The Complexity Behind Quality Measures

Metzger: Yes; and I don't know anybody else who's done it. And to do so, we had to go to each quality measure and its specifications, as well as the underlying data dictionary. Then we had to build a software program that allowed us to manage the information, to get the unique data elements associated with each measure. Because, for example, the stroke measures share a lot of data elements, so that the diagnosis for ischemic stroke, for example, shows up in many measures. So we had to figure out, what is the unique set of data elements involved for this set of measures? Every hospital has to get every unique data element from their EHR -that's what meaningful use is. It also says they have to confirm that the calculation and reporting were performed by certified EHR technology. The inpatient EHR is a bunch of applications, even if from one vendor-the order management piece, the CPOE piece, the registration piece-and it varies from vendor to vendor as to how that portfolio will be carved up. So we went in and figured out the likely source of each data element. Then we said, let's look at the subsets of data, to determine which ones will be easier to do, and which will be harder to do.

So the first question is, what will the easier data be? And 99 percent of hospitals have registration/ADT [admissions-discharge-transfer] systems, because they have to, to do billing. And another really easy type of data is laboratory results, because everybody has that online. Now, it will still have to be captured in the EHR, but at least they've got the data. So if you have those two kinds of systems, you have 18 percent of what you need for the measures-not a large percentage. So you've got those systems. In addition, one big change to the final rule [from the interim rule] is that meaningful use does include the emergency department, as do the measures.

HCI: Just to give readers one example, consider what's involved in facilitating the reporting on one of the 15 requirements, which is “number of patients who have received VTE prophylaxis or have documentation of why no prophylaxis was given the day of or the day after the initial admission or transfer to the ICU or surgery end date, for surgeries that start the day of or the day after ICU admission or transfer.” Ostensibly, it should be relatively easy to find and report out this measure, but in fact, as you point out in your report, there is a very complex set of inclusion, outcome, and exclusion data elements, spread out across multiple clinical information systems, that have to be gathered successfully in order to report this “single” measure; and the care settings include the ICU and the OR, and possibly the ED.

Metzger: Yes. It's complicated by a number of factors, including the fact that there are several kinds of VTE prophylaxis. And there is considerable complexity around surgical processes and timing as well, in the data elements for this measure. What's more, there are two kinds of VTE prophylaxis treatment, pharmacologic or mechanical; and look what the measure introduces about the timing, and over questions such as whether the patient is on a clinical trial relative to VTE, or whether the patient was admitted for comfort measures only. Further, is the patient an obstetric patient? Does the patient already have VTE? Has the patient already had a stroke? Or, if the patient is admitted for certain types of surgery, certain procedural codes will be excluded. The fact is, people who don't spend day in and day out collecting these measures simply won't realize how complex this is. It's not just, “Did we do VTE prophylaxis?” And the person who administers this is a nurse; so the outcome would appear within nursing documentation, which, by the way, is not a part of meaningful use.

HCI: So the drill-down leads to complexity everywhere.

Metzger: Yes, and it's in the expression of the measure, and to which patients each measure applies.

HCI: So the bottom line is that the work involved in collecting every one of these 15 quality measures is much more complex than people have realized so far?

Metzger: Right. And then you think that VTE prophylaxis is one thing, and it's much more than that. And then some of these things involve physician documentation and some don't.