set for cost of care measures work, Weiss started with a brief review of the process to date. He noted that much of the urgency on quality has come from the recognition that there is not always an efficient use of care. Thus, he said, the AQA came to the conclusion that it has to look at both efficiency measures and cost of care measures. The Cost of Care Workgroup has looked at (1) drilling down a framework on cost of care measures and (2) looking for actionable moments in the physician community to address cost of care. Referring to the 20-member candidate list of conditions, Weiss said that 20 was not a magical number, but rather that the subgroup drew a line at a point where at least half of the people participating felt that these items were of the highest priority. Weiss stressed that the conditions are not measures. Rather, he said, they are conditions and procedures for which AQA will try to press for application to measure development. Weiss added that in compiling the list the subgroup looked at whether this set of procedures reflects both the human lifespan and a broad range of  physical issues . Opening the discussion, one participant expressed concern that the AQA was biting off too much at once and would be better off with a smaller group of conditions that could be moved forward more quickly. He also expressed concern that some conditions had practice guidelines of varying qualities. A second participant expressed concern about number 19 (spine: lumbar), suggesting that it is too broad. One participant said that he was concerned about where the discussion was headed. He noted that the real goal is to find the true cost of care drivers, and noted that it does not necessarily have anything to do with the efficiency with which one person manages an episode. Instead, it is about the number of episodes. Another participant expressed concern that several of the conditions and procedures on the list (including gastroesophageal reflux disease, hip fracture, and sinusitis) did not have a quality measure that has been approved by NQF, AQA, or any other organization. She urged that they be removed from the list until quality measures have been approved. One person said he was concerned about having a patient-centered denominator rather than a physician-centered one (i.e., cost of care per patient rather than per practice). In response, Weiss said that addressing this question is an essential next step. One participant expressed concern that the Cost of Care Workgroup was very small and not broadly open to stakeholders. She urged the AQA to table the discussion until there was more discussion (and a broader discussion) at the workgroup level. On a separate issue, the same participant said that the list was ambitious and could lead to a significant amount of work. It should be narrowed down to areas where there are already robust quality measures in place, she said. Another participant suggested adding a section that lists specialty cost of care (e.g., dermatology cost of care), endorses some type of episode grouping (to get at continuum of care issues), and addresses unit grouping. Yet another participant said that dealing with the needs of patients may involve higher costs in certain populations or at various points in order to lower the overall costs to the system. So what is the measurement? The cost to the system of a diabetic patient? The cost of the entire system? He added that it is important to address the needs of the uninsured. Finally  a participant, also citing the high percentage of uninsured Americans, said that tabling the measure was not an option. Motion: To approve the Cost of Care Proposed Starter Set of Conditions and Procedures. While the motion of the cost of care starter set was adopted, there was some dissention on the number of conditions that should be included.  Weiss emphasized that the issues brought up would be addressed by the Performance Measurement Workgroup. Next, Weiss addressed the Cost of Care Measurement Discussion Paper. He noted that the paper merely offered a cost of care framework, and said the draft document will need to come back as a formal document. He asked whether people would be comfortable in moving the draft document forward. Motion: To approve the Performance Measurement Workgroup Cost of Care Measurement Discussion Paper as a draft working document. The motion was adopted. Work in Progress Weiss noted that ad hoc workgroups in the areas of Test Measures, Individual v. Physician Group Analysis, and Appropriateness Criteria were being established. Wrapping up the discussion, Weiss noted that the Workgroup on Performance Measurement has much left to do. The agenda moving forward, he said, includes continuing to review measures submitted by medical and surgical specialty groups, defining and developing principles for test measures, and establishing a subgroup on special populations. Back to top Report of the Reporting Workgroup —Randy Johnson, Motorola Randy Johnson very briefly discussed next steps for reporting principles. He noted that the principles developed by his workgroup are guidelines for reporting, and that the guidelines would be tested through the pilot programs. He also expressed his personal concern that while the pilot projects are very important, the process is moving too slowly to meet the immediate needs of many employers and purchasers. We need to move faster, he said, because we are delaying opportunities. Back to top Report of the Data Sharing and Aggregation Workgroup —Steven Waldren, American Academy of Family Physicians Steven Waldren opened his remarks by outlining the workgroup’s goals for the AQA meeting: review and endorse the Characteristics of the National Health Data Stewardship Entity document review the work of the HIT Subcommittee receive an update on the status of the pilot projects National Health Data Stewardship Entity Waldren said that in carrying out its information-gathering and decision-making processes, the National Health Data Stewardship Entity should possess 10 characteristics (based in part on the characteristics of the Securities and Exchange Commission’s Financial Accounting Standards Board). The characteristics are: Objective—to be objective in its decision making and have the ability to preclude placing any particular interest above the interests of many Independent—to have a governing structure that is independent of all other business and professional organizations Knowledgeable—to demonstrate knowledge and expertise in the areas of health care delivery, data management, and security or acceptable proxy for this Responsive—to insure input and use from key experts who possess knowledge of health care quality assessment, health data transmission, IT standards, physician and hospital systems design, and who have a concern for the public interest in matters of health care quality analysis, reporting, and patient privacy. The entity should also represent key stakeholder groups that are measured and users of this information. Trustworthy—to be recognized as a trustworthy organization by multiple stakeholder groups Adaptable—to be flexible enough to address issues and key stakeholder needs as the market evolves Transparent—to have an existing stable infrastructure for consensus decision making that is transparent and involves the broad stakeholder communities Timely—to have the ability to carry out activities and achieve goals in a timely manner Collaborative—to have the ability to engage and work with other organizations to ensure effective implementation of rules and standards Sustainable—to have adequate resources to meet long-term and short-term goals A participant opened the discussion with a question about the item on sustainability. Who will pay for the National Health Data Stewardship Entity? In response, Waldren said that the workgroup has started to look at this issue. He added that the workgroup has already held some informal interviews with selected entities to see if they exemplified all or most of the 10 key characteristics. Based on those preliminary discussions, Waldren said, the workgroup has decided to use either a RFI or RFP process to help gather the necessary information about funding and contract requirements. Carolyn Clancy added that the AQA has benefited from the fact that the Hospital Quality Alliance has hired a consultant to do some work on this topic. Clancy also noted that she thought the funding would ultimately come from a mix of public and private sources (although she also acknowledged that there has not yet been any real discussion of this). A second participant asked whether the National Health Data Stewardship Entity has the endorsement of the Centers for Medicare and Medicaid Services (CMS) and whether CMS data would be included. In response, a participant from CMS said that his agency was committed to contributing Medicare data. This is a public good, and CMS realizes that there must be a substantial public contribution. He also indicated that his agency was in the process of implementing an updated data system that would enable the agency to better collect and aggregate its data. Waldren joined the discussion, stressing that the National Health Data Stewardship Entity would not itself handle aggregation. Rather, he said, others would aggregate data under the entity’s rules and standards. Another participant asked if the entity will be the repository for aggregating measures. . In response, Waldren indicated that he was not aware that this had yet been discussed by the workgroup. Motion: To adopt the Characteristics of the National Health Data Stewardship Entity document. The motion was adopted. Health Information Technology Subcommittee Report Turning to the work of the Health Information Technology (HIT) Subcommittee, Waldren noted that there were two items on the agenda: the glossary of terms defining administrative data Regarding the glossary of terms, he noted that the HIT Subcommittee would continue to define and expand the glossary. Regarding administrative data, Waldren noted that there was much discussion within the HIT Subcommittee around the term administrative data as opposed to clinical data. In order to clarify the term administrative data, he said, the subcommittee decided that it was necessary to determine what data elements are being referred to and how these data flow from the point of care through the various steps of entry, collection, transmission, storage, and reporting (e.g. data entry, manual or directly electronically, transmission, and so forth). Waldren said that the subcommittee agreed that a separate task force should be created to further refine the data elements and the data flow dimension. That work, he said, is ongoing. This work is much needed and long overdue, commented one participant. He urged his colleagues to look at electronic versus mechanical data flow, as well as data sources (where data comes from—whether from a physician record or the health plan side). Pilot Projects Update Before turning to the status of the AQA pilot projects, Carolyn Clancy noted that the American Health Information Community has established a quality subgroup.  The AQA's specific charge in the short run is to identify barriers to electronic health records, she said, and member participation would be welcome.  Additional information can be found at http://www.hhs.gov/healthit/ahic/quality_main.html or by contacting Carolyn Clancy. Clancy then provided a high-level update on the AQA pilot projects. The program is continuing its progress toward the goals of meaningful performance measurement and effective public reporting, she said. Clancy noted that the central premise of the pilots is to use the starter set of AQA measures and to begin  reporting on these publicly in early 2007. She said that the pilot sites would pool both public and private data. Next Steps Finally, Waldren outlined the Data Sharing and Aggregation Workgroup’s goals for 2007: determine, through a formal application process, which entity will serve as the National Health Data Stewardship Entity work to clarify the elements of administrative data, and to develop clear terminology useful to the AQA and the pilot projects test the health information technology principles at the selected pilot sites monitor the progress of the AQA pilot projects as data collection and aggregation continue Back to top Report on the Formation and Workplan of the Quality Alliance Steering Committee —Carolyn Clancy, AHRQ —Peter Lee, Pacific Business Group on Health —Janet Corrigan, National Quality Forum Carolyn Clancy discussed the formation of the Quality Alliance Steering Committee, noting that both the AQA and the Hospital Quality Alliance (HQA) have been working to ensure that Americans will have useful information on health care available through the Internet. She said that the new Quality Alliance Steering Committee, announced on July 21, will work closely with both CMS and AHRQ. She indicated that the committee’s first task will be to coordinate and expand the existing pilot projects. Doing so will combine both public and private information to measure and report on performance in a way that is fully transparent and meaningful to all stakeholders.  All information about the specific activities of the Quality Alliance Steering Committee can be found at www.aqaallliance.org. Clancy noted that there were a number of questions that needed to be addressed, including how to get to better quality and meaningful reporting and who will pay for it. The Quality Alliance Steering Committee held its first meeting on August 4. As a result of that initial meeting, Clancy reported, five workgroups are being established that will help focus attention on particular efforts that are needed to accomplish the goals set forth by the committee. The five workgroups are Pilot Expansion Workgroup—The  objective of this workgroup is to focus on expanding the number and scope of AQA pilot sites. The workgroup is charged with developing a plan for expansion that includes both ambulatory and hospital care along with the ability to assess quality across episodes of care. The group also will develop criteria that will be used for selection and prioritization of additional sites for pilot expansion. Measure Harmonization Workgroup—The  objective of this workgroup is to focus on identifying measures where measure specifications are different and thereby develop a plan to reconcile measurement specifications/definitions across ambulatory and hospital settings. The plan should include methods/processes for ongoing harmonization of measures across settings as well as a way to refresh the measures and retire them. Pilot Infrastructure Workgroup—The objective  of this workgroup is to focus on identifying ways to provide infrastructure support to the pilot sites. This workgroup may investigate existing avenues, such as the Quality Improvement Organizations, contractors, and local support that could sustain the pilot sites. In addition, the workgroup is charged with developing a plan to track and provide ongoing evaluation of the pilot sites. This plan will include data collection and aggregation. Efficiency/Episodes of Care Workgroup (just getting off the ground)—The objective  of this workgroup is to focus on developing a comprehensive approach to efficiency that will include examination of the overall system as well as of group and individual physicians. In order to penetrate  the issue of efficiency, episodes of care need to be evaluated. The workgroup will develop a plan to evaluate episodes of care and efficiency of services as well as primary responsibilities for the care provided (i.e., system, physician, or jointly between physician and system). Cost-Pricing Transparency Workgroup (also just getting off the ground)—The objective  of this workgroup is to focus on the costs of care and reporting the costs/price of care to the public. The workgroup will investigate the issues surrounding reporting costs/pricing to consumers and develop a plan to implement reporting in these areas. Report of the Pilot Expansion Workgroup Peter Lee, who chairs the Pilot Expansion Workgroup, said the workgroup looked at four very large issues: the need to balance innovation with standardization and consistency funding (What is the ongoing mode of funding the infrastructure?) how to migrate quickly to electronic data collection the collection function of these pilots (Should collection ultimately be national or local?) Lee noted that his workgroup had looked at three different collection models (decentralized, centralized, hybrid), each based on the assumption that there would be a blending of Medicare, commercial, and other data. He noted that the cost of doing something nationally was lower than the cost of collecting data in multiple communities. At the same time, he said, there are benefits from a local-level model (including fostering innovation). Lee reported that the workgroup concluded that the best option was a hybrid model that would include a national collection mechanism for core consensus measures supplemented by both local and additional national measurements. There are implications for better quality information for Medicare beneficiaries, said Lee. He stressed that the six AQA pilot sites have a central role to play in assessing how best to manage national collection and address supplementary efforts. Lee highlighted several uses for the value exchanges: public/consumer reporting (with cost information) rewarding and fostering better performance supporting improvement directly by providers In order to achieve these goals, Lee continued, we need to foster collaboration across multiple stakeholders and use interoperative health information technologies for measurement as appropriate. Lee concluded that it was also important to evaluate these efforts. Following Lee’s remarks, one participant said that his workgroup had provided a roadmap for addressing the challenges of (1) pilot projects that do not have the technical skills to aggregate data and (2) the need to have uniformity regarding aggregation. She then asked for his thoughts on next steps for moving the process along. What is the critical path? she asked. How do we get where we are going? In response, Lee said that while his workgroup had not yet charted a timeline, clearly a roadmap was needed that sets out what will happen in 2007, 2008, 2009, and beyond. Carolyn Clancy added that the Robert Wood Johnson Foundation has funded four communities that resemble the AQA pilots, and is about to fund up to six more. She indicated that AHRQ has had discussions with the Foundation about how to align AQA and Foundation efforts. Report of the Measure Harmonization Workgroup Janet Corrigan, who chairs the Measure Harmonization Workgroup, noted that there were a number of measures in need of harmonization. As an example hospital-level measures often look at a particular aspect of care, and this might be specified very differently at the physician level. She also noted that there were many measures from specialty societies (e.g., smoking cessation) that vary by disease entity. The workgroup's goal, said Corrigan, is to make measures valid across settings (and to roll up and roll down). The workgroup  also intends to review physician and hospital measures in use and under development, and align them where needed. She noted that there are also some measures that will need to be harmonized eventually, and that the workgroup is setting out a timeframe for accomplishing this. Corrigan said that the workgroup also intends to address overarching harmonization issues. She noted that it is much easier to harmonize a measure during development than after it has been developed and implemented. For example, she said, there are currently no conventions on upper and lower age limits or standard age bands. Corrigan stressed that her workgroup is open to anyone who would like to join, and that she is hoping for the extensive involvement of major measure developers. To organize its activities, the workgroup has formed eight Focused Review Teams (depression, coronary artery disease, prevention, asthma, smoking cessation, cardiac surgery and surgical care improvement/ perioperative care, acute myocardial infarction and heart failure, and venous thromboembolism). The workgroup also is making plans to address other areas in the next couple of years. We want to harmonize where possible, said Corrigan, and see what other options are available (e.g., to get changes in measures) where harmonization is not possible. She stressed that one reason harmonization is important is that standardizing certain processes is essential for developing electronic health records. Finally, Corrigan indicated that the workgroup hopes to wrap up most of its work by the end of this calendar year. Following Corrigan’s remarks, one participant asked whether her workgroup was looking at harmonizing measures across the physician/hospital domain or describing a harmonization for measures within each domain. Corrigan replied that the workgroup is looking at both. The participant then asked  what the relationship is between harmonization within the physician measurements and what the AQA is doing. Can the participant  envision a decision tree where the measures are harmonized and delivered to the AQA’s Workgroup on Performance Measurement? He expressed concern that, rather than streamlining measure development and approval, more processes were being set up. Corrigan replied that her workgroup was trying to coordinate across the specialty groups to make sure that measures are harmonized. Many of these measures have already moved through the AQA, are before the National Quality Forum, or have already been endorsed, she said. It depends on where the measures are in the process. The current process involves putting out brushfires, Corrigan continued. To the extent that we can get measures consistent it will make it much easier to incorporate electronic health records and get to quality improvement. Our work will not slow down the process, she pledged. We are only trying to make midcourse corrections and improvements where we can. A different participant raised the issue of having the Measure Harmonization Workgroup review the multiple Web sites that are recording measures. Their specifications are different, he said, and it is often not clear where a measure is in the process (and, if endorsed, by whom). Irrespective of harmonization efforts, he said, we need these Web sites to speak the same language. Corrigan agreed, and added that she would like to see one consolidator for every measure, and to have that site also catalogue and maintain  an audit trail that shows every change that has been made to a measure over time. This is not, however, an inexpensive process, she cautioned. One participant cited the perioperative measures and said that there are differences between what has come out of the hospital level and the physician level. It is important that we do not lose key components of either, she said. In response, Corrigan explained that when a measure needs to be harmonized, the focus review team will come up with what it thinks are the appropriate solutions. At that point, the review team will go back to the developers and ask if they will agree that harmonization is needed and that the proposed  solution makes sense. She added that this overall process will take a number of years so that people will have to live for now with some discordant measures. It is not a perfect world, said Corrigan, but it is better than the one we are in. Another participant commented that even when there are harmonized measures ready to be implemented (i.e., in a pilot project), that process cannot take place until a whole set of additional specifications that deal with implementation of that measure in that particular setting are developed. She cited, as examples, sample size and how to attribute a measure to a given physician or practice. One participant asked about the Efficiency/Episodes of Care Workgroup. Will harmonization tackle efficiency as well? Corrigan noted that when the conversation moves to episodes of care, the lack of harmonization across measures is increasingly apparent. She added that it would be helpful to start to work on this sooner rather than later in the development process in order to create a framework around episodes of care. We realize we have to live with a lack of harmony in some areas, said Corrigan, but we want to develop a solid timetable to address these issues. She added that the ideal time to catch and address these problems is when measures are under consideration or in the early stages of development. Regarding  the problem of actually measuring the measures, one participant remarked that for many today there is no way to do it. He noted that there are no specifications to harmonize and no data yet to aggregate. He stressed the need to capture data faster and better. Back to top Final Remarks Closing up the meeting, Carolyn Clancy thanked everyone for participating and reiterated that the AQA has accomplished much over the past two years. At the same time, she said, there is a lot left to do, including addressing issues of competence, cost of care, and harmonization. This is not easy stuff, she said, but the alternative is to allow someone else to write the script for us. The next AQA meeting is scheduled for January 22, 2007, at the Capital Hilton. Back to top

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