[This Transcript is Unedited]
National Center for Health Statistics
3311 Toledo Road, Auditorium A
Hyattsville, MD 20782
DR. MIDDLETON: Good morning. My name is Blackford Middleton. This is the National Committee on Vital and Health Statistics Subcommittee on Quality Hearing, second day, October 19, and we have Panel IV speakers ready and willing to go but before we start off please let's just go around the table and around the phone and learn who is with us. Please announce yourself and describe your role and whether or not you have any conflicts.
I am Blackford Middleton. I am Co-Chair of the Quality Committee and a member of the full Committee and I have no conflicts.
DR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the full Committee and Co-Chair of the Quality Subcommittee and no conflicts.
(Introductions around room)
DR. MIDDLETON: And do we have any attendees on the phone this morning?
DR. MILSTEIN: Yes, Arne Milstein, Medical Director, Pacific Business Group on Health and Professor of Medicine, Stanford University. I am one of the panelists.
DR. MIDDLETON: Good morning, Arne. Welcome.
DR. ROSKI: This is Joachim Roski from the Brookings Institution, no conflict.
DR. MIDDLETON: Good morning. Welcome. If there are no others, well actually one more just in time for introduction.
DR. GREEN: Larry Green, member of the Committee, member of the Subcommittee, no conflicts.
DR. MIDDLETON: Why don't we go ahead and jump in. Yesterday we had three terrific panel presentations addressing various dimensions of the roadmap for quality measures over the next three to five year timeframe looking at it from the consumer perspective, the provider perspective, professional organizations and accrediting organizations addressing the question of what information and measures do those various stakeholders need to measure quality and value in the years to come.
This morning we will be asking payers and group purchasers and other thought leaders to address the question what information do payers and group purchasers need to measure the value of health care and use it for decisions about coverage. A terrific panel has been lined up with David Stumpf, Barry Bershow, Arne Milstein and Dr. Roski and Dr. Bershow, you are leading off. Thank you.
DR. BERSHOW: Very good, thank you for having me here. When I mentioned I have no conflicts that actually makes my wife sad that I do not have all of these extra sources of revenue. I am as you will see on the slide, Chair of the Board Minnesota Community Measurement but that is a not for profit and that position is unpaid.
Lake Wobegon, we are going to have a little bit of apparently MAC/PC dysfunction. There was a picture of Lake Wobegon on my submitted slides. But in Minnesota those who are MPR devotees know it is the town in central Minnesota where all of the women are strong; all of the men are good looking; and all of the children are above average. In health care we have always had the same sort of thinking where all of our female patients are sicker than average; all our male patients are noncompliant and despite that myself and all of my colleagues deliver above average care. It was not until Minnesota Community Measurement came along that we were able to pretty much bust that myth and show people how things were really happening.
This is screen shot from our current website with the breakdown of just some of the things you can look up: depression; diabetes; vascular disease. We have quite a few others but across the top notice that you can also find out about medical groups as a whole. For example, our large integrated system at Fairview where we own 40 clinics but you can also look and drill down and get information on each and every one of our individual clinics which is of course much more useful to the patients and a little bit more on that later.
We are a cooperative, collaborative body that includes employers, state government, provider groups, hospitals, health plans, consumers, QI organizations, all working very collaboratively. I put this partial list on just to give people a flavor of the diversity on the board and also on our reporting committee. The name you cannot see up there probably on your slides is from 3M. We have representatives from the Mayo Clinic, Public Health Consultants, individual health plan representatives, union representatives; Terry Cahill is a doc in a small rural practice in Minnesota, the VP of HR at the U of M, a large university, and the head of our Medicare QIO from Stratis Health. We have the Director of Insurance from the state handling both Medicaid and state employees and then representatives from the MMA, the Minnesota Hospital Association and the Minnesota Council of Health Plans. Again, that is just a partial list. You probably wonder how we get anything done and we recently had a retreat and the facilitator wondered how we were going to get anything done either with this size board but we impressed her quite a bit.
Because of the diversity and the collaborative nature of our organization that same data can be used for quality improvement, for peer group rankings, for pay for performance and this is now both external and internal so in our own organization we are already lining the four sites with a major shift in our compensation redesign where we are no longer paying people for volume but instead for quality. This year 40 percent of their pay will be based on quality rankings that tie back to what Minnesota Community Measurement is reporting and what we are doing internally.
DR. TANG: When you say they, who is the they? Who are you paying that is going to be?
DR. BERSHOW: I am sorry; Fairview Health Services is paying their employee physicians, which is in the four to five hundred range. We seem to be growing every time I look back at them. So it has reduced data collection burden for the groups doing the reporting and I will talk about that in a second whether it is the health plans coming in and doing the traditional HEDIS audit types for some of the measures or the direct data submission coming out of the group. We also avoid a lot of confusion for consumers. Before Community Measurement came along, there was one year when Fairview was ranked highest in the state by one health plan in vascular disease and lowest in the state in vascular disease by another health plan. It drives us crazy and certainly was not helpful to anyone trying to make a decision about where to go for medical care.
The direct data submission is the process where we are mining our own data. Most of us in Minnesota do have electronic medical records but we have a number of clinics who are on paper and who audit a sample of their charts and report and actually do quite well. So it does not have to be just an EMR. But the data, because of that self reporting, is granular down to the clinic level instead of having to be grouped just by the medical system or the tax identification number and it is clinical rather than administrative which I think everybody here agrees is far superior. I will I think an interesting anecdote on that in just a couple of moments as well.
So what does it look like when we do this? Well it looks pretty ugly actually despite the fact that we are pretty sure Minnesota is among the best in the country in quality. When you look at clinic to clinic variation, it is really quite extreme. Here you will see the x-axis, the second column in. That is just the diabetes blood pressure test. That was just whether that doctor took a blood pressure on the diabetic when they came into the office on their last visit. So this is not being able to keep them in control. It is not an issue being able to forward your medications or compliance in taking them. It is just did you even do what was necessary absolutely to take care of a diabetic. So you will see way over on the far right on the graph, the blood pressure under 130 over 80. The worst clinic in the state is in single digits. The best clinic in the state is somewhere around 60 percent but if you just look at how often they took the blood pressure test and then the next x-axis over did they even get an LDL test forgetting about whether it was in control. It was interesting to me that twice as many people got an LDL test rather than took a blood pressure when we get a much bigger bang for the back for controlling blood pressure in diabetics than controlling their lipid level.
I stole this slide from one of the health plans that was presenting at a conference I was at. I stole it because I noticed coincidentally my name was at the top as one of these reports. So what happens if we do not report ourselves by grabbing a hold of the reigns and working in a collaborative nature? Other people report on us. These are just some of the reports that are available. Now if everyone will be honest and not look at their handouts for a second and just stare at the screen, this I gave a talk in Cincinnati and the night before the talk I plugged in some of the docs I knew were going to be at the conference to see if I could get some ratings and I found this new pharma-stat site. I had never heard of that before so I put my own name in to see what was happening and you will see the rating categories of knowledge, helpfulness, punctuality and staff. Does anyone who has not read ahead know what I have covered up as the fifth rating category? Cost? No. It is hot or attractiveness. This is the honest to God website and this is a screen shot right from it. I did not make this up. I am sad to report I have no stars across any of those but I like to think that no one had rated me yet rather than no one thought I was hot.
DR. MIDDLETON: Just send a link to your friends.
DR. BERSHOW: So the question posed to our panel is what information do payers and group purchasers need to measure the value of health care and use it for decisions about coverage. Well people always argue about what value is. A lot of people think it is quality plus patient experience over cost. Whatever it is, it certainly has to include all three elements of the triple aim. So we have to have info on the quality of care, the cost of care and the patient experience in receiving that care. One thing we do not do well in Minnesota but what I encourage people to look into is getting data across the entire spectrum so that patients and employers can look at health plans and their service and their quality because that is actually the first big thing that people do often upstream of when they need to access and so it would be useful. It is too late once you are in the middle of the year and you discover you signed up for the wrong health plan and it cannot be about structure or process. It really needs to be about outcomes.
Long term outcomes? We are going to need more time to see are the things we are doing really saving the heart attacks and strokes and other chronic illnesses but at least we can use proxy outcomes now. Blood pressure is according to protocols and LDL is according to protocols. Admin data is especially horrific.
In Minnesota we have something called the diamond project. It is a depression treatment plan. The health plans pay the clinics a PMPM to take care of the depressed patients with a psychiatrist on hire, available for consult keeping the patient right in the primary care office and having a care coordinator to reach out to the patients frequently. There is some aggressive medication titration protocols. I would guess 90 percent of the patients enrolled in this program are on an anti-depressant. At ICSI, the Institute for Clinical System Improvement, we were auditing what was happening with this project and so I have screen shots from what three health plans sent us. This is health plan number one. The important number is in the lower right hand corner. The percentage of patients with anti-depressant scrip's: 89 percent at one of the three biggest health plans in the state; 70 percent at another, so probably statistically significant or at least within the believable range; and the third system, 19 percent just really not credible. If you give this kind of number to physicians and ask them to act on it let alone peer group them or base their pay or their quality rankings on numbers like this, it is no wonder they have not bought in and are fighting back.
This slide actually made up because the question was what information do payers and group purchasers need and I am a physician and I was doing a bike ride with somebody from Bridges to Excellence Minnesota who represents large employers and she said, why did they as you to tell what payers and group purchasers need. Why didn't they as us? So then she thought about it for a second and she said well at least they know you are reading from the same hymn book that we are. What she said and so I included it is that for large employers with coverage needed in multiple states, or for patients interested in domestic medical tourism national measures would be best but we do not have to have national measures if we have to settle for the lowest common denominator in some regions. So one of the health plans in Minnesota recently came out with a rating system where the end could be as low as five on your quality and they said this what the national employers are asking for and what they are getting in other states so that is what we have to do. The lowest common denominator to me is really painful and I think it is work avoidance to say that it is too hard to collect the data or unfair for those with harder patients is the other thing that you will often see lowest common denominator being set at for reporting.
So in Minnesota, this was in 2006 but the variation continues, this is a composite diabetes score; highest clinic in the state this year was Oxborough at about 36 percent. They did not make the x-axis too long on this slide. There were a lot of zeros out at the end. Not one patient in their entire clinic hit on all five diabetes measures on the composite. So knowing how hard that is, this slide is for those who say you cannot get the poor or ethnic minorities or others to do well. We have got to set lower thresholds for those clinics that take care of them. If you are on the slide, it is if you are on the handout you cannot see the pink but is the one that in 2006 was at 605. So if you look over in 2005, they were at 0.54 percent so one of 200 of their patients hit on all five diabetes measures. Sadly they were not even the worst in the state. As I just showed you there were some zeros. But if you follow them along just two years later, they were over eighteen percent. They were actually the second best system in the state and this is a network of community based clinics where half of their patients are on Medicaid, half are uninsured, most of them do not have English as a first language. So it is really possible once you set your sights and really get down to the work and avoid work avoidance to do a good job with these minorities.
The other reason you will see lowest common denominator is associations represent all of their members and sometimes want to protect the lower performing members so they will continue to pay dues. So we have a saying here in Minnesota, aim high and you will wind up in high places. That is true both for the actual performance on the measures of the clinics so when we set our internal pay for performance at Fairview, we set some pretty aggressive thresholds but also here I am talking about just making sure the measures that we are publishing are of high quality because otherwise if you aim low you are going to be disappointed even if you get what you set out to accomplish.
I would like for people to stop saying we can't do that because we have been doing it in Minnesota since 2004 and our task on this Committee as I understand is what do we need to do over the medium term: three to five years. That is actually just about perfect for replicating what we did in Minnesota. That is about how long it took us to get it right and to get buy in from providers. You have to set up the infrastructure. You have to do a year of reporting that is blinded so everyone can kind of see what their numbers look like and set about trying to improve them. Then you have to tweak them and do a lot of cultural selling. But within five years no one sneers at community measurement anymore and they would much rather be reported there than on Angie's List.
So what information do we need? It needs to be at the clinic level for primary care because we believe chronic disease is a team based sport and you need to keep your N's high but probably doctor specific for the procedural specialties. If the N is not high enough for them, I think that in itself, is telling.
Waste and appropriateness are important as well so not just reporting on what we are doing and how well we are doing it but whether we are even doing it when we shouldn't be. No use touting a surgeon's success in stenting if the procedure is not called for in the first place. I think most people in the room know evidence pretty shoddy to none existent that stenting will prevent heart attacks that loses its advantages over medical therapy quite quickly for angina. So in Minnesota we are getting ready to put out our first report on the frequency of high tech diagnostic imaging studies which are appropriate based on ACR and ECC guidelines. And then it has got to be timely so useful to both consumers for having the latest information. It is no use having two year old information which is a lot of what is out there and also for providers to understand what is possible to achieve so that they know what they are peers are doing currently which brings me to Barry's dolphin rule.
I am always flabbergasted when I speak to groups and find no one in the audience knows how you teach a dolphin how to jump through a flaming hoop. Very quickly you throw the hoop on the bottom on the pool. When he swims by it accidentally you throw him a herring. Then you make the hoop vertical. Then he accidentally has to swim through it. You throw him a herring; half out of the water, same thing. All of the way out of the water he learns to jump through to get his herring. You light it on fire and you are there. Well how effective do you think it would if you threw him a herring twelve months after he first swam through the hoop and really of course he would never, never do it. When we are working on old data and when we are not getting rapid feedback it is very difficult to improve.
So that last point on the bottom of this slide with all of the others is it has got to be credible. Thinking back to that admin data story I told, it has got to be transparent. The providers have to have faith in how it is collected. It has to be evidence based and it has to be nimble in its ability to keep up with advancing science. So we want to not have the state legislature or Congress pass rules that saying it has got to be this because then when the guidelines change it is too hard to move. So in Minnesota we have been able to adjust as the ACORD study and later the advance study came out and some others so it has been evolving.
So thank you very much. I am not sure if we have time for questions now or later.
DR. MIDDLETON: What we would like to do is take a little time now for questions and there probably will be time at the end as well. Paul?
DR. TANG: Thank you, Barry. Appreciate it very much. I think we share a lot of the same concerns about administrative data and the benefits, almost the quote free benefits of credible clinical quality measures because everybody wants to improve when they believe in the measure.
One of the things you also mentioned was the, you talked about the associations having certain biases in terms of some of the measures they bring forward to get approved or endorsed. The dichotomy, we ask this question, or I asked this question yesterday. I think you were here and I want to give you an opportunity to answer it: the dichotomy between measures that we use for internal quality improvement and those that are separately designed for public reporting. Sometimes you just in what you said, in the publicly reported often times it is designed to be a race to the bottom. In other words you want to protect everybody and the consumer, even probably yesterday let off saying you know consumers do not have any value and everybody is 90 percent. It just doesn't help anybody. On the other hand in the quality improvement activities normally people just rise to the top. Is there a difference in the measure? Well, there are differences in the way measures are constructed and defined. What is your opinion in terms of should there be differences and what measures are you used for one purpose or another?
DR. BERSHOW: Well it is more I think the speed that you can get the information back to yourself and then act on it. We use in my organization the same measures that are reported publicly so that we have some peer group references. When we first put our pay for performance in place at Fairview and at that time it was much tinier. It was ten percent potential bonus on top of an RVU based system which has now gone away. We only said get to ten percent because we were in the low single digits and we thought ten percent seemed like a reasonable hurdle given where the state was. We would have thought we were asking for their first born child. We can't do it and we can't make our patients come in. We can't make them take the medications but in the end when they stopped whining and we didn't back down, they actually finished that year at fourteen percent. So it probably would not have been reassuring to patients to see that number but we did not care in a way. We went out and published our bad results on the Fairview internet page: not internally, even before Minnesota Community Measurement was publishing because we thought from an ethical standpoint as health care providers we always want to know who is the best doc, who do I go for an orthopedic procedure. Who is the best cardiologist? Why wouldn't we want our patients to also have that privilege? Why should we have a special privilege that they don't have? So that was our ethic.
The next year we, after they finished at 14 and a half, we said okay, we will get to fifteen. More whining, more whining. We can't do it. We can't do it. They finished that year at twenty-two. So when you actually get out and publicly report what you are doing I think it helps boost that quality improvement because otherwise people are more slow to take it up and we are going to take the fairly brave step we think this January of posting quality cost of care and patient satisfaction scores in all our reception rooms so that patients can look at them while they are waiting for the doc. The docs are starting to come up with some talking points on why the numbers are not higher, but we think it is the right thing to do.
DR. TANG: So you commented on the use of quality measure reports in changing the culture but what about the definition of the measure itself. So for example, the quote a publicly reported diabetes measure is the percent of diabetics whose A1C is greater than nine percent. That is not very helpful to someone trying to improve score. It does not compare to the guidelines.
DR. BERSHOW: Right.
DR. TANG: So how do you use what I thought I heard you say is you use the publicly reported measures inside and then made it public. Do you find the public reported which are largely based on administrative?
DR. BERSHOW: Maybe I was not clear enough on what Community Measurement does, and I hope this doesn't sound too un-humble but we kind of scoffed at some of the national measures and so we never chose the HEDIS limits to report on. So out of the gate we used an A1C of less than seven as passing, not on less than nine and with recent changes in the literature we modified that to less than eight.
DR. MIDDLETON: Loved the presentation and very thankful for your coming and sharing it with us and your leadership obviously in this area.
One of the challenges I think I would be interested in hearing a little more color commentary on is the direct data submission process. Whether it is from an health IT source or from a pay for base source, could you talk a little more about that and then the return trip. I gather these are publicly reported but what other advisories come to individual docs who are trying to make quality improvement efforts and then the last part of this is really how do you get the doctor assignment or attribution right? Is this my patient or not is always a common refrain immediately after my patients are sicker than everyone else's. So basically how does the data flow? How do the reports come inbound and how do you make sure you have the right patients for the right doc?
DR. BERSHOW: I will try to remember all of them. Feel free to prompt me again. With the direct data submission, if it is coming out of the EMR and our system is Epic so I know more about that, we can create a report in the application called Clarity and it is exported and there is a portal site at Minnesota Community Measurement that the data is directly exported to. Then Community Measurement does a spot audit. The first year they audited everyone but then once they were confident the code was right they would do just like eight charts and if all eight were exactly what they expected by from an eyeball chart audit then they assume the rest of it, the data was good.
I know in Cincinnati that Minnesota Community Measurement is serving as an aid in getting their system up and running. They have some groups having their paper charts scanned and then natural language processing extracting some of the data and then getting it into the portal. I cannot speak to how well that it is working. They have been up one year on that system but even if you do not have an EMR that is an option. For those clinics in Minnesota that do not have an EMR, we let them do thirty charts hand audit randomly selected and again those charts are re-examined.
I am sorry the second piece was?
DR. MIDDLETON: The return trip, the quality report to an individual doc.
DR. BERSHOW: Because it is our data going in, we know what it is even before it is published and we also have a lot of confidence in it and we can give them in terms of the attribution. We got a lot of whining at first, well this is not my patient or the data isn't right but when we put out the reports internally we give it by all of Fairview, by the geographic area, by the clinic, by the doctor and then the list of the patients that go into that doctor underneath it. So they can go in and they can look at each and every patient. After they saw the reports were pretty good they stopped complaining, but the attribution problem has been taken care of from us. We have some denominator definitions that Community Measurement puts out so for example some conditions they have to be seen twice in the last eighteen months and once in the calendar year being measured. They vary depending on what the initiative is.
Internally at Fairview we have taken a little tougher stand. If you see them once, they are yours. Go get them. If their numbers are not good it is your responsibility for tracking them down, getting the records from another doctor, outreaching to them. So that is the stand that we have taken.
DR. MIDDLESTON: One quick follow on, so a lot of quality reports HEDIS as well you know have data which is not really or include data elements for the reports. They have to be from the clinician or from the provider; diabetic foot exam. That is not a laboratory data that can easily pick from a database and send wherever you want to send it. So those data elements that are really from the clinician, how are they getting into the reports? Is there a special structure data entry in the record obviously or elsewhere? Is it the physician or is it some other allied health professional, etcetera?
DR. BERSHOW: It can be anyone on the team. Again we are moving towards team based care so everyone, the room medical assistant or nurse, the physician, the diabetic educator, the pharmacist, whoever is touching that patient is responsible. If the data is not in there when it comes to them, get it in there. So blood pressures are all collected in discrete data fields not dictated into the note. If we did a clunky work around for foot exams and eye exams where the docs actually place a non-chargeable order for that which then can be tracked, Community Measurement just for clarity does not include that as one of pieces of its composite. We felt the data was not 100 percent reliable as to the value of the doing that and documenting it. But anytime there is not an easily track-able data field already built into the EMR we just build a fake order for it and the team puts it in. Then if they fail because again they are getting the reports every month, it doesn't take too long before they see I am not doing that well and I am looking bad compared to my colleagues and because we pay them money to do well they pay a lot of attention to it.
DR. MIDDLETON: Barry that was beautiful. I have two questions: one about appropriateness and one about one of your slides. What is your opinion about the current state of the art in the measures for appropriateness of care and particularly do you know what do you think about appropriateness of care when the problem is not a evaluating a disease but a complaint or a symptom?
DR. BERSHOW: I think that is an area that we are immature on certainly and it is one of the reasons it is our last report out of the box at Community Measurement. It was not until there was a state-wide project going on to use a common vendor for content and to be able to look at our high tech diagnostic imaging appropriateness as rated by American College of Radiology, American College of Cardiology that we had something we thought we could really point to and say if not everyone agrees at least most people agree if you get a scan for this indication and it has almost no utility at all, it is not likely to give you some information and worse yet you are probably going to need to do another scan that you just should of ordered in the first place. We felt comfortable that that could be something we concentrate on first.
We are also looking at trying to delve into reporting unnecessary frequency of colonoscopies. The gastroenterologist and colorectal surgeons in the state have said we probably have the capacity to do a colonoscopy on everyone who needs one if we weren't actually redoing people more often than the guidelines suggest. So we are looking at people who didn't need one the next year or three to five years later when they could have had one seven to ten years later. That may be our next appropriateness measure. But to get to the core of your question I think the science here is still more confusing than in other areas on what is waste in the system.
DR. GREEN: Thank you, a question about one of your slides. I was really struck by that improvement slide what you referred to the community health centers. I am wondering what your opinion is about what explained the improvement in particularly what type of pay for performance system was the community health centers in and did it have anything to do with it?
DR. BERSHOW: Well as I understand they did not use any pay for performance element but they felt a very firm commitment to have their patients get state of the art care and so they set about an aggressive pattern and I think their main technique was the use of care coordinator. They made sure that they had people who could speak the patient's language, who would reach out into the community with phone calls if they had a phone, door knocking if they did not trying to get them in, working with them, helping them navigate with a medical care system that can be very confusing and that is how they did their major improvement.
DR. GREEN: So slip this back to one of the first things you told us about the need for the same data to be used for QI pay for performance peer group rankings. Are you sure we need to have the same data to do pay for performance?
DR. BERSHOW: Well I believe it was you yesterday that was making the case for measure once, use three times. So I am assuming that you are just prodding me a little bit with this smile on your face. But I think from a waste standpoint in the medical system it cost money in human resources and cash to build our high diagnostic imaging reporting system back into Community Measurement was a 30 to 50 thousand dollar project for us. We are big system that is around in here but it is too large for smaller groups. We do not want to be collecting or reporting data unnecessarily that cannot be used for multiple purposes unless we feel the one purpose it is used for is so important, so worthwhile it can justify the cost of it. One man is on the looking in.
DR. TANG: I just have one quick question. You talked about going in for primary care, the granularity going down to the clinic because you thought it was team based and then other times you talked about going down to the provider. So how many providers are in a clinic and how do you reconcile the two statements?
DR. BERSHOW: Inside our system we have clinics as small as two physicians and we have clinics that are probably as large as twenty, twenty-two so it can vary. While it is true that clinics specific is not going to help you if you are an individual patient. You are looking for an individual doctor and if I had another half hour I could tell the sad tale of variation within our system. Jack Windberg's geography as destiny comment, is even true to which hallway you are roomed at one of our clinics, to an extent. But because we report internally un-blinded, we report externally by clinic. No one wants to be in the clinic that is not doing well so there has been a lot of provider peer pressure wandering down the hall and kicking their partner in the chin they are not doing well.
I can tell the story after 2005; our first year of pay for performance, there was one clinic where every single doc in the clinic missed a $17,000 bonus because one doctor blew off the initiative. He offered to resign. They turned him down but said we do not expect this ever to happen again, met next year. They were a high performing clinic. So we think that over time that internal peer pressure has really narrowed the variation from where we started out to where it is now. Still not perfect but it is getting there.
DR. TANG: So did you say that you then do measure by provider internally?
DR. BERSHOW: Oh internally yes, yes I am sorry. We do our clinic rewards in our pay for performance by clinic but we report internally to them on the provider level so that they know how they are doing and they can see the patients attributed to them and they can work that list so that they can see who is not doing well and try and reach out to them if they are not coming back in.
DR. MIDDLETON: Mike, could you introduce yourself?
DR. FITZMAURICE: Michael Fitzmaurice, the Agency for Health Care Research and Quality. I think I heard you say that if there is an non-chargeable eye exam for example that it is not counted in the quality measure. So I am wondering how do you communicate to the doctors exactly here is how we want the data, here is how it is defined, here is how we want it represented and what you report to us?
DR. BERSHOW: Are you talking about at the Minnesota Community Measurement level or at the internal Fairview level?
DR. FITZMAURICE: Um, you have got me because I am not sure it was what you were referring to.
DR. BERSHOW: Okay, that measure because it is not something that is reported to Community Measurement there are no guidelines or standards for how that comes in. We wanted to track it internally and so we put out some education so we have got videos. We have got emails. We have got paper handouts. We have got clinic administrators going around and showing them again you know you are not doing well in this area.
We do not think it is because you are not ordering them as often as your colleagues. You are just not getting the data here. This is where you have to put it. So it has been a continuum. When I talk about three to five years, all of this did not happen in the first six months after we went live so a lot of provider education. Minnesota Community Measurement puts out a set of standards at the beginning of each measurement year. This is what we are going to be looking at. Here is the denominator definition. Here is the numerator definition. Then they have consultants available to come out and help you if you don't understand but it is usually pretty clear.
DR. FITZMAURICE: And you get into the ICD-9 codes and the CPT codes?
DR. BERSHOW: Correct, correct.
DR. FITZMAURICE: Thank you.
DR. OVERHAGE: Blackford, this is Marc. I would like to raise my hand.
DR. MIDDLETON: Sure. Please who is on the phone?
DR. OVERHAGE: Okay, I just didn't know if I was in the queue, I think. Marc Overhage. A few things for the presentation I will say I learn a lot and I think you have alluded to this. Could you give us a sense of the timeline for change? You started down this road and talked about the yearlong sort of run in and those kinds of things. I wonder if you could just go through from inception, report delivery, clinician engagement, to the kind of changes you were able to achieve, summarize the timeframe for those.
DR. BERSHOW: Okay, thanks. I am sorry I actually have slides on my computer but none available for this presentation showing that. So Community Measurement started their first report blinded. Each group only got to see their results and the blinded high and low and average in the state. So that was year one just so that they could learn how to do it. Year two, there was public reporting at the system level and the state average at that time was I believe six percent on the diabetes composite. That was the first report out of the gate. This last year the state average was twenty percent I believe give or take one percent and the higher performing groups, the highest group in the state last year was at 60 percent. There were quite a few groups over 40 percent. I bet twenty to twenty-five clinic sites in the state over 40 percent but it took that long and it was a gradual, continual improvement. There was not the one year jump up. It went from like six percent to ten percent. Then I think it even stalled in the low teens for a bit then into the high teens and to right around twenty percent. So that is kind of the timeline for improvement.
The timeline for how this is done internally, a lot of education is needed to the provider community early on. You have to get the buy in; lots of hand holding and individual selling. People like myself and some other colleagues in the state who felt really passionate about this going out to other systems, talking to them, explaining as I did about the Angie's List what is going to happen if we don't do this ourselves. If we do not have measures we think are important, if you are seeing this does not represent quality, whose fault is that? It is not Community Measurement or Angie's List or the health plans or HEDIS. It is our fault. We really have to grab hold of these reigns; define what we think is quality; define how we think we should measure it. So I kept making that pitch over and over and over again. I do not want to take full credit. I was not the only one out there and I was actually at the knee of some other people who were teaching me along the way. Just gradually we got everyone to swing from I hate this. This is all wrong. It is terrible to this is really pretty good. What does Community Measurement say about this, is the common phrase I hear now in the state. It has really been remarkable.
DR. MIDDLETON: So why don't we shift gears. Thank you very much, Barry, really a terrific presentation and rich discussion. Thank you all and while we are switching gears for David Stumpf, Marc would you mind introducing yourself on the phone?
DR. OVERHAGE: Thanks Blackford. This is Marc Overhage for the Regenstrief, Indiana Health Information Exchange, member of the full Committee and the Subcommittee and I have no conflicts. Thank you.
DR. CARR: Blackford, this is Justine Carr, Caritas Christi Health Care, Chair of the Committee, member of the Subcommittee, no conflicts.
DR. MIDDLETON: Good morning to you both. Anyone else on the line who has not yet been introduced? Okey Dokey. Well, while David is just teeing up I thought we might plan for the 10:45 session. Dr. Steven Solomon will be joining and discussing perspectives from the DHSS Office of Health Care Quality and if time allows in that block, I would ask if the Booz Allen folks might present the environmental scan perhaps the second half of this session. That would be terrific and David, if you are ready please take away.
MR. STUMPF: Thank you Blackford, and thank you to the Committee for this invitation to speak. I might actually to get a little continuity pick up on the last point that was made by Barry that the way that this quality measuring needs to be done is by the providers in those environments at the points of care and so on. We as payers of course have been in this field because of pressure we have received from the purchasers, the employers. But we have said all along that we would like the providers to do this themselves. So what I am going to focus on is sort of the ideal future state if you will and some of the steps we are taking to get there.
I am here on behalf of the United Health Group which is a Fortune 25 health and wellbeing company and it has two major arms. One of those is the payer segment which is actually merging. Now these two buckets, the individual employers and our federal and senior programs are actually moving together for some of the reasons that you mentioned. They are trying to create accountabilities across all of these because doctors do not make this division. They take care of all of these groups. Then we have what we call our services group, the enterprise services group which is where I spend most of my time in eugenics and Optum Health, and together we now serve actually over 80 million Americans with the services that we provide through these channels.
My role in the company is strategy. I do not have direct operational responsibilities. I spend a lot of time outside of the company with quality organizations as well as inside the organization connecting dots because we are a very big company with lots of silos and a lot of value from my participation comes from connecting those dots. I try to assess the environment, identify the gaps and advise our executives so they can create their own strategies. I do not tell them what to do but I do think I can influence some of that. Of course one of the big issues is change and how one manages change and creates more diversity of how we actually do business is one of the biggest challenges I think we face.
This presentation was designed around the charge that I was given: to look three to five years out and try to identify the paths that we need to go down and what are some of the gaps that we need to know and address and what kind of information should be useful. So I have distilled that down into how do we presently link value to benefits. What is that ideal future state and where are the gaps, challenges and opportunities?
Our current state, I think most of you are aware is fee for service. It is fees negotiated with providers and sold to employers. This system has many, many problems. We did not invent it by the way. We often get blamed for the fact that it doesn't work but we did not invent it. We implemented what providers told us they wanted to do.
We have a lot of projects in the mill right now to try to help redesign the system. We have over a dozen medical home pilots going in various markets that are based on NCQA requirements and each of them is a little bit different, testing various hypothesis and models. They continue to have some fee for service. They have a flat rate which I emphasize flat, per member per month payment. They incentivize shared savings in some programs and they also have incentives for population outcomes, not just individual ones.
One of the companies we just set up as a start up is Liprint down in Arizona. This is a laboratory if you will. They are going to be setting up a chronic disease clinic and creating accountabilities for the providers in those clinics and it really becomes a laboratory where we can investigate what works in accountable care organizations. Some of the models I will get to in a minute will be a good test bed for those. They obviously will be looking at again these various payment mechanisms but also some business processes that will be different than what we now have.
We like the Fairview model that you just heard about. We have some large provider organizations where they actually set up their own quality reporting and incentive programs for their doctors and we create for them a quality pool so we don't just pay all of our money for fee for service to those providers but we give them a lump sum at the end of the year and they distribute it according to their internal quality metric thing. So this is a step in that direction I talked about from us stepping away from the measurement and reward system and pushing that out to the point of care.
For those who do not have that capability we still have some systems that will push our quality analytics out to the market place; gap reports that we can identify in our data which is a good bit administrative but we also have laboratory data. We also have prescription data and we, by the way, know when we do not have the data so we do not report on gaps when we do not have the data. We try to do this in a way that connects to some of the meaningful use targets. I want to talk for a minute too about the targets of opportunity that we are addressing because we are trying to align those with national drivers which I will get to a little bit later.
So the ideal future state I think for all of us and us included is a work in progress. I am actually leading a workgroup in eugenics which is looking at the ideal future state. Our timelines are meaningful use phase two and phase three; where do we want to be at those points in time. But I can give you a few illustrative examples about how this work is in progress. We do collaborate with health information exchanges and we started off like most people I think just jumping in the water and found out that there were some problems and so that led us to lay out a few principles about getting to the value, getting to sustainability and those have been clearly annunciated I think by our company and we provide data to HIEs as well as some of our analytics under certain circumstances and some of our companies help HIEs actually move data around.
We have an emerging business group which is actually quite new in the company. It is only a few months old and they are still actually defining themselves but this is a group that is going to have access to capital to invest in innovation. They are still refining how they are going to do that but it basically gets into we build it ourselves. We buy it or we collaborate and I put the emphasis on the "collaborate" because I think you are going to see a lot more necessity of collaborating in order to get where we want to. This group will have some funds to set that up.
In eugenics we are really looking at point of care analytics. How can we push the analytics out to the point of care? How can those analytics be done when we do not own the data but we provide the tools that the point of care is using for that. We also are looking at work flow enhancements which we have already heard something about that. How can one merge work flows? How can one repurpose data for accomplishing multiple purposes? Then we have a lot of capital and we are out buying companies right now.
I think you are going to see a consolidation in this industry around HIT and outcomes. So for instance we acquired Quality Metric which is a company that does a lot of work with functional outcome measures that the SS surveys are all there. We are incorporating those now into some of our analytics and some of our business strategies. We acquired Axolotl which does a lot of work in the HIE space and is a platform on which a lot of things can be delivered as well as just moving data around. We have acquired two companies that are at the point of care right now. One of those is Pisces which is a company that is in emergency rooms, operating rooms, ICUs getting streaming data coming out of those units and applying analytics for decision support.
The other interesting company we acquired is Executive Health Resources and EHR is in emergency rooms applying analytics to raw data in emergency rooms: chief complaints; symptoms; laboratory data and rendering decisions about where that patient should end up. Do they go home? Do they go into observation? Do they go into an inpatient or an ICU bed? This company was set up and designed to maximize the efficiency of the administrative process for a hospital so that if they place somebody in this unit, they are not going to get hassles about their claim. It is going to run through smoothly. It also maximized their reimbursement but when you look at that model, it actually has a lot of other applications for how one can make those decisions based on quote raw data, you know unrefined data because as we all know especially in those acute settings the data is not refined and is probabilistic. Diagnosis are uncertain at that point.
We also have an HIT department if you will really a large component of our company that is working on some innovative things like the use of multiple devices, super computers that we are applying to some of our analytics and working on our service oriented architecture strategies. Then we have within Optum Health a bank and that bank is looking at some interesting financial services which we think can be transformative in this industry as well.
I want to now kind of shift into what are these drivers of changes. We looked at the national agenda for that. This is not something we create again, and I kind of put them into three but major buckets here. What are the unmet needs? We participated in and believe in the national priorities partnership and the gaps that they identified there. They are part of our key strategy. I am a particular fan of the National Quality Forums Coordination of Care model for some reasons I will get into in just a second. This model has the capability of addressing most of what ails health care in my opinion including the data requirements that we have going forward. I would just refer you to their website for the document.
Then one of the RT drivers in looking at the ideal future state is to implement impactful technologies. So we were active in the HITSP process and what we have decided as we develop things because we have tended to be product oriented. We want to have this product and that product and that product. What we are no focusing on are capabilities. This gets into really some service oriented architecture strategy. You want to have the fundamental capabilities and then link them together to create products and services. That is a fundamental shift for us that I think will over time give us more agility and flexibility in responding.
So let me run you through one of the things that I am working on right now and I think our company is. The only revision I would make in this slide I think right now is rather than patient centered coordination plan is to make that person centered coordination plan because most of people would prefer not to be patients but rather healthy individuals who have a limited need for the health care system and in fact most health care occurs outside of what we would traditionally think about is a health care system. But one of the big challenges, how do we get structured data? How do orchestrate the process? And this model actually I think provides a mechanism, a mechanism, not the only one, for how this can be done.
This is structured document presumably in the way it is being envisioned and developed, an HL7 Version 3, CDA adherent document which has sort of an unlimited amount of nesting that can occur. It has two kind of key components. One of those is the patient characteristics and that includes the typical things you would find in a health summary but it can also contain other things like functional status, beliefs, desires and intentions of that individual which will drive their behavior in the marketplace and so on.
The second component are the tasks. These are obviously can be linked. This diagnosis or problem or issue will be linked to this task and the patient characteristics can be utilized on an individual patient level to create a dataset, really to extract the dataset of similar individuals or a cohort on which you can then look into your crystal ball which in the modern era we would call a probabilistic outcomes and choices so that if we have this 53 year old diabetic, hypertensive person we can look at our data already and find hundreds of thousands of those people. We can then look at the characteristics of them and where they are headed in the health care system and we were trying to now work on how can we use that data to look at the paths, the various paths that those individuals take in the system. Of those 10,000 diabetics, you know 1,000 of them have a stroke and 9,000 do not. What are the things that distinguish them and what are the modifiable decision points that you are going to get at in that population?
The other thing we can do with this is calculate the risk adjusted PMPMs which provide an incentive for providers to generate those characteristics and also provide the data which is necessary to create the task. The task reports then have three key elements: the task itself; the accountable entity, who is going to do this and that frequently will be the patient; and what is the outcome metric, and those outcome metrics can take on all kinds of characteristics. They can be EBM based, consensus based. They can be a business process or they can be a functional outcome to name a few. All of this then can be linked to the outcome that you anticipate which can also be rewarded in a whole variety of ways. One of the fundamental things that is emerging from some of the groups trying to implement this is the need for a business process management and the ability to orchestrate this whole scenario.
Here are what I see as some of the high level gaps. The workforce, I think what we are bumping up against is how do you translate all of this clinical data into the kind of HIT analytics that you need and clinician informaticists are absolutely essential for this. You cannot do this with people who are used to administrative data and there are too few of them. They are too dispersed and getting critical mass in this field I think is one of the real challenges.
The sociology is another very big issue and in fact I think the biggest issue. I quoted the Intel Chairman you know that culture eats strategy and I certainly find this inside my organization. Changing a culture is the hardest thing. The incentives need to be robust, pervasive and very directional and I think they need to apply to everybody.
We also focused on business process management and some of the issues we talked about before and then the last point here is the capabilities need be turned into applications that have several requirements. They have to have a sustainable production environment where professionals develop these and I could comment more about that but I do not have time. There is a real need to stimulate this area and we also I believe need to get the plug and play so that the capabilities that we develop will enable the implementation of what we could call a platform as a service so that these services can be delivered seamlessly to the points where they are needed.
So with that I will stop.
DR. MIDDLETON: Thank you, David and I want to apologize for having to shorten your presentation a little bit. I miscalculated myself not recognizing there were four speakers for our block this morning and I was timing for three. So thank you for your acceleration on that.
Is there one burning question for David? Yes, Mike.
DR. FITZMAURICE: Do you use quality measures in the measuring value and where do you get the data?
MR. STUMPF: We do have quality measures. We have some 700 EBM rules that we run, can run. We use about 150 of those in our quality reporting for physicians. The data comes from several sources. It comes from the administrative claims. It comes from pharmacy data and it comes from laboratory data. The emphasis right now is on getting more laboratory data. We get about 50 percent of our claims for labs are associated with results and those results are increasingly important in the analytics. We also get it from some patient input through our consumer portal. We also want to increase that and part of the incentive for these care plans, coordination plans from our perspective is the ability to integrate some of the clinical information in designing the incentives. Again, the idea here is to push that out to the point of care so the doctors and other providers are telling us what is the task I am trying to accomplish here? What is the outcome I am expecting so that we can incentivize that.
DR. FITZMAURICE: Thank you.
DR. MIDDLETON: So David, thank you very much for a terrific presentation; very rich and we may have questions after the fact based upon your testimony and the slides. I know we can reach you via email. Thank you again.
Let's now turn to two presenters from the phone: first Dr. Arne Milstein and then Dr. Joachim Roski and we will endeavor to wrap up at 10:45, sharp. So Arne, please take it away.
DR. MILSTEIN: Thank you Blackford, and out of respect for constraining time I think I will skip over some of the introduction, other than to say that purchasers, large employers, large labor unions, they are self insured. Large state government is self insured for their employee benefit plans. I think most of them would agree with the long term vision for what the U.S. and health information systems needs to look like that was articulated in the NCVHS May 26 concept paper. We thought it was terrific. So what I have done this presentation to kind of hone in on a shorter list of U.S. health information system enhancement that would be especially useful in efforts by large employers, large unions and their employees to improve the value of their health care spending and broad brush the enhancements I am going to recommend fall into three broad buckets.
The first is scope of data collection. That is what is getting collected. The second is things needed to make the data more useful. And last but not least is the issue of due speed because I think we have all been a part of that for I think it probably was some of the visionaries among us not including me, probably long ago could have written something very close to the May 26 concept paper, that even in which you approached it has proved to be for the pi side of the market meaning that large employers and the union workers who are competing against more efficient health systems in other countries has been not what we would hope it would have been. Let me just hone in on these suggested near term priorities and then I would be glad to take your questions.
The first category is the aim to enhance the scope of what gets collected. We think there are opportunities to improve that in four ways in the near term. Our first recommended target would be the routine collection of standardized electronic information on patient reported health status and experience of care. These two components of the triple aim represent consumers' essential purpose in seeking health care. That is they want to get better and that they want to be treated reasonably in the process. We do not think there is any inherent reason why this information cannot be routinely and economically collected at the inception close of most patient contacts of the health system and at intervals thereafter. That is someone who is given healthy intervals might be for collecting status, health stats for patient status would be obviously, it would be more infrequent than for someone who was here for chronic illness.
We think electronic versions of the Dartmouth pull up(?) instruments illustrate one feasible element of such a data collection system that could apply to multiple but not all health care service types but it is really illustrative. We are not recommending that as the actual standard.
The second opportunity we think near term opportunity that should be pursued to improve the scope of data collection was either routine collection of standardized information on whether any high risk or high cost, non-emergency clinical service meets current appropriateness criteria and was subject to robust share decision making process. While we are waiting for universal adoption of sufficiently robust electronic health records to enable such routine information collection, we think we should in the interim move ahead with the establishment of clinical registries to serve this purpose. We think registries should also be initiated to track outcomes and care problems for health conditions generating substantial disability and health spending that may be unrelated to specific high cost or high risk discrete health services.
A third recommendation on scope of data collection is the routine collection of standardized information on the payable charge for every service or in a bundled reimbursement arrangement of a service bundle. Right now, particularly in California we are facing some behaviors by typically market dominate providers that we think will go done in the annals of infamy, in the history of American health care. Some dominant geographically dominate health systems that have placed a gag rule on the sayers including self insurance lawyers disclosing the amounts that they are able to collect due to their advantaged market position for whatever unit of service they are being paid at whether it is a capitated rate for professional services or all inclusive cap rate or fee for service.
The fourth opportunity we think near term that we think should be prioritized in terms of data collection is the routine collection of standardized information on each patient health care relevant quality of live and end of life preferences I see as such collection is authorized by a patient. The reason for doing this we think is self evident given the substantial evidence of non-concurrence or maybe it is a better way of putting it is the inability of providers to intuit what patient health relevant values or preferences are. We think the only way to do that is to routinely collect such information and preferences on a regular basis particularly over the course of a life evolution.
Again we finished up four of the eight specific recommendations for near term priorities for health information system improvement. Let me move to three recommendations that fall under the category of data usefulness. The first of these would be the conversion of electronic health information into structured data in standardized format. Many of the clinicians managing information systems on an inpatient and ambulatory basis point to this is a tremendous problem that is a lot of the useful and usable information are now being collected electronically is in a non-structured format and therefore a real challenge to make good use of.
The second recommendation in terms of short term priorities under the data usefulness category is the linkage of all personal relevant health and health care information on a real time basis so that it is available to inform the health and health care decisions of patients as well as of their clinicians and the in-home care givers when authorized by a patient. This is obviously been a problem. Fortunately there has been some initial progress. For example, the blue button is now available to veterans in the U.S. This gives them a version 1.0 axis to priority care information and now application developers are free once that information becomes available to begin to create a more useful personal involvement in health and health care information about each person.
Last in the data usefulness category is the following priority. We believe that for patients and clinicians that request it, we should begin to aim for the continuous generation of active decision props whenever there is a new opportunity to take an action likely to improve health or health care affordability for the patient. Our vision is that most people go about their daily lives and do not want to occupy their mind with the question of gee I wonder if there might be a way that given updates in my current health status that I might improve my health or improve the affordability of health care to me. Accordingly we think that really quite parallels with the evidence that it is really active decision prompts for clinicians that make the biggest difference in improving performance. We think the same system ought to be pursued so that a patient and clinicians on a real time basis can have new information about them accumulate that they are alerted anytime there is an opportunity to take an action either by the clinician or the patient to improve patient health status and or improve the affordability of health care for a patient.
The last and eighth recommendation in terms of near term priorities that we would make a big difference in the ability of private purchasers, private sector purchasers and patients to play a more active role in encouraging doctors and hospitals to excel on the value of care they deliver would fall into to the category of a reduced fee and I think what we would like to see is use of the Secretary's authority, referring to the Secretary of HHS, to adjust Medicare and Medicaid and SCHIP payment as needed to encourage most U.S. providers to meet the above described seven priorities within a reasonably prompt period of time. We think that most of the things on that list if they were nationally prioritized could be in place within a period of four or five years.
So that is, I met your time limitations but the there are recommendations for near term priorities fall into this category of scope of data collection and data usefulness and in due speed and we make those recommendations while simultaneously endorsing the much broader and more inclusive long term vision articulated by the NCVHS in its May 26 concept paper.
Thanks, Blackford.
DR. MIDDLETON: Thank you, Arne. That is really terrific: a big vision and a really thoughtful across many dimensions of the problem. I am very thankful for your testimony. I wondered, did you actually are you producing a written testimony as well or even a power point?
DR. MILSTEIN: Yes, I forwarded that to staff last night.
DR. MIDDLETON: Okay, so we have it but I don't have it. Maybe it is in my stack. Okay, I was copying furiously, Arne as you were talking.
DR. MILSTEIN: I sent it to Matthew Quinn and Debbie Jackson.
DR. MIDDLETON: Yes, they have it. I probably have it too. So let's just take a couple of minutes then for burning questions for Dr. Milstein. Mike?
DR. FITZMAURICE: Arne, Mike Fitzmaurice here. On number three, routine collection of standardized information on the payable charge for every service or service bundle, by payable charge do you mean the amount paid for every service or service bundle? I mean forget the charge –
DR. MILSTEIN: Yes, sometimes when there are prolonged, the reason I phrased it as amounts payable is sometimes there is a prolongation of the collection process and most providers know based on the nature of their contractual relationship with any given payer what the amount payable is. It is analogous to the field on the new UBO core which is labeled amount due. The amount payable, amount due, it is the amount that under whatever contractual relationship exists between the provider and the payer that is payable for the service by virtue of the contract. The only place where this is a little bit challenging to implement is where the patient does not have insurance and presumably that is going to be a much lower order of magnitude problem going forward.
DR. FITZMAURICE: Many states are starting to set up all payer databases to try to get at this payable charge so I think that that is one of your many good recommendations.
DR. MIDDLETON: Matt?
MR. QUINN: Thank you so much for your testimony doctor. This is Matt Quinn from AHRQ and I had a question under data usefulness number five, conversion of all EHR information into structured data in standardized formats. Our last hearing that the quality subcommittee had was on meaningful measures and one of the things that came out of it is that for the ability to use electronic health records to their potential to support quality measurement we needed to have standardized data formats underneath.
One of the things that we struggled within this is you can standardize everything but then where do you start in this in building it out to balance the needs of the measurement community and the needs of quality improvement but also with balancing the needs to maintain not too much work for the individual clinicians?
DR. MILSTEIN: Well I guess it is in a sense that obviously a good point and I think probably in the interim we will probably need to rely more heavily on software that can make reasonable guesses based on an inferential logic. That is obviously not the ultimate solution but I think in your question you correctly articulated that this is a problem that is eventually solvable and the only question is what, when we expect it to happen and how tolerance of error we want to be with respect to interim fixes such as software that could make a reasonable guess based on the electronic text as to what the answer is. I acknowledge this is something that needs to be finely calibrated. If you move too fast on accelerating the workload implications on clinicians associated with getting everything into the records in standardized electronic format, you could induce an unfavorable reaction.
So I think it is the kind of thing that Office of the National Coordinator have laid out with essentially signatures and imagine this could be woven into the definition of the escalator level so that the greatest reward is for providers that achieve a higher rate at this whether they do it through being more rapidly insisting that providers use and adhere to this discipline of standardized format or whether they in the interim fall back on software that can take a pass at the electronic text and draw out reasonable inferences.
DR. MIDDLETON: Last quick question, Larry Green.
DR. GREEN: Arne, thank you for being so clear again. I have a question about the registry idea. Could you go back to that one - the registry of at risk or high cost patients amenable to intervention. What is your thinking about how that gets formed? Does it exist in real life? Is there someplace we could see one of these and touch it?
DR. MILSTEIN: Sure, I think in some ways we do have some great national models for how this could happen and work. I think for example the Vermont Oxford Network of NICUs. We have some very nice expansions on that to other facets of perinatal estimates in California being led by Jeff Gould and colleagues at Stanford. The American Colleges of Cardiology at registry on interventional cardiology are comparable and preceding registry that was established by the SDS. These all advise you and show the way and show that it is doable.
There is a regional, there is escape for it and that providers can be engaged. I should have thrown in by the way another I think really admirable step forward that has been launched over the last several years and that is the American College of Surgeons' adoption and now promotion of NSPT(?) These all illustrate that since these things are doable in the U.S. and they also show that once they are in place they can be infinitely expandable into things that patients care about. For example the evolution of measurement of risk adjusted outcomes that move beyond mortality against the measure complications both in during hospitalization and in some cases during a reasonable period of time after discharge.
DR. MIDDLETON: Thank you again Arne, and now quickly switching gears, Dr. Roski.
DR. ROSKI: Yes, hello. I am happy to be speaking to you today and I am really sorry I could not be there in person. We had some last minute scheduling issues that prevented me from being there.
What I thought I might be able to contribute today is offering my views on the trajectory of performance measurement and how we can capture value. In order to be efficient in my presentation what I would like to do first is introduce a few thoughts about where I think we should be in three to five years and then offer some perspective on that vision and what might be a pathway to get there.
What I will try to do also is keeping in mind with my comments where if you will the majority of the country will be in terms of capacity to reach that vision rather than focus on what a few advance systems might be able to do. I will reference in my comments the work that we have involved in here at Brookings in working with payers and at hiring accountable care organizations which to some extent may represent some laboratory with some specific incentives to produce useful information. And I will also talk a little bit about the very early impressions about what is happening with the Beacon Community Program along with Booz Allen and the Institute for Health Care Improvement. Brookings will be offering some technical assistance to these communities over the next few years.
Let me start with where we need to be in a few years. I think one of the things that we need to figure out is how to develop a more patient centric view on quality rather than a physician centric view of quality. We have heard a little bit about this earlier today about rather than focusing on individual physicians we may want to be focusing on clinics or care teams as a unit of measurement. What I am suggesting is that it might be even more useful to talk about a patient centric view that tracks people or patients along the episode of care be that a cardiac episode and so forth so that we are going to be able to tell more specifically keeping in mind of how a particular form is or is not successful if patients along there continuum of care receive all of the care that they needed and were able to achieve the outcomes that were hoped for.
What we clearly will need to do for that is over time move away from the often process focus measure that we have to move towards outcomes be they intermediate or quote unquote real outcomes that we can track across care settings and for groups of patients look for particular conditions' needs and secondarily figure out ways not only to capture information about the biological stage of these patients but also gather patient feedback about preferences and values that these patients have in receiving care and particularly as it pertains to preference sensitive care so that we can more effectively initiate decision making and so forth and I am specifically also addressing not only the need to employ quote unquote after the fact patient survey but develop more real time opportunities to collect patient information that can be stored alongside clinical information to track quality of care.
Clearly what we will need to do in order to get to a value based assessment of care is link these outcomes with the resources tendency that was associated producing. That has got to be a clear focus of where we need to be including developing more accurate ways to measure cost of care at the various units that might be useful as we have heard from Arne and others about potential ways to get at that. Then in my book what we need to lay out is given if that was the vision, how we can build a trajectory to get there assuming that it is not going to be an on and off switch that we will have available to us to make this become reality but figuring out ways of what measures could become available, by when, given some intensive focus.
Given that vision, let me offer some perspective on what we have learned in working with organizations around the country. We are currently working with about 80 aspiring A-fields around the country that are trying to become accountable care organizations, or at least have a great interest in learning more about what this may be. As part of that we are working with five A-field pilots and their care partners in a very intensive format to help them actually implement contracting provisions, building a network, figuring out what the metrics are going to be and so forth.
What is very clear is that given the, that there is a great deal of interest in this particular format of care that may get away from kind of a procedure by procedure point of view to a more comprehensive view of care, that there is a great deal of interest in getting to, having some guidance, getting some consistency, the ability to receive feedback about performance not in relationship only to where that same organization was at the previous time point but also in relationship to others.
What is clear also as a result of that is the great hunger for some consistency that will allow for the such comparisons to take place which then may lead you to think about what could be some core set of measures for example that would be consistent across many of these organizations and what might the other measures that could be augmented based on local needs and requirements and so forth.
The site that we were working with I would describe as representing an advanced group of organizations but not a vanguard group of organizations. The reason why I am stressing that is that that was a very deliberate decision on our part because we think that if these are going to be successful, they have to work for a very large part of the country who are otherwise it is going to be more of a nation of programs that is not going to transform health care in the way that I think we are all hoping it can be transformed.
One thing that we learned very early on is that these organizations who are very committed to transforming themselves are at very different points in their trajectory of being able to measure themselves ranging from organizations who have recently formed and are trying to either install or reconcile different standards that are in place between different health IT systems that have been put in place in these organizations to entities who actually have an EMR system or EHR system that spans much of their organization. It is very clear that most of these organizations are very early on in their process.
What that has led us to pursue relative to the measurement then is to lay out a trajectory of where we need to be and where in the first round of measures that are going to be used we are going to be relying on measures that could be computed to administrative records where the payers actually will compute these results on behalf of the ACO covering demands such as effectiveness, preventive care, pharma care safety, overuse and so forth and feed that information back to these ACOs in a consistent way.
In parallel to that we are setting up an additional mechanism to get to additional measures that will require more time for these organizations to compute it and that is intermediate outcome measures that will require information from about lab results and various other components that would not be contained in administrative data.
Interestingly enough there is no one pathway to get this information from these sites. As it turns out, one of the more effective ways may be in having the payer identify quote unquote the denominator for the particular population and the provider side or the ACO providing quote unquote the numerator or any exclusion criteria that may be relevant that could not be captured in the administrative data.
When I say that there is no one pathway what we have learned is that many of these organizations have already developed some internal mechanism to produce information for feedback purposes that differs between these organizations ranging from figuring out how to more directly access electronic lab fees so that information becomes more available to working with web portals where physicians might be sending specific pieces of information that have been prioritized to some data warehouse to use some internal and external registries and last but not least, several of the organizations still rely on manual extraction if they cannot get at the information in any other way.
Hopefully the meaningful use programs and other incentives will accelerate that but one thing that I have certainly observed over my career in health care is that the hope for more information becoming available tomorrow once some new technology has been implemented has frequently been thwarted meaning it has been much slower than one would have thought. I think Arne's comments sort of spoke to that as well.
One of the issues that we are going to be working with or that we are going to be considering of course if once we have intermediate outcomes available for example, those might replace process measures that otherwise are now being produced through administrative data. For all of these organizations we have been working with it is probably true that this is a heavy lift even for the measures many of us might consider very boring and run of the mill. For many of these organizations that we are working with it turns that simply producing them is a significant effort for them, particularly for organizations that are just now forming as opposed to let's say more mature medical groups that may have been working together in different parts of the country such as Minnesota or California where some of this may already have been underway for quite some time.
What I would also observe is that what we are seeing here with these ACOs I think is actually fairly representative of what we are going to be seeing all around the country. In other words if this is where organizations are at that are trying to by ACOs who integrate here and come together in ways that are unprecedented if you will, it will certainly apply, or let me put it this way, then organizations who are less evolved, who are more fragmented or represents small clinics, these issues will be even harder to implement.
I have had an opportunity, and I would encourage Marc Overhage who is leading one of these Beacon sites to comment on this as well. I had an opportunity to attend one of your early meetings of the Beacon communities and one thing that became clear to me is that there is a great deal of variability in what these communities can achieve, where they are at at the moment in terms of their IT infrastructure and what they can produce and it will be interesting to see how quickly they can realize the aims that they have set out in their proposals. The Beacon Community is of course by definition if you will were meant to represent the most advance communities we have in terms of producing information that currently is not being able to be produced and so I think we need to keep a very close eye on what is possible in those communities thinking about them as a laboratory if you will for what might become more possible in a few years time in many more regions of the country.
Thank you.
DR. MIDDLETON: That was really terrific. Thank you for your thoughtful comments and insightful, as well. If you have a couple of minutes, can you entertain a couple questions?
DR. ROSKI: Absolutely.
DR. MIDDLETON: Okay, super. Are there any questions for Dr. Roski? One question comes to my mind, I guess thinking about the standardization problem, taking it down a level which is inevitable sometimes for this group to get into the weeds, do you have thoughts about merging those clinical and administrative data to make more insightful measures and intermediate outcome assessments? Which way do you see the winds pointing if you have thoughts there.
DR. ROSKI: How to create more meaningful measures you mean?
DR. MIDDLETON: Well and standards relevant to those more meaningful measures.
DR. ROSKI: Yes, I am sort of two minds if you will. One thing that I was very struck by in working with the various organizations is that some of these organizations have developed this work around if you will that are trying to get around the issue of not having fully operational EMR systems in place. To some extent while we are working on standards for how EMR systems may want to capture information we may want to also think about a transition period where information might be coming from several different sources and figuring out how for example in one instance information that is directly set by a lab to a claims database could be considered a standard and how that should be implemented figuring out work around using web portals to transmit some pieces of information rather than making a lot of pieces of information available and so forth. Hopefully that will only be needed for let's say three to five years until EMR systems are more widespread and have implemented the type of standards that are all ready being worked on now.
DR. MIDDLETON: Larry Green?
DR. GREEN: Thank you very much. I would like to ask you to link your thinking if you could and share it with us from one of your first comments about patient centric care, moving from provider centric to patient centric where you, if I heard you correctly mentioned the need to know about episodes of care.
DR. ROSKI: Yes.
DR. GREEN: And then jump to the needs of the aspiring ACOs.
DR. ROSKI: Yes that is actually a very good point and very important. It would seem to me that as a payer or as a country we would want to know that people with heart attack or people with particular procedures six months after the fact are as healthy as they could be or as functional as they could be. That information would in my view, be very difficult to obtain if we simply focused on whatever is in one cardiologist's records or in one surgeon's records or in one hospital's records. Instead it would be information that would need to be compiled from the ambulatory physician, let's say a primary care physician, the hospital, the rehab unit, the ambulatory site, or cardiologist, who takes on the ongoing care of a patient with cardio conditions and so forth.
And examples that we have worked on for example with the ACC is figuring out the American College of Cardiology, are there ways for example that information could be more effectively linked across the continuum of care. So for example, if we were to link information from registries which in this case procedure registries which for the most part contained information that is very detailed and which about a small part of the episode to information that have some record on what happens to the patient after the fact. Is that patient on the right medication? Is that patient alive and so forth? What we worked on for example is to link this registry information with information that is contained in for example administrative records, linking it to on the one hand string together an episode of care and on the other hand use the clinical information to enrich and adjust quote unquote information on the administrative side and enrich the information sitting in the registry with long term follow up information at a somewhat thin level but at least at some level that is currently not available in most registries. Certainly that would by true for the ACC registry.
In my book if we could for example in the context of an ACO achieve and promote those types of linkages so that at the end of the day we could say there is a patient with a heart attack six months after the fact lead as healthy a life as she could then that would be the information that I think would tell us more about health care value than we currently have available.
DR. GREEN: Would you go so far as to say that the meeting the aspirations of the ACO depends in part on the ability to discern, define and operationalize episodes of care?
DR. ROSKI: I would say if an ACO has the heart. I would say that an ACO who does not have the right information available along the continuum of care, they may not in the end produce the value and cost savings that I think we are all hoping for. So to some extent we are going to be entering into an experimentation stage here over the next two years where we will try to see maybe facilitated through the center for innovation that is being built at CMS what seems to be working, what type of programs that are being implemented including those relying on data linkage will get us to the right outcomes.
DR. MIDDLETON: Paul Tang.
DR. TANG: Hi, Joachim.
DR. ROSKI: Hi, Paul.
DR. TANG: Very good presentation. I liked your thinking on that; also enjoyed the request to pull in patient both the preferences and real time collection of their information in terms of outcomes. May I also make a plea in terms of you made reference to saying well maybe as far as capturing some of the measures the payer would provide the denominator and the clinician provide the numerator exclusions. My concern about the payer providing denominators is when you define it using those administrative you know the two encounters within a measurement period, etcetera, you miss a lot of folks the very people that we probably need to reach out to. The corollary to that is you end up artificially inflating the score because you are only going to include in the denominator the people you are already working on.
DR. ROSKI: Yes, in the case of ACOs it works a little bit differently than at the, if you will, and the individual physician level. Here you actually assign whole populations independent of their condition. So what you would do is you would assign, or the way that we have doing it is to define the overall population that is quote unquote enrolled in that ACO and then within that group look for particular series of events.
I would go back to what an earlier speaker said is that that is not the way we would ideally want to do it. Ideally what you would want to do is have the ACO themselves generate this information. However what we are finding is that they cannot do it. They cannot reliably at this point find all of the people with diabetes or all of the people with particular other conditions you name it and that is kind of an interim strategy in order to get to some denominator that the payer believes the ACO should be accountable for.
DR. TANG: In other words, so if you are doing it. I did not know which numerator you were referring to. So if you are doing it by condition let's say diabetes, could use other data like the lab tests or even the medications in diabetes for example and that is more accessible to the provider than it is to the payer. So I can see identifying the quote assigned group from the payer point of view but most everything else where you want to measure whether it is the health or the disease or the chronic condition state, you might be better able to help them find out then do it on your own from administrative data. That is all.
DR. TANG: Thank you.
DR. MIDDLETON: Again, thanks again. Blackford Middleton here. Terrific presentation and you were very generous with your time. We are now ten minutes over. I am going to suggest we conclude this session and propose a five minute bio break. I do not know if anyone else feels the same way but let us try to reconvene in five minutes and we will take it from there. Thank you.
DR. ROSKI: Bye.
(Brief recess)
DR. MIDDLETON: Thanks everybody for coming back quickly after a short break, but we want to continue on our agenda which is just running a little bit late with Dr. Steve Solomon, welcome to you, from the Department of Health and Human Services, the Office of Health Care Quality. I think part of the goal with this discussion is to learn more about your thoughts on all of the questions and your office's activities and help you understand more and I apologize we have not met but about NCVHS activities and its current efforts. So please take it away, Steve.
DR. SOLOMON: Thank you very much and I am sorry I cannot be with you in person. Normally we are in Washington but we are here in Atlanta at a conference on health care follow the elimination of health care associated infections.
So I would just say a little bit. In this time I am going to give you about a ten minute or so overview of the office and some of our activities and then perhaps we can have some dialogue and you can ask some questions and we can get really at some issues that you may be most interested in.
The office got its start in 2008 and 2009 as a result as you know very, very well of rapidly increasing interest in the issue of health care quality and the decade long growth in the tremendous interest in patient safety and the patient safety movement. The office was established specifically to improve coordination across the HHS agencies on the subject of health care quality to serve as a focal point for coordinating and leveraging the agencies' activities and to serve as a point of contact for external groups looking to interact with the Department and its agencies around the issue of health care quality and to provide leadership and innovation as well as to try to increase the efficiency and effectiveness of the work that HHS does in health care quality.
Our initial and real focus has been on health care associated infections which was an area of extraordinary interest and continues to be obviously both in Congress and in the executive branch. We have also worked, I have staff working on public health quality issues in recognition of the fact that these are really health systems issues and that a lot of the improvements in health care and health care quality are going to result as a result of better community services and improvements in the public health system.
The structure that was set up to manage activities across the department was a steering committee, executive level steering committee broadly representative of HHS's agencies and offices and other components of the Department with high level representation from those various components. That steering committee has a number of subcommittees and working groups that contribute to its overall efforts and the first major accomplishment was the development of an HHS Action Plan for the prevention and hopefully eventual elimination of health care associated infections. In the beginning that Action Plan addressed only work in acute care hospitals and focused on five areas of specific types of infections. Those were three device associated infections: blood stream infections, catheter associated urinary tract infections and surgical site infections and two organism specific infections: Methicillin-resistant Staph aureus and class treating of difficile infections, set some very ambitious goals including a 50 percent reduction over five years in the incidence of catheter related blood stream infections.
That got off the ground in 2008. The baseline for a number of these measures is 2008 data collection. The primary data collection source is the National Health Care Safety Network run by CDC although some of the measures are drawn from the HCUP Project managed by AHRQ, the SKIP Project managed by CMS and the Emerging Infections Project also managed by CDC.
So the work in acute care hospitals was deemed the tier one effort. In 2009, at the end of 2009 and during this year, 2010, we have expanded the scope of the action plan to include the so called tier two activities of which extends us into the outpatient area and those are specifically infection prevention in ambulatory surgical centers and in end stage renal disease dialysis centers and we can talk if you wish about why those were chosen, as well as extending into the area of health care personnel health and the area of influenza vaccination among health care personnel.
Specific chapters have been developed for the Action Plan to expand the Action Plan. Those draft modules have recently been published in the Federal Register. I think they were released actually just about two weeks ago in the Federal Register. We are now reviewing the comments on those drafts. The Action Plan itself is undergoing an extensive revision and we hope to have a new version of the Action Plan which includes those new modules and the extension into the outpatient area published sometime in the first quarter of calendar 2011.
In terms of the measurement and the goals that were set in 2008, 2009 and as I know you have been taking about and we are taking here at the meeting in Atlanta very, very important to have good measures to be able to track progress and we recently completed a meeting, a stakeholders' meeting that we held in Arlington, in Washington area just the end of last month which and I was able to hear some of your earlier discussions this morning about a more consumer centric view. In fact we had a very good representation from consumer groups and patient advocates at that meeting and worked very hard to engage them. At that meeting we presented our progress over the last two years since the targets were set.
I mentioned the 50 percent reduction and we are in fact on track. The progress that has been made of two years has seen substantial improvements in the rate of catheter related bloodstream infections as measured by the National Healthcare Safety Network and if we can maintain that pace of change, we will hit that target. And we are also on track to meet the target for reduction in surgical site infections. That is a more modest target. That is a twenty-five percent reduction over five years of what we are on track for that one as well. So we continue to monitor that progress.
The new modules for aim at surgical centers and end stage renal disease dialysis centers as well as for flu will set very specific targets and goals for achieving improvements in infection rates in those settings and for those infections and we continue to work on that as sort of the core of the work we do from the standpoint of promoting innovation.
We give seed money primarily to the agencies and to other groups at HHS, to fund projects that would not necessarily be a part of their regular mission but certainly that encourage cross agency collaboration. Those are again pilot projects or seed money for things that are done both in the area of research and in demonstration projects. We are now supporting a similar type projects in some of the HHS regions and we actually very, very proud of those because they are also stimulating work. For example to look at infection prevention in small and rural hospitals in the West, to look at communications strategies for reaching out to consumers, to enlist consumers in helping in the goal of improving health care quality and preventing associated infections. So that is the bulk of our work within the area of health care quality.
I will just mention very briefly, the public health quality work. We have a very, very dedicated if small staff working on that. They have also done a terrific job of reaching out throughout the public health system particularly the governmental public health organizations, state and local health departments as well as other experts in public health. They have developed a working paper on priority areas for improvement in the public health system and that document is going to be released and presented. It is scheduled to be presented at the meeting of the American Public Health Association which is coming up in about two weeks in Denver and that will, if all goes according to plan, that will be presented by Dr. Howard Coe who as you know is the Assistant Secretary for Health. So that is the other major area that we are working on.
That is a very, very brief overview but I know you as always are always challenged for time. Let me stop there and see if there are any questions and then maybe we have some time for me to elaborate on some points that are of particular interest to you.
DR. MIDDLETON: Thank you very much Dr. Solomon. There probably will be several questions. Any burning questions on the table? Larry.
DR. GREEN: Can you say more about this public health quality measurement group and particularly help us understand where you seeing the intersection with the redesign of the delivery system that NCVHS is very interested, particularly its Population Subcommittee but also this Quality Subcommittee in finding the new epidemiology. Have we developed new numerators and new denominators, collect data once use and use it often reuse it, reuse it, reuse it, reuse it, reuse it. That is sort of a mantra almost. Can you tell us where you are headed and what the reach is of this report and to whom it is intended?
DR. SOLOMON: Yes, absolutely. As of this point, it is not measurements per se. There is a section on public health measurement but it does not get into the area of choosing measures. It says that those are very, very important and recognizes a tremendous amount of work is going on. That particular work which is going to be presented at APHA really focuses more on systems type thinking and the idea that we need to take a more systems based approach toward improving public health quality. What needs to be done within the existing public health system to change some of the models of care and as is often discussed, Larry and I will let me just digress for thirty seconds by saying that yes the funding through the American Reinvestment Recovery Act really sparked tremendous growth within the public health system.
The meeting that we are here is a meeting of state health care association infection coordinators and what is being discussed is adopting the paradigm of elimination. Some of you are familiar with other campaigns. For example, the committee to eliminate tuberculosis in the United States and the long standing approach within the public health system to have. We have the state TB coordinators. We have state chronic disease coordinators. We have state environmental health coordinators. Well as a result of the ARA funding, we now have state HAI coordinators. That is the group that is meeting here in Atlanta from all 50 states and territories to discuss what public health departments do to help eliminate health care associated infections. That is tied in with the growth in the public reporting of health care associated infection rates from hospitals and other health care institutions.
Just to complete that digression, obviously the Affordable Care Act contains a number of provisions that reflect back on population health. We are in fact the targets that we have are national targets. Those are population based targets for the NHS and a measurement for example for central line associated bloodstream infections. I will say that the HHS Action Plan which I mentioned is actually cited in the Affordable Care Act legislation as the milestone to be used for measuring progress for health care quality improvement.
So from the standpoint of population health, that is the work that is going to be presented at APHA does not get into the specifics of what types of measurement systems but really talks about how to restructure the health care, some ideas for improving systems work within the public health system. So I hope that clarifies that.
I think the other part of the question, Larry, was what is the intersection? Clearly that is as I note you have been discussing is part of the Affordable Care Act the idea is to keep people out of the hospital. To keep people healthy. The so called downstream work or upstream depending on your point of view, the primary prevention that public health departments and communities need to be engaging in that helps keep people in the community, helps keep people well and keeps them out of the system. I think that is the broad brush stroke on that.
DR. MIDDLETON: Steve, Blackford Middleton here. I was wondering if you could give a little more color commentary on the Action Plan details that will be the interventions reducing hospital acquired infections or you know the cath-related blood stream infections, etcetera. What is the intervention that you are proposing and how is that being implemented across the country? Is an IHI type thing or what?
DR. SOLOMON: Yes, these individual subgroups that work as part of the steering committee work across a range of issues. There is an information systems and technology subgroup, an incentives and oversight subgroup that talks about things like pay for performance. There is an outreach and messaging subgroup that is very involved in both consumer engagement and the engagement of health care providers and there is a research subgroup that talks about what are the knowledge gaps that need to be filled.
There is no single, there is no magic bullet. However what is being discussed quite a bit at this conference and as you may know at many other conferences is the so called CUSP type approach, the Comprehensive Unit Based Prevention which really talks about having three components. One is what is the best evidence. What are the evidence based recommendations and what are the high priority recommendations?
CDC's Hospital Infection Control Practices Advisory Committee has been developing guidelines, evidence based guidelines and producing those for many, many years and in fact there are several hundred specific recommendations and one of the calls was that there needs to be a prioritization of what are the most important guidelines. What are the most important things that hospitals and other health care agencies can do. So we are not only having the evidence based guidelines. We are prioritizing those.
The second component, is the data is feeding back both national data for benchmarking and local data which obviously as you know, is the most important thing. What is happening in your institution? What is happening in your hospital? What is happening on your ward? What are the rates associated with your surgeon? That type of local data is extremely important.
And the third component is really the so called culture of safety which again gets at this issue of either some folks view it as the social science issues. Some folks view it as a complex systems or a systems thinking issue. But it is really to address the model of the way we think about health care and health care associated infections at the local level. So that is a very popular approach that has been used, developed by Peter Pronovost among others at Hopkins. It has been used with tremendous success in Michigan in a collaborative with the Michigan Hospital Association and that is spreading to some other states. Tennessee has had some good results with that.
So I would not say it is a thousand flowers blooming, but there is a recognition that within each state, within each community, and within each facility you have to take these best practices and learn from them and adapt them. But I would say as very, very well the three cornerstones of that are having the data, having the evidence based practices and then in fact changing the culture to be more prevention oriented and variations on that theme does seem to be working.
DR. MIDDLETON: Matt.
MR. QUINN: Thanks Dr. Solomon. This is Matt Quinn from AHRQ. Just a quick question. Is there a way that we could have a roster of the folks who are part of the group and then some of those subgroups around IT and technology and some of the others?
DR. SOLOMON: Absolutely, absolutely and we can get that for you. The folks in your shop most involved have been Del Munet(?), Kathy Crosson and Jim Quinn and Jim Battles who is here at this meeting. Those four folks have really been in the lead on working with us on the steering committee and on the subgroups. So I am happy to connect you with them or I am happy to get the information.
DR. MIDDLETON: I was going to see if you could send the whole thing to Debbie Jackson. That would be great and she can send the list to the group.
DR. SOLOMON: Yes, sure.
DR. MIDDLETON: Thank you. I am going to suggest we move on if there are no more burning questions, and perhaps the desert for our meeting is the next part here. Booz Allen has conducted an environmental scan which Paul and I have had a chance to preview. I think in a way we can begin to think now about to tie together of all of the four different panels and the various themes we have heard from all of the expert testimony and now relate this to the environmental scan and begin to frame a quality letter to go forward to the Secretary for this vision of a measure roadmap for the next three to five years. So, Kristine please take it away.
Agenda Item: Environmental Scan
MS. MARTIN-ANDERSON: Great and I was not here in the very beginning so I am Kristine Martin-Anderson from Booz Allen Hamilton.
I am going to take you through an environmental scan that we started in about September as the hearing was being planned and explained how we did it and what we had found. Starting with the executive summary, I think that most of the summary actually resonates well with me from the panels and what we have heard. What we wanted to address was where are the main gaps and there are still many, many gaps around information that can track progress toward an efficient health care system and then a gap that we talked about a lot yesterday came up again today. Information that actually can engage and activate consumer assessment. It is not really health reform. It is participating in their own health.
We noted a pretty obvious difference between what consumers desire to manage their health and health care and what is important to regulators and purchasers. Consumers do not really equate information with measures and they do not use the current measures but this is actually something really important that we will come back to which is that a lot of our scan was focused on how do you get measures that matter? How do you get measures that actually advance health and health care improvement? So we will come back to that a little bit.
Provider organizations have embraced the need to measure and improve and demonstrate efficiency in health care systems. It is really not a matter of lack of desire. It is really a matter of problems still around methods and measured gaps and this concern about burden of measurement and the potential that it actually could divert the resources from quality improvement where they really need to be spending time to advance. So it is again that measure then reuse, reuse, reuse is something that we hear again and again. Providers have a particular need for information about how to engage consumers and how to coordinate their care and how to assess their progress. So we are going to go through some of the details. But those were sort of the high level findings.
So why do we do this scan? It was to support this Quality Subcommittee in their development of a letter to the Secretary with recommendations. We really wanted to gain perspective as the Committee really wanted to gain perspective around several different stake holder groups. So those who use or consume, does it provide care, accredit and regulate and then who make decisions about coverage. So you saw that the agenda was actually structured that way. I am not going review the questions because are the same questions that are in the agenda and that our presenters actually presented so I am skipping now ahead to page seven.
This is where we really talk about how we approach this scan. The guidance we got from the Co-Chairs from the very beginning was this need to be forward looking. This is not supposed to be an environmental scan that looks back upon all of the things that have already been tried and says you know what needs to continue. And so in order to do that, the guidance that we got was look for the measures that matter. Look at places where performance improvement has occurred and what measures help drive that. Look at places where performance improvement is not yet getting us where we want to be and look to see what people are articulating the gaps to be.
So the way we did that really was not a classic literature review. We did look at the literature but was also did searches that were more oriented toward improvement had occurred and then trying to look back at those projects and say what was it that, is there anything in these descriptions of efforts that tells us what they attribute their improvement toward. How do they get there and what role did measure play in there.
We had to look at a lot of different information and we also wanted to look at the roadmaps and frameworks that were already identified because the idea of doing a measures roadmap is brand new. There have been quite a few done and there have also been a number of frameworks around how to think about measurement and so we also then looked at the existing frameworks and wanted to make sure that we could sink up with what those organizations said were the gaps then compare that to what we saw the gaps were in practice for those who actually were advancing quality improvement.
When I organize these results by the four questions and the first question was what information and measures would help consumers better understand and become more active participants in managing their own health. The findings here really very much reflect what we heard in the panel yesterday. They were looking for condition specific information and also patient specific information. They wanted personalization, so actually if I flip to the next slide it makes it easier to summarize it.
For the consumer measures, the message back was they are not so interested in these fragmented quality measures. They really want holistic measures and also customized to their own condition ideally linked to some kind of coordinated guidelines that are not about each individual specialty that they might come in contact with. They want answers to the questions like how am I doing relative to how well I should be doing post surgery or what is my likely outcome given my circumstances. We heard a lot of that yesterday. So that was not too new.
Really consumers do not use quality measures to select providers. There have been a number of surveys that prove that. The most recent one we found was a Deloitte survey that was just done in 2010 where and it was around selecting hospitals. Quality ranked sixth among factors that consumers use to choose a hospital. So this was consistent across most of the literature that we looked at. That is not what consumers wanted. They wanted much more information about how to coordinate their care and they wanted to know how well their provider coordinates care. They also wanted to know if the whole person was taken into account. So we talked about yesterday about functional status and quality of life indicators. They also want to know something about what are my options given my insurance choices, etcetera. Very personalized information.
Within the consumer groups, we also saw a bit of consistency in the writing around linking what we want to give to consumers to what is happening in community health, so connecting health and care. So, looking for metrics to help connect clinicians and the communities, and population health metrics, and potentially composites to measure the impact of community interventions and medical care improvements. There were a few communities where we found that already occurring in Minnesota and San Francisco and a few other places but it was not the common response.
In this journey in talking about how quality improvement, quality measures and improvement are linked we came across a lot of references to technologies and when we found those in the what worked thing part of the scan, when we found those I think the story was that there were lots of improvement stories that told how they had integrated technologies into moving from measures to improvement. So these are just a few of them talking about capturing consumer specific information that was put into PHRs and the accessibility of that. Functional assessment information, that was also collected through in-home monitoring techniques. Patient experience information that they were able to create their own feedback links and also talk to others with similar conditions through social networks. Then also different ways of doing patient navigation so one of the main interests of consumers was how do I navigate this health care system. There are lots of different formats by which they were able to do that. I think this is presented more for context. If you are thinking about the role measurement plays in improvement, you also think a little bit about what else plays a role in improvement and how do we make the whole system work together.
Then on providers, I am going to switch to just the measures as a way to talk about it. Okay. We did see quite a bit about customization of quality measures. I think Barry talked about that a little bit this morning, what you use internally within your clinic or even within the Minnesota Community Measurement. It might be a little bit different than what is out there for public reporting. So they might not always be the same. They sit together right? These are measures that are often times overlapping with something else that is a priority at the national level, and that led us to ask the question in sort of a ruminating way, is how do you provide the least burden on providers. So if there are for instance process measures that are more likely to be customized, how do you think about getting you know nesting quality improvement and public reporting or should they really be the same? This is really something for the Committee to talk about some more and decide which if they feel a particular way for their recommendations.
But there were sort of two sides to that. There were some who said look for QI I really need to be able customize some measures because what matters in my community is what gets my clinicians to engage. It does not have to be same as what is measured nationally and others that said look we really need to reduce the burden and that is the number one concern. So we are going to use the national measures and we are just going to repeat use of them for quality improvement. But providers also expressed a need for better understanding of non-clinical outcomes. So how do they, for their particular population so they can support patient centered care. They are also aware of the fact that their view is often fractured of the whole patient.
There was a need expressed for providers to understand how their peer clinicians are treating the same patient. So the lack of information that flows back and forth between a primary care physician and a specialist is something that they saw as a gap and they needed better metrics to think about as they refer to specialists. How do they know who is the best or who is the right one for that particular patient.
Providers saw gaps in areas that were mostly do to methodology or information constraints so there are not good measures for care or coordination or transitions of care and there have been some focus lately on hospital as opposed to acute rehab, home health, etcetera. Episodes of care not being satisfied as of yet with the way that episodes are constructed and that measurement comes out of episodes; that the methodological issues have not been resolved there.
Efficiency including patient flow, how do you get a sense of not just efficiency within an individual site but what is an efficient episode.
Specialty care? There are some that are in proprietary registries and are not accessible to everyone and there are other specialties where there really is not a lot of data that is collected. Then trying to segment their population and disparities and understand how health disparities is impacting outcomes that a lot of the data that does not exist in order to be able to parse their own data to understand performance.
We also again as we talked about provider, looked at a provider information, saw these references to new technologies that are enabling improvement. Most of the references in this case were around clinical decision support technologies and helping point of care but also talking about there are some examples of informed referral systems, electronic referral systems that are more advanced that met the need. I think the point really between this slide and the last one is there are examples of technologies that are advancing this. They are just not necessarily universally used.
Then this consumer provider intersection was another area that we pulled out. The lack of understanding and measures around self care strategies, and which ones work. How can providers or health care facilities include patient input? Measures of patient engagement and shared decision making are not broadly adopted. Measurements of population specific care coordination and care transition and then expansion of this patient experience of care survey so that there is a feedback loop across the management of a medical condition and not just experience I think that should be with an instance of care. So having a better holistic view of what the patient is experiencing beyond what they are experiencing in their office or in their facility.
Now switching gears a little bit we also looked then at professional organizations, accreditation organizations and regulators we get to a different place. I am going to go to slide twenty one this one.
The regulators and accreditation organizations are largely who is driving the national measurement agenda and they desire more measures covering a broader population. So the mantra that you will hear more measures, more measures largely comes from this group and the purchasers which we will talk about as well. But they are not necessarily creating the measures but really choosing which measures get broadly adopted and implemented. They express a need for new ways to measure systems of care as care is bundled and organizations become jointly accountable through ACOs.
The next two are more reflections so I want to make it clear that these are not things that were said in any one particular report but more sort of fodder for the Subcommittee to think about. There seemed to be distinction between procedural and knowledge based care to identify differences about how do you think about how you measure across those two groups? So for instance what do you do when you know that volume is a big driver of performance for a procedure? How does that get incorporated into measurement and would that be different from other areas where there is not such a high correlation between volume and outcome?
Reflected on the lack of the examination of the decision making process and this really has to do with the fact that not all decisions are date driven and if they are they do not all use the same data. So looking more for some systematic link between measure and behavior change so if you want to think about these organizations that desire to move the system in a certain direction, what measures best moved system and needing to understand what types of measures matter to different groups.
The last group that we looked at were payers and group purchasers, and here we saw more of a focus on measures of value and efficiency, the need for consensus definitions around how you measure value and efficiency. Desire for more resource utilization measures during an episode of care so how do you get to overuse and under use?
Integrated quality and administrative data? I think it also should be clinical and administrative data for quality.
Outcome measures to evaluate the impact of a coverage decision. So there has already been some research that has shown that what you cover impacts what utilization of which services will be used but more need to understand how that lever of changing coverage impacts quality.
Then information on patient satisfaction experience and quality, in relation to overall care efficiency. But in this particular area, there was lots of writings about the deficits and the ability to define value because of the lack of agreement on measuring costs and how cost could be attributed to certain treatments, products, people, etcetera.
Overall the payer and group purchasers tracked really closely with the regulators and accrediting bodies on measure means broadly although there was more focus on value and the need for resource utilization that brings measures. Measures of value are really challenged by changing perspectives cost to whom, value to whom, and also you know this discussion we had yesterday around is it out of pocket costs or is it total costs that really move a consumer. If it is only out of pocket costs that move the consumer but it is total cost that need to move to satisfy the payers and group purchasers how do you reconcile that and have it all pull in the same direction?
Then again this reflection on how do we access value when coverage decisions influence consumer and provider decision making in really non-random ways?
Take some questions?
DR. MIDDLETON: Thank you Kristine. That was terrific even on a repeat hearing with all of the nuances that you added in we can consider now after these two days of testimony. So I guess now what I would like to do is open it up for discussion across all issues from any member of the Subcommittee or any testifiers still here. Any parting shots on synthesis or integration of themes and concepts?
When I think about what we have heard about over the past two days there are many, many different themes that come to mind for a measurement roadmap. You know first perhaps the measurement science issues around what will be measured and what are the constructs of measures both in the temporal sense over time but over space as well perhaps in a geographic sense. How do we assess the transitions of care and measure quality across transitions? How do we assess quality across providers in a care team? How do we assess quality in relation to a patient context? And where do the social, environmental, clinical and financial impacts on an assessment of quality? How are patients themselves contributors to quality through patient activation and how do we measure that and perhaps even think about measuring provider activation or a system activation thought that all three might relate to a quality assessment? What are the sort of the physician attributes whether it is certification, licensure, or other fundamental assessments of a knowledge base as another element of a system characteristic physician as a component of the system. How do we assess that and its influence on quality.
I am reminded of Justine Carr's quality circle that the NCVHS created a while back. I think we should surface that and think about it again as it relates to a quality roadmap. It might be fodder for an extended view of quality development over the upcoming years. Then how do we even visualize quality. The compass ideas and the triple aims and the four axis of a compass. What is meaningful to both the provider seeing a patient and thinking about a population or a cohort or to a patient who is trying to assess a health care system or a provider for a particular condition of interest. So those are just some very quick thoughts. Lots and lots of ideas and extraordinarily fertile ground I think to actually do something useful and interesting that will help which is always nice.
But let me open it up for questions, discussions, synthesis from anybody else. Paul.
DR. TANG: So my true lumping style I can only think, I almost bring it we talk about measures that matter and when we talk about costs and quality I guess I am in the camp that says if you make appropriate decisions then the cost will fall out of those. So similarly I think if we pay attention, if we looked at a systematic sort of look at the various stakeholders in quality measures, that the people who matter are one, the person we are focused on the patient in the care situation and two, the folks who most influence that through their orders, the clinicians and particular physicians. So if I hone in on those two groups, start with the folks that we are trying to influence in what they order, let's say, and in particular docs and time and time again both hear the story that Barry told and experience it my own organization where if you give docs credible measures almost for free they want to improve. There is nothing better than free in the sense if it does not consume any more societal resources. So, credible data is powerfully motivating. So that is the give people, give the people you are trying to influence, whose actions you are trying to influence, the data and credible measures and things will change.
On the patient side, I think really we have done almost nothing for them up to this point. The plea that is very simply stated was a couple of times which is just give me a way to know what is going to happen to people similar to me which is what Eva said and was repeated by Kristine. If I had measures like that as a patient, not the average patient where everything is basically normalize and the meaning exact away from it in terms of how can I as a patient who wants to make an informed choice use this information. So in a sense, stratifying to some major groups where I can try to match like your MPG, your miles per gallon in a car, I either drive in the city or I mostly drive on the highway. Let me know what is going to happen to me. So I either have lots of comorbidity or I am basically healthy or I am this age group, etcetera. Let me know how I could I sort of have an idea of what would happen to me if I were under your care or your system's care and oversight. I want to put it, I do not want to only possess care. If I developed a relationship or partnership with this health system, how would my overall health improve? I would like to know that as a consumer, as an individual.
So I would almost focus on those two kinds of things and I think actually the payers would get what they need out of that too. One, what you want I am looking at Dave Stumpf who represents the payer when you just want high quality cost effective care. If these other two make that happen, it really doesn't make. You can stop running your machines I think. I am somewhat being categorical but also for the people on the phone, David Stodding.
Now regulators have it a little bit different. I mean we heard some very interesting comprehensive way to figure out well are you in their case, are you a good doc. Do you know the stuff? Do you know how to do the stuff? Do you do this stuff? That is really good information and that is another complimentary piece of information for a patient to know. I would just like to focus on getting measures to people who are trying to influence on the professional side, the docs and clinicians, and the people who are receiving of these services on the consumer patient side. I think those measures are largely unavailable in the public sector now meaning publicly reported so what Barry said is unabashedly said you know what stuff that is handed over and that we are forced to report on right now just really do not measure up to what I need to influence the docs. So we use this zip(?) set of measures happen to be the credible clinical measures. I think that is the message for me. So, sorry that that was what I took away from Dave's.
DR. GREEN: Before we lose them, is there any of our testifiers who are still on the phone and for Barry and David, I wish you would say more about anything that is going through your head right now.
DR. BERSHOW: Partial question for Kristine and then the rest of the group or a comment first and then the question. I agree with what Paul just said and what Kristine had presented that in general consumers have not been paying attention in our own website hits and if we track where the come from they come from doc's health systems, insurance plans, big employers, not from consumers. In a way you can think well it doesn't matter if we can really get the quality up then it doesn't matter what they see but we know in fact that variation is always going to exist and even if we get it to be stupendous at a 90 percent versus 100 percent, there is going to be some who want to know who is the 90 percent and who is the 100 percent.
So my question is, is it that consumers are not really interested or that they are operating under the false assumption that quality is like water in the United States no matter what tap you pull it out of it it is excellent. It is safe. It tastes good. I think if we could get the information in front of them that on the average looking back at Minnesota five, six years ago that only ten percent or less of the diabetics were getting the care they need. The immunization rates are terrible. The cancer screening rates are terrible and that there are huge variations spot to spot. If they had that information would they be more interested and then we would not have to drive it to them.
MS. MARTIN-ANDERSON: I do not know the real answer to that but I can tell you from looking at the literature that we looked at and at the programs that we looked at that the message was different. It was that at the end of the day they really care about how they can personalize the information to themselves and that while they might interested from a societal view of what is going on in this sort of health are ecosystem that when it came to the point of decision, they really just wanted to know how do I use any of this information because I want to know what are my chances of survival. What is the difference between how I might operate? How functional I might be a month, two months, three months, after surgery? You know what is the likelihood that I will experience that complication? So I think it was stated best by Eva, there are very, they have a lot of other things going on. So spending time to study the health care system is not on their list.
MR. STUMPF: Dave Stumpf again. So I like Paul's comments as well, but maybe just to step back. I mean what we now do as payers is sort of viewed as managed care and I think that at a high level we are moving to a different model. It is not, it is like all politics are local. All care is local. You are moving I think more to a collaborative model where the various players in this enterprise are collaborating with each other and there is not this management from on high and part of this is cultural too from the whole industry. I mean physicians certainly speak very highly and being what I do too of the relationship between the physician and the patient but at the same time they really do not know a lot of the details about the patient that are absolutely critical to their successful care.
One of the models that intrigued me in thinking from a big corporation standpoint was the FedEx model: not FedEx, the Fidelity. Fidelity collects all of this money for our 401K plans from our employers just like we might collect all of this money from employers for health care. And yet they view you as the individual, as their customer. So you can go to the Fidelity website and see your account and move your money from one account to another and do things like that. We have not had that focus on the individual as our customer and on the payer side. I think that is something that could change.
I think that there is a couple of very high level things to think about that are low hanging fruit and where there is experiences in other industries that have changed things. One of those is eliminating middle men in the system. There is a lot of waste there. Somebody mentioned catalogs of services and things like that. It is part of the model we are looking at now too. Eighty percent of the reimbursement in health care occurs with the very limited set of codes. Those could be put into catalogues and instant payments retail models and eliminate most of the clearing house functions.
If you listen to the AMA they report that about fourteen percent of a doctor's revenue is going into collecting fees and that translates into billions of dollars that is going into just that administrative process. It could be simplified.
The idea of insurance exchange is to me the attractive thing about that is the ability to eliminate brokers. Brokers account for about five to seven percent of health care costs and they are just merely in the middle of connecting an employer to a insurer. The travel industry was able to move brokers out of that role in about two years. Now most of those travel agents are still working but they are doing it in a different context that has a lot more value than what they did before and so I am not suggesting the brokers get totally eliminated but that their role is refocused into and not in a role that it is currently at.
So I think again I am not speaking on behalf of United Health Care here because we use brokers a lot. We depend on them and this actually gets into a third point which is how do you get from here to there. One of stories I like to tell is I was on the hospital board at Northwestern at a time when we rebuilding the campus and we had these old facilities and we had this new facility that we were building. In the context of the capital and operating budgets which I was on those committees, the question always came up is when do we stop repairing the leak in the roof on the old building because it was leaking. We were still admitting patients there but the roof leaked and at some point we said no more. The same thing is true with the equipment. What do you move? What do you scrap? What do purchase brand new? We have a lot of those dilemmas in health care right now. We have products around quality metrics that make a lot of money for us. They work. The industry wants them. They use them but they are not suitable for the next generation.
So how do you, when do you stop supporting those and start migrating the next level of things that push it to the point of care and things like that. These are very real issues and when I start thinking about shared savings, you know if a group can push the price down on something, you have to distribute that to where it is actually going to be impactful. So for instance you know the experience up in Virginia Mason when they suddenly cut out all of the imaging for back pain. They were left with a dilemma. They had all of this capital investment that they had to depreciate and part of the shared savings it needs to go back into depreciating those assets so that people are motivated to actually make the move and we haven't thought I do not think enough about the cost of the change process because that is a very real cost.
The emphasis I put on the content in my talk is that we do not have enough content so that we have structured data documents for all of the things that go on in health. I am a neurologist. I am need a template for a new migraine patient, a new epilepsy patient, a new this, a new that. My professional society ought to be creating those templates for me and yet the societies do not have the resources to do that today and there is not a incentive built in for the organizations and I am advocating now for more money going into some of the organizations to create this kind of content because until you get them funded and empowered to do this, you are going to have I think a real shortfall in your ability to collect standardized data. That ability to collect standardized data is critical for quality measures, for maintenance, for certification processes, creating registries, doing all sorts of things. It is a fundamental infrastructure thing we need.
DR. MIDDLETON: Go ahead, Justin.
DR. CARR: Okay, thanks. I have appreciated these fantastic presentations. They are just tremendous. I had a couple of observations. I think that we are living in this world of clinician generated data and we are working with the standardized measures that we have, and that is what we are pushing out on the websites. So we are clearly hearing that the patient wants to understand what does it mean for me. In the spirit of grid you know I think there is almost like a two by two kind of thing where outcomes are what physicians tell you about on the y-axis and on the x-axis is really patient burden. So for me to live five years with stage four whatever, I can do that but what is the burden on me in terms of the complexity of the care, the frequency of hospitalization, the cost of care, the likelihood of complications, and I just think that there might an interesting model in beginning to move toward representing. The physician is always going to be thinking in terms of outcome and mortality and so on but overlaying with that the patient's burden whatever that might be cost or complications or hospitalization.
So that gets me to another observation which I think we talked about in that May 26 summary which is just the need for education at large. We have to educate our patients and our providers but we need to develop a new workforce of data developers and part of that is what was just mentioned about template creation within the specialties societies but then also looking at how do we depict data and what do we use and how do we risk adjust and how do we make these dashboards and I think that this is a new discipline that needs to be part of our universities, part of NCHS and others to really develop that.
Then just a third observation as I am looking at some of our own care and cost data at the moment it is that FTS and UHC and various aggregators have very rich risk adjusted broad database data but it is held up with contractual relationships and even, not necessarily able to be shared so in many ways it has more granular data but it is held captive because of these understandable proprietary relationships and so we default back to things that are maybe not risk adjusted by publicly reportable. So just my three observations.
DR. TANG: I wonder if I could go back to Dave Stumpf because I thought he said a lot of insightful things and now I am going to challenge a little for a different relationship because he also mentioned collaboration. So one I will remind you that payer is a middle man, too.
SPEAKER: Payers are what?
DR. TANG: Are middle people, too. So speaking somewhat categorically, in a for profit payer you are using this data and your analytic techniques in order to find profitable arrangements. Tell me if this is true in the health insurance reform, in theory that should be less important because you will have to take more risks across the board and that is where you can tell me well actually that is not true anymore, it is not really true. But if that were true then it seems that for you to make your margin on your piece of the transaction, it goes back to our saying if the providers you contract with just make more appropriate decisions, deliver better care in a cost effective way, you still make your business and so you would be less inclined to have your proprietary way of analyzing data and more vested in working with the providers, collaborating with the providers and helping them get better data to do their side of the game which is do better care in a more cost effective way. Is that holding water at all? One, is it true that under insurance reform in say 2018 will it be less incentive for the payers to try to differentiate themselves among say other payers by sort of doing their proprietary data bank and would that, could that actually translate into more collaboration on the data analysis side with the provider?
MR. STUMPF: Yes, now I understand. It is a great question. What you are addressing is the fact we really do not have health insurance in America. We have prepaid health care that then gets thoroughly managed and I think what you are describing is moving more back towards an insurance model where you have a more predictable risk and part of the problem right now is the data is limiting on what you can predict with risk. I mean even with the best analytics that we can do with episode treatment groupers and quality functional outcomes with the SS36 all of this kind of stuff you can get to a level of predicting risk. This may be 40 percent and you miss a whole lot of detail with what you can do now.
So that is why there is a lot of emphasis on managing various aspects of the system. The mission I think is, so what I think you are going to see as a movement this is why I think our company happens to actually be well positioned because we have this big payer component. We also have this big service component and it is possible to translate a lot of the things that are going on in the payer side which are costing money for everybody into services that are actually revenue generating for the people who are able to provide the services.
So if you can take what now might be a report card to try to hang up and say this guy can do better and instead you turn that into services where you are delivering analytics and data and things to the point of care where they are actually in the beginning at the point of care making the right decision, you do not then have to manage it on the other side. So I think in addition to kind of merge workloads and get this data repurposed you want to try to convert what are now cost centers into revenue centers on the other side and to get people delivering more services to the point of care instead of trying to manage it from on high.
DR. TANG: And will reform move in that direction?
MR. STUMPF: Well yes I think it will. I think there are some things that could be done to stimulate that though myself. For instance, right now the payers do tend to get viewed as the bad guy here, the heavy hand. You have to ask yourself what are their incentives.
Now there is always the capitalistic ones but there are other things that can be put in there so for instance you could think about a tax incentive for a payer like we heard here who is paying 40 percent of their money is being paid for quality. That could be incentivized to that payer so you know you are in a tax free state but much of the United States is not and a lot of health care, well their health systems are nonprofits in Minnesota.
That is kind of unique market but in the for profit areas where that takes care of a lot of costly care, there could be incentives actually that are positive incentives to move payers to a different model. If you were paying, you know set a target, 20 percent of all your things based on outcome metrics there is an incentive for you financially to do that.
MR. QUINN: To build on some of your discussion as well and an appreciation. It is so much that collaborative care is important and we would certainly hear about medical homes and ACOs in the model, there is sort of decision or maybe it is not a tradeoff but there is certainly x amount of resources and effort that can be spent in the next two to five years on improving measurement and one set of activities could be focused on the health care enterprise and improving measurement capabilities and measurement validity for health systems, individual providers and then there is another set that is not you know there is definitely overlap here but one that I would argue will take concerted effort and heavy lifting, cultural, political, technological, etcetera, that is actually connecting communities so that we have good measures of coordination of care, connecting so that we can look at attribution of care and frankly, an ACO that includes more than one hospital system or will require that. How should we balance those and is putting too much effort in the latter going to do the ability to accomplish the former?
MR. STUMPF: In my opinion, yes. I mean we can invent quality metrics until the cows come home but is how you implement them that is going to be the most important thing which is why I put the emphasis on sort of this business process management and the coordination of care model which gives you accountabilities and traceable information that allows you to measure the quality. I mean I think if you create that ambiance or that environment people will become creative with the quality metrics that they are doing and there will be a definite stimulation oh this is what we are trying to improve.
So yes, I mean the current pipeline for quality measures is very cumbersome and it takes years to get them all down through the system. We need something that is a production environment that is much quicker so that you have this iPod I have got and you just download the app. This is app to improve the quality of diabetic foot exams. People will take Blackford's example. People will get very creative on how they begin to create and gather that data. That can then be plugged in as the one of the outcome applications for diabetics. So I think the infrastructure and how you are going to orchestrate that is very important to quality improvement. I know people take issue with well it is not about process improvement but if the process improvement is necessary even to measure the quality because right now the whole pipeline is very cumbersome.
DR. MIDDLETON: You know David one thing following up your thought I guess what we did not talk about in this panel or this committee, this set of hearings was really kind of we talk about roadmap and kind of development agenda and perhaps the target areas, etcetera. We did not talk about implementation at all. I think that is okay but many interesting and thorny issues will become apparent.
When we think about implementation of quality measures writ large whether it is local, regional, national, the production life cycle, implementation, methodology obviously with all of the details and then the measurement and assessment process for the whatever the implementation is, I have a particular interest in this because I think decision support is obviously the front end of quality in one way and we are conducting as some of you know some intriguing experiments about distributing decision support services via the web to anyone who is interested to publicly subscribe.
Could the same thing happen with quality? Could quality measures be distributed? Could assessments be done in a distributed way that might help establish at least the first order of business case for quality is how to get it done? The second order of business case for quality though I think remains challenging because one person's savings is another person's loss in the classical dilemma and the patient perhaps is not as sensitive to that as much yet under varying degrees of out of pocket expenditure, etcetera, but we do see a trend in it sometimes on sharing of data for quality assessment to view that patient then, actually a transparent view across providers. So some have overcome this in very interesting and creative ways but that is the second thing we did not talk about in this agenda was sort of the explicit business case considerations.
MR. STUMPF: Quality measures I view as decision support tools. They are as CDS said, one mechanism of clinical decision support. In this set of circumstances this is the right decision to make. I like what you are saying about it is one subcomponent of clinical decision support. Most clinical decision support does not have evidence behind it. It has got consensus and business rules and experience, et cetera.
The more we can encode that the better, but even more and it is better because having encoded it we now can collect data systematically about how that decision was done and eventually that becomes evidence. That is really I think the basis for comparative effectiveness for search Q. If you get these various decisions encoded and one doc is going in one direction and another one is going another one, how does that node influence the outcome and then you begin to generate evidence from the standard workflow of a doctor and you create a learning environment which is exactly where I think we want to be.
MS. MARTIN-ANDERSON: This fits with one of my sort of takeaways of what I have learned through this past month process and one of the main issues was where can measures serve to provide the link between assessment of performance and behavior change whether it be at the clinician or a patient level. It strikes me, if you think about measures from the perspective - certain types of measures make obvious links.
So for instance if you think about outcomes, the risk adjustments that you do to get assessments if you turn it on your its ear it is risk assessment that can be used at the clinician patient together or consumer alone level to try to face what about me. If you plug in the same parameters and it can tell you what is your risk for some are hard, some are easier. Then if you also think about process composites and if thought about process composites to include not just what the clinician does but what the patient does.
You have got a broader process composite and you understand which we do not yet, the link between that process composite and outcome, and the contribution of each element. If I stop smoking or if you check my eye exam, right? What is the likelihood that we are going to get improvement in outcomes and you could also create a calculator around that and say well if I stop smoking what would happen or if I actually went and got my lipid for my hemoglobin A1C went down what would that be the outcome.
Then you can also do that on treatment options where you begin to connect the two. That was one of the aha's that I had, is I do not think we think enough about taking measurement, which measures are actually effective in behavior change and which measures just are not effective because in and of themselves discharge instructions. You have to take that further than just that piece of paper because you are going to anything out of that.
The other aha that I had was the meaning of health IT sensitive has become much bigger for me. I used to think of health IT sensitive in terms of measures of could you reduce the burden of creating it. So can we get -
SPEAKER: That is enabled.
MS. MARTIN-ANDERSON: Okay so I might not get the right words. I am pointing, when I think about health IT enable or I do not know what health IT sensitive means so I am probably thinking on the enable side.
DR. TANG: So let me give you the common law definition of those two terms and see which one fits. So HIT enabled means that it makes it easier to get or easier to capture, to retrieve or to capture. So that is enabling. HIT sensitive means that there is literature that says the presence and effective use of this HIT solution, CDS reminds me has an impact on the clinical things you are trying to measure. So I think what you are talking about is HIT enabled.
MS. MARTIN-ANDERSON: Right so yes, I think now what is happening for me is getting the full breadth of HIT enabled and sensitive begins to make more sense to me in the sense that it is not just, that we have to really think about the consumer level and the provider level levers that you get through that technology beyond just the measure itself. I think that is the question is that both sensitive and enabled in order for it to cross the threshold to really push. And I was also thinking about the fact that right now we talk a lot about burden reduction through health IT. But a think we need to talk a whole lot more about burden reduction around all of the patient education and everything else that needs to go around the interventions that could happen because of the health IT which is bigger than an EMR.
Then the last one, the last sort of ah-hah and Paul agree with what you said in the beginning about providers and consumers. The area that I would like to see payers and purchasers think about more is the coverage decision element of how does that really impact. That is one of the ways that they actually pulling levers that makes a difference in the outcome and how do we articulate what that might be.
DR. TANG: Of course I will add on to our idea. So if we could make a composite of a different kind. It is composed of things that the health care professional have a lot of influence over. If I do not want it to test, can't go get it and there are things that user patient have a primary responsibility.
If we could allocate responsibilities and we design the benefits and some of this is already being done to influencing both of those components to a quote quality measure or an outcome measure more or less, then we can get everybody pushing in the right direction and have it aligned with what a patient might guess is oh, I have a better quality of life and I have a better health status. That is what I always wanted in the end anyway, but none of these other things told me that.
MR. STUMPF: The example you gave is something I think that is doable. One of the clinical decisions support things which is consensus based is appropriateness criteria and appropriateness criteria can be bumped up against medical policy and payers and automate that process so this a good case where the doctor is using clinical decision support something they want and at the same time is feeding an administrative task that they do not like. So that is something that we are going to be over at the American College of Cardiology tomorrow talking about that very thing. How can we mesh what you do with appropriateness criteria with medical policy to begin to automate the process.
DR. MIDDLETON: Larry.
DR. GREEN: Borrowing from Kristine about her ah-hah moment my ah-hah moment of the hearing, I want to see if I can give voice to and particularly again invite our testifiers to react to it. It would go something like this. The existing health policy of the land, fundamentally is the market will decide what is best. I am hearing in this hearing in the testifiers that we are questioning that fundamental highly American principle that it is heretical to question. When I listen to various presentations earlier this morning laced throughout it in its ability over a four or five year period to make a difference was a great deal of cooperation and it was in a specific community.
The New England Journal article two weeks ago about Grand Junction, the fundamental lessons wrung out of that is what happened here was when the payer, the IPA, the hospital, the specialist, primary care folks, mental health folks, the social workers decided that maybe they should work together, they improve results and reduce their costs. This suggests that in the last twenty minutes which I basically just loved listening to you guys, you pointed out how important collaboration is going to be for us to get to where we want to go and we carefully extended the notion of collaboration to be all the way to the person who dares become a patient as part of that collaborative model.
So my aha goes like this. We may be stuck in developing quality measures in our quality roadmap because we have not yet agreed who we wish to advantage by the creation of the quality measures. It seems to me that this is very important. The purpose to which we want a quality roadmap probably should be stated and made explicit and I do not have this quite right I am sure but listening to David two or actually three times now made comments, it may be that we have to decide that we want a quality roadmap that advantages patients instead of where we have been in my opinion where we have been looking for quality measures that would advantage me whether I am a broker or whether I am a hospital director or I am a cardiologist or I am a pediatrician. What will the quality measure do to my piece of the industry and the enterprise and I am for it if it makes me look good and advantages me in a payment system where I get paid more because I did that and I am against it if it disadvantages me. This is I think quite fundamental.
Yesterday afternoon when Kevin was here and was talking about what was going on at the American Board of Medical Specialties this really bothered me last night when I started thinking about what we had heard. His presentation and also the lovely lady from ABIM, they were showing us and we saw it again in your slides, Barry about the community health center that there is a thing grounded and taking care of sick people, or people who fear being sick and are promoting health that is fundamentally based on professionalism in which we do things that benefit others even if they do not benefit us. We saw glimpses of the medical specialty boards flirting with actually staking out some professional territory. We saw in this hearing some examples of where absent pay for performance just because it was their mission and what they were supposed to do in their town, community health centers went from the bottom all the way to the top without ever getting pay for performance dollar out of their work, if I heard you right. I think this is Committee's work around this and I would like to frame it as a question Blackford and Paul. We should be explicit about for what advantage will quality measures be used.
MR. STUMPF: Well you have raised another important issue which is who are you measuring and the emphasis has been on providers whether they are hospitals, physicians or whatever but a lot of health care is delivered today by non-physicians and in fact I think a lot of what is in fact evidence based medicine you know use Porter's term, precision medicine is better done by non-physicians yet we are not measuring them.
The data that we have now coming in even administratively is pretty rich in non-physician data but we have not used to get to say you know these nurse practitioners and nurse anesthetists but we have a nurse anesthetist actually. It was really controversial. We got ourselves in trouble with the American Association of Anesthesiologists over what it looked like. What you are trying to measure is precision medicine, the evidence based kind of stuff and most of that is not done by physicians and that is an important group to get a handle on.
DR. MIDDLETON: I am going to give Paul the closing comment because we could go on for a long time. This is very rich but we do have to move on.
DR. TANG: Well I think I am going to move something that Larry and Kristine said. I mean basically I would move that this quality roadmap be designed for the dyad of the patient and the professional health team, and that picking up on a different thing that Kristine said that we attempt to portion some gross very qualitative assignment of responsibility and a lot of it is going to be joint so that we can help educate all of us about our respective responsibilities on this journey for an individual's health.
Then in the future it could be used by benefit design folks to help even strengthen that responsibility and the rewards and incentives for taking action there. So just like that pyramid of the MOC and of what you know and getting into the action, a patient has the same thing.
Now we, the people who are paid to do this stuff should be helping to educate the patient on their triangle just like the professional associations are trying to measure this. So I think there is just a new theory of quality measures and the subsequent use of it you know whether it is in rewards or measurement, whatever it is but the notion is we have got this new dyad that happens by the way to be empowered because of HIT.
None of us have any information which is why we have gotten down this roadmap on ridiculous measures is because we had no access to the data. None of us so HIT has been enabling but what we should do to take the ball and run with it is to create a whole new purpose for this stuff and who has benefited from it. Who is the beneficiary which means who do you pay attention to in designing the new stuff then let the other stuff follow in. Talk about ahas. That is the thing, the aha got to me in the entire two days. It is a yellow brick road. It really is opens eyes in terms of this could be a whole new place.
DR. MIDDLETON: So on that high note with that passion, I agree with Paul. It is a change and I want to thank everybody for taking the time to come and share your wisdom and expertise and experiences and insights. Members of the Committee and Subcommittee and support, everybody, thanks so much and we are adjourned.
(Whereupon, a luncheon recess was taken.)
DR. MIDDLETON: Well, good afternoon. Welcome back from the lunch break. This is the reconvening of the Subcommittee on Quality of the National Committee for Vital Health Statistics. The next agenda item is to work with the Booz Allen contractors to begin to draft the final product of our letter to the Secretary and I think that work has begun and why don't we just it from the top with Kristine, whenever you are ready.
Is anyone dialing in from the Subcommittee on the phone? Is anyone dialing in on the phone?
DR. CARR: Blackford can you hear me? It is Justine.
DR. MIDDLETON: Hey, Justine welcome back.
SPEAKER: Are we going out on the internet?
DR. MIDDLETON: No.
SPEAKER: Yes.
MS. JACKSON: Yes, we are. This is an open meeting.
DR. MIDDLETON: Oh, okay then we still are open to the public as well?
MS. JACKSON: That is right.
DR. MIDDLETON: Welcome any observers. So as soon as we are ready, Kristine. Or we could talk further about feelings, okay.
Well I guess maybe the first thing to do is just to begin to think about the structure of the letter and what are our essential components and reviewing past letters. I haven't had a chance to review past quality letters but if there were any in it might be fun to share with the Quality Committee or just give us those pointers and share with the contractors as well.
MS. MARTIN-ANDERSON: Actually we did. We looked at the past two letters and then also used the structure of the last letter. I think it is the May letter to set up the outline for how to write this letter.
DR. MIDDLETON: May is the May information one.
MS. MARTIN-ANDERSON: Just for this outline, right. Isn't it the last one that you did right, May?
DR. MIDDLETON: Was that the meaningful measure one?
DR. CARR: This is Justine. I think what we generally did was figure out what our recommendations were and then develop them and then there is some kind of customary opening paragraph about NCVHS or this or that.
MS. JACKSON: I can add to that. Thanks, Justine. This is Debbie and that is kind of the and just when you look at the end of the last after the morning session when there was so much on the table and we were going in dimensions of time and space and trying to identify, codify what you want to tackle and what message you want to make, what story and what journey. There is a lot going out there so that is how we have seen the best way to handle that just crystallize as things were kind of coming to their own kind of natural crystallization at the end of the morning session and to build from there and then you kind of fill in the pieces.
DR. CARR: I think the last time when we wrote last year's meaningful measurement letter, we wrote about what we didn't hear; not what we did hear. That was the most powerful thing.
DR. TANG: Okay we are not going to compose the thing in front of us, right? We are just going to do some outlines?
MS. MARTIN-ANDERSON: Yes, we are going to show the outline up there and then we can talk about each section. That might be easiest and she is going to real time take downs so we can write.
DR. MIDDLETON: Okay so maybe just by way of getting a little rhythm going, I think Justine just pointed out something which I think is very important to do. Somewhere near the beginning of the letter is to frame what the letter is about and what it is not about and we had some discussion about that at the end of the morning. It is not about a business case for quality. It is not about sort of technical implementation details for quality. What it is about is a quality measures roadmap from these four different perspectives. Does that sound like kind a set up in general.
Maybe before we get too much into the weeds we might want to just step back to a thousand feet and say and Paul started to do this and I have a few thoughts, what are the overarching recommendations that we think are the key themes coming out of this. Maybe we should just start there. I think Justine was suggesting that as well, or Debbie.
DR. CARR: I think that helps a lot and then I will make sure that we all agree on what we are going to say, what we heard or what we want to put forward.
DR. MIDDLETON: So the sea change, the last moment from the morning session was the epiphany reached when we recognized that quality is being turned upside down and we are going to take a patient perspective and quality will be patient centered from here henceforth, evermore.
DR. TANG: I wouldn't say it that way.
DR. MIDDLETON: We are just brainstorming, Paul. We are not wordsmithing.
DR. FITZMAURICE: Is this the time for an Amen?
DR. MIDDLETON: Other big themes?
DR. GREEN: Blackford, I think one of the framing big theme issues for the letter we heard in our conversation and also in testimony was the claim that there is a crossroads that is occurring because of the intersection of meaningful use, ACOs, PCMH, the quality movement. There is a lot of fluidity and a lot of things going on all at once now that answers the why now question about this letter. We need to do this letter now because of some reason. I think we heard testimony that supports the notion that it is because new opportunities are here that are very, very important and are achievable now. That would set up a conclusion but we do not seem to have a clear vision of where we are headed. We need a roadmap for that.
DR. MIDDLETON: We can sort of play off the why now, who cares, why me. Who cares? Stakeholders. We have extraordinary pressure on cost and value of health care and that is not going to abate. It is going to get worse. We need to be able to demonstrate value and produce quality, etcetera.
DR. CARR: Right and I think actually following on that we have invested gigantic amounts of money in this transformation and it has got to come out as quality access and costs and how does that happen. So we have the building blocks but just sort of taking and tying exactly the operationalizing it. Actually you said that at the end, the operationalizing of this is a big thing.
DR. MIDDLETON: Another parenthetical comment perhaps not yet for typing is I worry a little bit about the fact that we have not benched the quality curve or the cost curve heretofore. We really have seen only marginal improvements in quality with the exceptions of course none of you but in general despite a big investment in quality itself it has been difficult to demonstrate improvements in quality so I am not sure if that means there is something about how we are measuring quality or what is being measured that needs to be considered here. This is still in the brainstorm mode.
DR. CARR: And I also think the measures that we do have of patient experience of care you know did I understand what I was told. Did I understand, did I have everything I needed when I left? Did I understand the nurses and the doctors that you know that the scores are not high. Unlike the core measures where 100 percent of people get an aspirin on admission for acute MI, the measures around the patient experience of care are nowhere near that high even in the best places.
DR. GREEN: I want to build off of what I heard Paul say just before our lunch when you used the word three or four times about the dyad and supporting the dyad. That in my mind Paul linked to David Stumpf's comment about that many of the currently used products of the health care industry are not suitable for the coming system. That is because so many of the products are provider centric and designed to meet their needs and so when we get to your dyad it seems to me the letter is positioned to call for some transformative approaches to the development and implementation of quality. Help me out here. I am trying to build off of what you were saying.
DR. TANG: No, I think that is right and if I look at the work we have so far before the dyad, it is the same old, same old. That is what doesn't seem very transformative. So I think going back to whose behavior are we trying to influence and there is two. One of them we always pick on which is the physician and we are expanding that to the health care team and the other we paid so little attention to and that is the consumer patient. So that is a new theme. So we expanded it to health care team and we are expanding it to the other part of the dyad which is the consumer patient. I think that is a big difference and it goes back to what you are saying of we have always written everything and targeted everything towards the provider and that is not getting us anywhere, because it is more than being quote patient centric. One, it is just so overused and two, you could describe all of our measures as having to do something with the patient but that is not what we mean. It is really focus on the behaviors of the two parties of that dyad. And all of a sudden you want to measure different things. You want different contribution like consumer generated information you are going to look at all in all because there is a guide that the health care team wants to know that. So it just sort of forms a whole new paradigm for how to use this stuff.
SPEAKER: And a shared accountability.
DR. TANG: And the accountability piece. Any easier word than accountability would be responsibility at this point because it just; it is a more humanistic and holistic way of looking at it mainly because accountable is so laden with blame and penalties. We are trying to introduce the patient and the rest of the health care team who we ignored up to this point and we all ran into accountability. I am playing with the words here.
DR. MIDDLETON: In a way that I do not want to lose the attachment to what is in the current vernacular about accountability but I accept a similar point of view.
DR. TANG: Maybe we could do it the other way around so shared responsibility, open paren and accountability. Do you see what I am saying. It is just a different frame.
DR. GREEN: It is a accountable and responsible for what?
DR. TANG: For behaviors associated with improving the individual's health. So as the health care professional I have some responsibility and accountability to act in certain ways. It can be an educator. It could be someone who orders tests. It could be someone who performs procedures. As the patient I have some responsibility to learn about things, to modify some of my behaviors where with the assistance of other parties you know in the whole activation model.
DR. GREEN: For me what helps with the accountability responsibility thing is the prior question about the purpose of the quality road mapping is to work with the dyad to advantage the patient and share responsibility for advantaging the patient. Advantage does not seem like such a loaded word to me. The accountability thing and the patient centered phraseology and responsibility and personal responsibility we just flaunt those words to death and couldn't support it.
DR. CARR: So in this letter, are we setting the background for this as a sea change of where we are today as the measurement needs to now expand to encompass whatever. Is this a letter about measurement ultimately?
SPEAKER: Yes, yes, yes.
DR. MIDDLETON: Yes, and I think even if we do not use the words put sea change somewhere at the top because we want to underscore this and make it almost as paradigmatic a change as we can possibly make it because if we do not write it that way, it is not going to be.
MS. JACKSON: Sea, S-E-A.
DR. MIDDLETON: Thank you.
SPEAKER: Actually both words could probably work.
MR. QUINN: That was on of the questions that I had is that one side of this, one of the balances here is that there are paths of less resistance and then there are paths of transformational change and what we saw from the meaning measures as well as what we heard is that there are pockets of excellence and the question how do you develop a plan that is implementable not just in one of three places but is something that can be adopted very widely. We heard some examples of that today and so people are thinking about that. The further and this is a little bit of a different way of thinking about it. Those who are probably most excellent in the current paradigm of measurement might not be those who will be capable and excellent in measurement with A different paradigm.
SPEAKERS: That's right, right, yes.
DR. MIDDLETON: It is a good point in itself, Matt.
MR. QUINN: There is a lot of investment in the current but if the current changes, well you got an A all of the way through middle school but now in high school. You know after the sea change.
DR. MIDDLETON: All of a sudden it is going to be harder grading. What is that really going to mean? Part of me thinks too, again brainstorming more for a second, we kind of maybe at some level want to address the fundamental values for which quality is going to be assessed in this country. It is challenging given that responsibility is shared between provider and patient but you know the values with which any benefit assessment are always intrinsic to whomever stakeholder perspective you are taking, right? So if you do not know the stakeholder perspective you are taking and you do not know the value structure with which the assessment us being made from a very traditional sense. So I wonder if you just want to talk about that, or not but whether we need to address kind of a values for quality or the values for measurement. Brainstorming logic.
MR. QUINN: Maybe the title for this is the patient centered quality roadmap.
DR. MIDDLETON: Before we get to title, let's flush it out more. I like dyad because it is doctor patient. It has a lot of resonance in lots of different ways as provider or patient but I also think we heard stuff about a broader perspective quality and patient provider system and really community or we did not really hear public health but community. We did hear some about all of those other dimensions too and particularly other dimensions at the provider side of it you know the provider assessment and knowledge base actions and, etcetera. On the systems side sort of a traditional structural measures of system components that influence quality. This is where I think we are going to see a new world here partly too based on testimony and my own opinion. For example the NCQA structural measures for the patients at a mental home will be used to kind of assess patient centered mental homes but that is just the beginning. There will be other types of structural HIT and non-HIT measures I think, too. What do you think?
MS. MARTIN-ANDERSON: I was just thinking about one of the concrete ways that influences around how many just selected for use. What I heard over the last two days is perhaps we have the wrong criteria around importance to measure and relevance to measure because that criteria is largely interpreted by the purchaser. And if you were to interpret it by the consumer or by the dyad, importance and relevance would have to truly have to do with improvability and behavior change and it would no longer be as important to measure something that is really narrow that lets you stratify the provider as it would be measure something that you could work with the patient to change.
DR. MIDDLETON: I like it.
DR. TANG: That has huge ramifications on the whole endorsement process that currently exits. That is just a comment.
DR. MIDDLETON: We are going to get there.
DR. GREEN: Let me build off of Kristine's comment and ask Justine. Justine are you there?
DR. CARR: I am here.
DR. GREEN: Would really like your insight and advice about whether or not this letter could take a position akin to the NCVHS position around the NHIN. Can this letter be a framing letter for it is a vision of the way quality measurement ought to be in the new world as opposed to the way it was and be somewhat.
DR. CARR: You know I am new at this but I would say that we when we do that we are appreciated. I have gotten feedback on a number of things that even the letter from last year when we kind of put out there you know what is the next thing. I think that is what we need to do so I do not see a prohibition to doing in this. I think that was the point of it that we would try to envision. The one thing I would say is for us to keep a little bit in mind the discussion that we had, the idea that the Population Committee brought forward. Now, Blackford did not hear that because came up in the executive session but as we speak about this, we ought to be keeping in the back of our minds a broader perspective that goes back to that earlier NCVHS diagram of the role of community, and that addresses population health and the influences on health that are outside the health care system. I do not know if that is too much to think about with this but to answer your question, yes I think it is good for us to vision and I think we should keep in mind our population health perspective in some way.
DR. TANG: Another one topic that we talked about. I do not know that we have discussed this for a Subcommittee opinion is the whole notion of risk adjustment versus risk stratification. I think risk adjustment turns all numbers into bland ones and wipes out the information. I think the risk stratification is one way that first thinking about the patient consumer can start to find themselves. That is one good point and another one is for the health care team to figure out where they can spend more of their effort and time. So that is really another kind of a sea change.
DR. CARR: You know it is tying on a little bit of what we heard yesterday that risk stratification may be your condition of it may be your environment. If you are very low income and you have a very high deductible, you are also in a risk. You may have constraints on accessing care even though you have insurance.
DR. MIDDLETON: This one I think is the patient's like me one. To get measurement framed from the patient's perspective so it is not the patient belonging to a cohort. It is the evidence synthesized from the patient's perspective so patients like me with this therapy can experience having this.
DR. TANG: I think it was stated patients similar to me.
DR. MIDDLETON: I know. Apologies to Jamie. We are not going to use patients like me.
MS. MARTIN-ANDERSON: Instead of a hospital comparing nursing homes now it is patient compare which how do you find yourself in it.
DR. MIDDLETON: Relevance, your word. The other one, I do want to come to Arne's comments because he was just so provocative in the sense of describing a cascade of actions that transformed the way we do quality. We can decide I guess to which level of detail relevant, appropriate for a letter to the Secretary but I was just enamored or it was very appealing to me. I have to digest it more thoroughly but I think we should return to that and think about what is the boundary up to which we will go sort of recommending specific actions or methods or techniques as he was outlining.
DR. TANG: So I might ask us whether we want to, I would almost think about this as a higher level and this is our first volley. So we are cheat sheet almost everything including the actors of the future, all of the actors in the future world to try to get specific seems like it is more than we actually did due diligence on for one and it may be too much to have in the letter.
MR. QUINN: This is a reframing. We are talking about a reframing of the quality measurement framework. In order for this to have in impact we have got to discuss some of the consequences if we follow the status quo and keep on the same course so that would be something else that we.
DR. TANG: There is a good point and maybe that has developed, it is a rationale that maybe leads up to, well let us see.
DR. CARR: Could you repeat that, Paul? Somehow it just went dead.
DR. TANG: Well Matt was talking about somewhere along the way we have to compare to what is going to happen if we do not change our quality measurement paradigm. So I am trying to figure out whether that leads to the summary.
DR. MIDDLETON: I think it is motivation and rationale. I mean in a way what we know is that the current quality measurement process is insensitive to a lot of what really matters is important or relevant. So that is what we are trying to fix. And the secondly is this new perspective sea change. Paul, to your point about sort of the first volley, if it is one volley of two, three, four, whomever maybe that is what we need to describe to is a roadmap for the roadmap. This could be the first sort of reframing we expect in a year. Not too long, but in a year to talk about implementation details. That would be pure roadmap and then a year later talk about assessing the implementation of policy changes needed. The thing that I might differ a little bit though, I think Arne he really took the message. He had a four year horizon for these changes.
DR. TANG: But they were specific before knowing necessarily. I mean he was not aware of what we were talking about right now because he was shooting towards standard this and standard that. You have to figure out what the that is. Listen to that we are describing different this's and that's.
DR. MIDDLETON: He didn't name the this and that, though.
DR. TANG: He said there should be so there still is the naming the actual substantiation.
DR. MIDDLETON: It is not an implementation. It is a recommendation.
DR. GREEN: I just re-read Arne's stuff. I wrote it down. I think Arne's contributions align with what Blackford is saying. I do not think it takes in a different direction but he just starts getting more concrete. It is very good actually I think we need to give the letters some clout. I mean it is not just your outcomes starts moving towards the sorts of thing. It talked about the importance of pay for vital services connects to what you have got to do. You have to be able to find those data from all of those different sources and bundle them up. You have to find the patients that are at risk or those that are expensive in the registry. Those are the sorts of things.
DR. TANG: To me it actually paints it in a payer framework perspective when we are trying to actually focus. I agree you can but the way it is written is it perspective? Oh yes, in the brain. And one of the possible directions we are going is we are going to focus on the first two: the dyad. The other things will fall from that.
DR. MIDDLETON: Okay so I think we had testimony from four stakeholders and to leave two off and only focus on provider and consumer I think we are doing them a disservice. We invited them here. We heard them.
DR. TANG: No, no, no. I mean I did put the motion put forward was okay so their personality is we can either worry about costs and separately we are about quality or you can take the perspective you know what if you make the appropriate decisions you will get both cost and quality and cost effectiveness. Okay? So that was the analogy. So in this world we can either design in the extreme we could design measures for each one of the stakeholder groups however many there are or we can figure out what are the ones that matter. That was the people that matter. People that matter are the consumer patient and the professional sides they are trying to influence to provide services and advice or whatever it is and then the others, which I think the purchasers and the creditors should be able to get their information as a by-product. So that is just a theory so I am saying that to not ignore but that the others are a consequence of the first two.
MR. QUINN: There is an evolving role of purchasers and payers in that dyad as well.
DR. MIDDLETON: Thank you Matt.
MR. QUINN: I was going to say that a lot of the testimony that we heard from the payer and purchaser group and the accreditation groups was around their influence or how to shape that dyad interaction and so we heard United talking about how payer data could help inform both sides of that and we heard about how in Minnesota they are bringing data from different organizations and bringing it together to do that and then how the SGIM and other groups are trying to influence the position of quality measurement activities. So those organizations have their own data needs but I think they are focused on how to impact the patient clinician dyad.
DR. TANG: Actually Dave Stumpf gave a concrete example saying in United they have two lines of business. They have more than two but primarily it was the payer side and that is where they made their money. In this new world we focus primarily on the dyad, they could move over to the service business and they had a payer function. In a sense that is what the agreement really was saying. The payer perspective is subsumed or subservient to the patient consumer provider.
DR. MIDDLETON: I am still struggling a little bit because I think there are already payer source of data if you will that we really talked about trying to look at this in a sort of in a technology neutral way and perhaps data reuse, reuse, reuse. If we think about getting data from where it is to where it needs to be, payers have data that is relevant to that provider intervention or the consumer intervention. So maybe we are limited by this stakeholder perspective and we should really be looking at it from a quality perspective sort of first and foremost.
Yes, framing it as just an dyad is an acceptable one alternative approach. I just worry thought that focusing only there will not get at the value question. The value question comes from the payer side. I mean creditors, I think we heard some extraordinarily interesting testimony about quality assessment of providers themselves. You know how do we measure providers and what data from the environment under the relevant to accreditation process.
DR. GREEN: What would you think about, I mentioned moving to reconciliation mode here. As I listen to you guys just try this out. This may totally misfire and be useless. I think maybe we should conclude that quality is about finding value and that may mean that quality is everyone's business. All four groups we heard from have got to get serious about quality. If you pick out a dyad, pick out two of them, it is not going to work. Quality over cost. All four testifiers, the way the hearing was organized. Maybe we should just find that none of them get a buy on this. It is going to take all four groups if we are going to envision this new world of quality measurement and advantaging patients through it. Okay say that was not helpful and we will go back.
DR. MIDDLETON: It was helpful. You got me. I guess I am not the lumber. I think, now I know my role.
DR. TANG: Oh, man just team me a counter replacement.
DR. CARR: I heard that.
DR. TANG: In its corporate and your perspective so just because someone performs a payer function has data doesn't mean it is not important to the perspective of the consumer. Does the consumer care about costs? Yes. So there is nothing to exclude them. It is a refocusing of the perspective and the consequence to the framework that talks about what it means. What does cost mean to the consumer but not to the payer.
DR. MIDDLETON: But in fact patients are mostly insensitive to real costs and number two, payers' assessments of value goes way down into if the patient is actually interested in. They are interested in a value conversation with the provider. The patient is almost secondary. A payer provider conversation is about I am going to give you x amount dollars for a CHF care in your hospital and with the readmits, etcetera. You are going to have to produce care at this value level and you need to measure that.
DR. TANG: The consumer is eventually going to feel that and within the next years the consumer will make these decisions. The other party that is going to feel that is the other side of the dyad. So the fact that there is not enough money to keep escalating the amount that providers are paid makes the provider sector interested as well. There is nobody that does not get interested when society's resources are limited. So I do not see anybody that of these two dyads if we are going to focus on them that would not be interested in societal costs.
DR. MIDDLETON: I do not understand. Am I ever going to pay out of pocket for my entire CHF hospitalization? You said in a few years I would. I don't see that.
DR. TANG: In a few years you will be sensitive to what it costs to take care of your CHF.
DR. MIDDLETON: Americans already pay more of pocket than any other industrialized country in the world. We are not going to increase out of pocket payments in America. It is just not going to happen.
DR. GREEN: Okay I want to try this again. I do not understand why we need. We have good testimony. I mean it was a rich hearing. We learned signing. We learned something about all four of these but why would we want to frame the letter in a way that sort of to find out of our letter of what we learned from any one of the groups. It seems to me we should frame the letter to be position to be inclusive. We are going to have a findings section too and we have time. From my notes I feel like we have good interesting findings from all four of these groups so I do not see why we would want to frame the letter just around two of them.
DR. TANG: Because you are not a leopard(?).
DR. MIDDLETON: So we may have to make a directional call here and make a vote of the Subcommittee which would be totally fair or a straw poll. And further more, we can do some drafting Paul and see how it looks like. I think your focus area is right on target because the action is going to be in the dyad but if we fail, so you heard it already, I think we should include the secondary dimensions both from the creditor and from the payer and we can make them secondary.
DR. TANG: That is all I am saying.
DR. GREEN: Wait, wait record it. We heard it.
DR. TANG: Throw away the other pages, you just put it in from your perspective of how it impacts.
DR. MIDDLETON: Yes, the only thing we still have to see how it unfolds is I think there will be independent dimensions of the perspective from payer and creditor that do not pertain to the value specifically. I mean so we will just have to unfold it.
So now that we got over this temporary roadblock, what are the other key big chunks of recommendations? Did we capture something Matt about you know the physician assessment as a measure of quality? I cannot remember.
MR. QUINN: Kevin Weiss.
DR. MIDDLETON: Kevin Weiss and Lipner. That I thought was interesting, new and different.
MR. QUINN: I would almost frame the Kevin Weiss and SGIM testimony is that there are levers that are pushing that aspect of it. Less says that that is more of the part of the why rather than exactly the what and between the two groups that have hard from and the joint commission they have a little bit different philosophies on low bar, high bar, exactly what to measure. They just want to see activity being done and I think that if quality measurement was reframed that they would follow suit. But the important thing is the mechanism, the lever that this is part of being an accredited physician.
DR. GREEN: I agree with Matt's last comment. The sea change from that part of our hearing is that certifying boards for this nations physicians, have all gone into the quality business. That is the statement. They used to give tests to protect turf. They are all moving into the quality business. That is part of this disruption, this liquidity stuff. They are actually thinking that maybe they have something they each participate in a meaningful way. They are connected up with meaningful use already. They are already connected up with CMS around PQRI. They are changing their modus operandi. We detect that as a significant development for Paul's dyad. The last statement about the lever, we should not lose sight of the lever. When these boards defrock a physician there is hell to pay for that position. It does not usually go well.
It usually has serious disadvantaging properties that come to bear on that physician so they have their attention and they have a new model called maintenance of certification in which they have at least four strategies that they are trying to implement all designed to change practice so that it is better. Now that is a pretty big deal in my view. Both sides of that equation; they change their business and they have got big levers. We should notice that.
DR. MIDDLETON: And the new data types part here? You know if you are examining the record to see what a patient provider actually did with a variety of patients by type to attest his performance in reality that is a new data type for accreditation. I am not suggesting we talk about that specifically but there are new measures that can be developed based new data types such as that will be relevant to physician attestation or physician certification. The flip side of this one, which we have heard loud and clear too was patient activation. I do not know where it fits in exactly but the patient activation measure was how cool was that. Think about it in fact as a vital sign. I should think about a Pan score so I think about what diabetes therapy or CHF's therapy is going to work for this patient as opposed to treating everybody the same. It is more about care for me, about me, because of me. Whatever.
DR. TANG: So does anybody know the answer to the does it cost money to use?
SPEAKER: (inaudible off mic)
DR. TANG: Well, that stinks.
DR. MIDDLETON: Well we would have to know that if we were going to recommend something like that.
DR. GREEN: Well that could be one of our findings. That is one of the issues to address is the availability of the data that is proprietary. Who owns it and just because it exists does not mean you have access to it if you needed it.
DR. FITZMAURICE: That is correct we do not want to endorse a certified product, but it is also an impediment.
MR. QUINN: If you go back to the accrediting group I think that that is more likely. They are not going to come up with new schemes of measurement as much as they are going to adopt the ones that seem to be most relevant and the ones that are going to I think the challenge for them is going to be changing the paradigm and explaining to their member base why the paradigm is changing. I do not think that there is for a while now we have been trying to push or they and everybody else have been to push measures of a certain flavor and there has not necessarily been acceptance of it so that is the difference.
If you see the dichotomy of the measures that we track internally versus the measures that we report and it is kind of a big deal if you give them both versus sort of going through the motions on both. I think the accreditation boards and joint commission and others are going to have a role in helping sell the new paradigm especially if it makes sense to their members and their members' patients. I do not think that they are going to be the ones out front on it but they are going to be the ones that are, it is going to seep down and be in their new programs, hopefully.
DR. MIDDLETON: What was the joint commissions' lady's name again?
MR. QUINN: Margaret VanAmringe
DR. MIDDLETON: The other dimension I think is patient provider, the dyad and its appendage to a payer. Whatever you want to call it. But then the system, so she had some interesting things to say about what are they thinking about in their accountability framework for you know clinical integrity and their processes for a system if you will quality assessment and measurement. Somehow we have to fold that in.
MR. QUINN: I think that she talked about, that she showed this entire wheel of different kinds of programs that they have got. Each one, I think Larry asked, how many measures are encompassed in all of this and I do not know probably some number of times ten to the third and we asked, I think your next question was around how many of these are system measures or measures that go across these and it was like zero.
DR. GREEN: She emphasized the unmet need of the accrediting organizations to measure quality they need to be able to measure care transitions. That was what I thought was her fundamental testimony. You must measure care transitions and then she said, and we have zero of them.
DR. TANG: She said that transition communication was the number one safety issue. Now the other thing she has talked about was and I did not get a chance to ask her the definition she called of the accountability measures versus the non-accountability measures. So accountability measures are things that are effective like the core measures. Things that are not, she called put them in the bucket, like smoking cessation counseling and heart failure discharge. Another way to look at it, these are things that are being gained without any apparent benefit. So it would be interesting to know what their criteria for accountable levers versus non-accountable levers.
MS. MARTIN-ANDERSON: Maybe one way to frame that all together is if you think about where Blackford started about we have not bent the quality or the cost curve, right. And because of that, a large part because of that the creditors and the purchasers have sort of put the screws on for measures to try to get the attention of the providers. That was really important if you want to say what it looked like five years ago. But now the attention is here and if the attention is here and the dyad is actually working to get sea results that are actually going to go in the right direction, then you do not need the same level of attention on the creditors and payers to make it happen. They still made a long cost. I am not clear on the value side but I think if you try to say it is more about taking accountability for the direction of the future. If you look at how we got here I would say you would look differently at what they are doing.
DR. TANG: The corollary to what you just said is I do not know that the current measure developers at the ones that are going to supply the measures of the future. That is another one that has been there disrupt a bit. That is important. See there are so many things that are ramifications -- so if we adopt a framework or a philosophy or a paradigm it is almost worthwhile starting in this letter to talk about the conceptual and the implications. That is just going to take so much time to develop that. I do know if getting down into the weeds, is something we can do in a future letter and I think we should do more due diligence around it but I just think it has all of the implications and I do not know whether speculating.
MR. QUINN: Lay out the three that this one is the framing document and say let's get our heads on straight on what quality measurement is about. The second one is prioritization of operations.
DR. MIDDLETON: Implementations, details and implications.
DR. TANG: And what is the third one?
DR. MIDDLETON: And the third one is kind of you know a status check, evaluation. I like that Paul. The only thing I might do in this one if we did that part I think that there is this whole issue that you are putting your finger on of kind of the production life cycle for measures and it is a mess. We have heard it. Somebody said it is a mess.
DR. GREEN: And they say it has to be accelerated.
DR. TANG: Actually we said it was a mess and we said that there was no organized way of getting it better so that is nice to build. We can remind them at our preamble of where we came from. It says you know we tried to figure out one of the meaningful things we have now is that well, not too many out there and it doesn't look like there is a optimism in that.
DR. MIDDLETON: I mean it is just like standards acceleration.
DR. CARR: But you know we also in that email I thought were very EHR centric in measures in that figure so we may want to think about referencing going beyond that as well.
DR. MIDDLETON: Thank you, Justine I agree. I think the other thought here is somewhere in here we should say make illusions to there is a future world of measures where information will be coming to inform measures from different places. We heard about it coming from different places. Not only HIE based upon EMR, but hospital but potentially PHR and potentially other consumer source data, etcetera.
MR. QUINN: I think one of the questions for the next one on the operation, the implementation and implications, we heard a lot about registries. Registries are different from HIE an those are two different paths and registries are different than ACOs.
DR. TANG: So the writers, where are we in terms of how much do you have and what are the gaps you need from today's meeting?
MS. LESIKAR: I think that what we talked about now is sort of the framing in the beginning and I guess what I am not clear on is in terms of those specific recommendations because I think our next step would be to take those recommendations and then go back, something more concrete or specific, and then go back through the testimony and find the tie together the evidence that supports those. So at lease that is the structure of the previous letters where it had three, four different recommendations and then we can tie the evidence to that.
MR. QUINN: This letter we did an observation and recommendation paradigm. Is that what you are thinking for this?
MS. LESIKAR: Yes, that is what I was thinking. I thought that flowed nicely where you had an overview statement sort of a general themes. Here is the three themes you know or here is the theme of this letter and then three specific recommendations and the observations is the evidence that led to that recommendation.
DR. MIDDLETON: We could take the perspective where we made recommendations around a consumer set of issues, a provider set of issues, and other set of issues. I am keeping it simple. You know a creditor and payer and that might give us a little more specificity our you can use that same three and bucketize some of these recommendations. Or we have to do some iteration by email.
MS. MARTIN-ANDERSON: Can I just add the first couple of things I heard you all talk about that sounded like recommendations. I just want to check. One was certainly about reemphasizing the for what. Right? The for whom that quality measurement exists and saying in that that it was really about the purpose of the roadmap is to work with the dyads to advantage the patients. In that case we could talk more about how measure is tied to action and actually improve the health of the patient actually on behalf of the provider and the patient and that is sort of sounds like it. It is the focus of the roadmap should be in that space.
Also talked about the lack of involvement of patients. The party observation was the lack of involvement of patients and consumers and they need to take something like patient activation and see it as a vital sign and use that, find ways to connect measurement to how do I engage those patients even if their stratification of the measures to be how you might change the providers' behavior or in better understanding why some patients are not actually changing behavior and how to get them there from an education point of view and you can take it deeper than that.
The last one that I wrote down that I am not sure how deep you want to go on is that changing the frame around risk adjustment, risk stratification, the patient compare idea. How do you really make measurement relevant to patients. I think it is different than inducing change. It is related but different. So all three of them have the theme around them of this engagement but they are different.
Now the last one I did not really get it a recommendation I can still see disagreement was around the role of the third parties who have their role to oversee the health system either because they pay for it and want to see their money well or because they accredit and therefore they are part of a body that says it is functioning well. We talked a little bit about value and whether or not that would fit in there or not but I still think that there needs to be something about what do you see their role in the future to be.
DR. TANG: Let me try to re-edit your lumps. So the first was the focus on the dyad to advantage the patient. I think that is sort of well stated and we have all of the consumer, well a lot of the stakeholders, well particularly the consumer and the payer actually as David mentioned that but anyway, the focus on the dyad to advantage the patient which is a change from the physician centric measures of the past using administrative data.
So going down the next one is talking about the dyad so the second recommendation focuses on producing credible measures that assist physicians in measuring and improving their practicing, the care team. Exactly, no that is a good one. So we can go into the implications of that for what kind of measures are those or they come out of the electronic systems like EHRs in this case as a by-product. That is another thing that does not exist today. So on and so forth so you develop that stream.
The third one we can introduce the notion of shared responsibility and that is where we are talking about the consumer patient. So it is a shared responsibility with the consumer patient. How do we help them? One, we give them data that is more meaningful to them which is the risk stratified not adjusted quality measures and the importance of activation however we choose to measure that. So that is in this recommendation are three.
Then your forth one and maybe you came closest to finding a way between the dyad which was we have the primary people in the dyad and then you have the secondary users of that information. The importance is that they do not create another silo. They make other uses of the same measures and the same data which creates the efficiency. They just have a different perspective that is not divorced from the patient's or the consumer's perspective but it has special attributes in the payer side and the creditors' side. How does that fit, feel?
DR. GREEN: Can I keep going over that? Your second point about producing metrics I would like to enrich that just slightly. They have to be national metrics. We heard that loud and clear. Cannot be one offs. Can't have a different one in Nebraska from what we have in Louisiana. There cannot be variations. There has got to be some national metrics to move the dial and the other that is the place I think to make Justine's point from moments ago about it is not just out of the HR but it is the HR and additional sources for these. That belongs in your number two I think.
DR. MIDDLETON: I had a similar orientation and I will just give you some color commentary to help flush it out. I think the first bucket is something about enhanced to patient measurement. Whatever the right word is, patient centered, patient something and it is about all of the issues that have been discussed patients similar to me, stratification, personalization, prediction, my own care experience, and what I may reasonably expect, roadmap for me, you know, blah, blah, blah and then the patient contextual stuff measures of the social context, environment, the usual clinical measures and then the financial issues that pertain to that patient perspective on health.
I think then we can talk about the dyad and focus on the provider side of it. Measures of team-ness, measures of coordination of care, measures of communication, measures of knowledge that is where we can fold in the accreditation stuff even if it is in other licensure stuff, measures of action and performance. Do you know what to do and did you do what you know to do or are you making errors and then outcomes, traditional.
I would like to see something about a system level of measurement you know does the system support quality measurement with the right data, the right standards, the right information, the right technologies whether the right technologies are in place, whether it is paper or EMR and that data is being managed and that value data is being produced.
I could leave it there or I could throw in one more. I think it was sort of matched to what Paul was saying. The only one that is outside a little bit is kind of this whole community and secondary use of data. We want to be able to drive and reuse, reuse, reuse these data pharmaco vigilance, public health, all the kind of other meta quality stuff that I would be remiss not to say something about on this roadmap.
So now you have some buckets perhaps to work with.
MS. MARTIN-ANDERSON: We talked earlier about, before lunch about a new concept of composites where you recognize the responsibility of the patients and of the care teams and potentially even of the insurer because they have to have proper coverage for something to happen. And I wonder whether or not some of this context of community fits in well there because a lot of the public health initiatives fall into behaviors that exist in one of those areas.
DR. MIDDLETON: Yes, we had a little bit of this conversation on the phone too remember about sort of these population effects which can influence individuals whatever all of that stuff. It may be in this bucket two or somewhere in here. We should talk a little bit about measurement science because we heard people complain about the ability to measure an episode. That is what I meant about temporal dimensions of measurement. You know how do you tell when an episode starts and stops.
DR. GREEN: And longitudinal doesn't make sense.
DR. MIDDLETON: And geography, that is, it is hard to tell who are the team of people responsible for this patient. So measurement science stuff I think just throw some illusions into and get a lot of research dollars from.
DR. GREEN: From my notes we still are supposedly talking about our recommendations right? In so many words I heard this out of our various testifiers that there is a need to fund a two or three of them used the word fund a movement of measurement of development and mapping by a new workforce with new depictions of the data. I grabbed that out of about three different testimonies of this but the idea was is that where were the comments about needed clinical informaticians and new depictions of the data so that they could be meaningful to both sides of the dyad and individualization of that and I forget who it was, I am sorry, but someone sort of crystallized that from all this and said you know this is going to be a piece of work.
SPEAKER: It was David's.
DR. GREEN: That is an important tenor for a recommendation in my view.
DR. MIDDLETON: So we can say something about measurement science and research agenda as part of the roadmap too, just at high level.
DR. GREEN And then going off the ranch here, we did not hear, I did not pick up much guidance from the CMS perspective in the innovation center that was there but in my because I know it has been created and has funding, my imagination goes awry here maybe a little bit but I am just wondering if we don't want to call attention that this might be an extremely powerful application of that funding to measure quality in this sort of way. There might be a good match up that the Secretary could use.
DR. MIDDLETON: Absolutely. I know we are out of time.
MS. JACKSON: Quick process question before we do the handover. Would that be looking at the importance of where you are going with some of these issues with something with a task to you as members of writing down maybe three bullets of where you think the highlights of where of the points or do you feel that it is already captured. Where are we in getting it down?
DR. TANG: I think a combination of what Matt put up there but Sandy and Haley are doing.
MS. JACKSON: You think it is kind of already down in text?
MS. MARTIN-ANDERSON: Why don't we send back the first version that is just I am editing that one. Do we all agree we are going in the right direction and get your feedback there. Then flush the next one because I think we captured the verbal bullet points. Then we will iterate the next one, we will iterate and annotate that one until we agree and then we will flush the letter through. Does that work?
DR. MIDDLETON: Perfect. That is great. Big help.
MS. JACKSON: Because considering where we were with the scan and everything I think that we have got a good handle on the big concepts and kind of where you are going from there.
DR. GREEN: I want to ask for help from both of you guys and also you, Justine. I am going to need help explaining this hearing to the Population Subcommittee. So help, please. I want to put a space holder out on the table right now. I think that we learned out of this hearing what the Population Subcommittee needs to do with the hearing about the reuse of data for the new numerators and the new denominators needed for public health and an idea that I got out of this hearing is I have been thinking of it more as we have got to get to public health world. We have to get the public health world.
I am beginning to think that we should contemplate designing that hearing to have a balance set of presentations from the provider world and the public health world about the data that they are collecting that could be dragged down into new types of measures that would measure population health but would also be the reused data sources.
DR. TANG: You said the providers and the who?
DR. GREEN: The usual suspects from public health.
DR. TANG: The only question is that would seem to me to reinforce the status quo.
DR. MIDDLETON: Here is a thought. What I heard was in a way sort of broadening it from just the public health traditional population management stuff with population data because now management population does a clinical exercise but this third thing we heard that numerators may come from clinicians and denominators may come from the payers so I actually would have a –
DR. GREEN: Could you write that down? That is what I am asking for help with right there. I think we could frame the Population Subcommittee hearings in a way that was very complimentary to what we are hearing and keep building off of it in terms of the nation's statistics. So Justine will you help too please?
DR. CARR: Of course, of course. No I think it is very important that we keep thematic and there are themes that are emerging that are complimentary and I agree completely.
DR. MIDDLETON: So Paul is almost out the door.
DR. TANG: Thanks to Matt for putting together this hearing. Thank you.
DR. CARR: As usual, fantastic job. Thank you.
DR. MIDDLETON: Thank you, Matt and thank you Debbie and thank you everybody for coming. Mike, good to see you and all of who are on, folks, thank you. Carol, guests and others. So I guess now may I say we are officially adjourned.
(Whereupon, the meeting adjourned at 2:30 p.m.)