The Complexity Behind Quality Measures

Now, going back to the logic of the paper, let's say I'm a hospital that has registration, ADT, and lab systems; that gets me 18 percent of the way. And then if I meet all the explicit data capture requirements for meaningful use Stage 1, how much better off am I? Well, the answer is that you've only captured 17 percent more of the data elements, so you're now up to a “whopping” total of 35 percent of what you need. So when you do CPOE for meds, allergy lists, and problem lists, and vital signs (though vital signs don't help you with those measures), you're up to 35 percent of what's required. Among other systems required to make this work are CPOE beyond medication orders, physician documentation, other nurse documentation, discharge instructions, medication lists, and other documentation (physical and occupational therapy).

HCI: Those systems, along with the eMAR, provide up to 64 percent of the data needed to move forward successfully in Stage 1; that is a “wow.”

Metzger: Yes, I think that is the “wow.” It says that people had better start thinking about these quality data elements right now.

HCI: Some CIOs are moving forward on basic CPOE and basic physician documentation, but many have not even begun to move forward yet on eMAR. But it's clear that your analysis shows they do need to move forward on eMAR and the more advanced physician documentation-notes, etc., right?

Metzger: For the physician documentation, I can imagine developing a very basic patient face-sheet, not really the full notes, which might bridge that gap. And sometimes, you can embed data capture into a condition-specific order set. I know there are CPOE systems that allow you to include in the order set questions with pull-down answers. So for the VTE prophylaxis measure, for example, the physician would have the opportunity to say why they're not ordering VTE prophylaxis, which is one of those troublesome data elements; so there are a few ways to get around that problem for the moment. But a lot of systems aren't set up to do that. But I don't know how you do the meds administration part without eMAR.

HCI: So in other words, if they don't have eMAR, they won't even be able to capture the measure data elements they need?

Metzger: That's right, because meds administration has to be done and documented by nurses; the specifications are clear. So the way I read this is, it isn't some quality nurse coming in after the fact doing the electronic documentation. So that's where the combination of the specifications and the data dictionaries sheds important light on these measures; which is why we took the approach we did. Another issue revolves around your systems in surgical suites; we found that nine percent of the data elements involve care actually delivered in the surgical suites. And even when we did this analysis for the interim rule, 14 percent of the data came from ED systems, and that's true in the final rule also. And in some hospitals, 75 percent of patients are admitted through the ED. The challenge, of course, is that many hospitals that have true clinical OR systems, not just scheduling systems, and have ED systems, generally have best-of-breed systems in those areas that aren't from their core clinical vendors.

HCI: So the huge implication in all this is that if you don't have CPOE beyond meds orders, and advanced physician documentation, if you don't have eMAR, if you don't have ED and OR and have those systems linked to the core EHR, you won't get there?

Metzger: That's right. And everybody's been focused on that table [laying out the general requirements in the final rule]; and they haven't drilled down on the one line item for quality measures.

Healthcare Informatics 2010 October;27(10):40-42