In September, the Agency for Healthcare Research and Quality (AHRQ) released a new report, “Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practice Guidance,” which “examines the intersection of health IT and quality measurement, reflecting the expectation that health IT-enabled quality measurement can make quality improvement possible.” As the announcement on the agency’s website stated, “It is presented to share information, stimulate discussion, assist communication among stakeholders, facilitate understanding, and to provide guidance on potential infrastructure enhancements that could be pursued, individually or collectively.” The report was prepared by Booz Allen Hamilton, and its authors were Rebecca A. Roper, Kristine Martin Anderson, Christina A. Marsh, and Anjanette C. Flemming. Roper is director of the Practice-Based Research Network Initiative within the Health Information Technology Portfolio at AHRQ; she reports to P. Jon White, M.D., director of the Health Information Technology Portfolio.
As the report notes, “Until recently, quality measurement relied almost exclusively on the use of electronic claims data, manual chart abstraction, and patient surveys. However, the enormous, recent growth in the adoption of health IT provides an opportunity for more efficient quality measurement, the development of new types of measures serving various purposes and end users, and tighter integration between quality measurement and quality improvement. The sudden increase in availability of digital information,” the authors point out, “raises expectations across all stakeholders who use, work with, or oversee aspects of the healthcare system with respect to how data can be used to improve care, while many of those same stakeholders are simultaneously facing the challenges associated with acquiring new health IT systems and integrating them into the healthcare delivery organization.
The report acknowledges the importance of the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Affordable Care Act (ACA) in accelerating healthcare information technology development across the U.S. healthcare system. Based on some of the progress taking place, the authors recommend the following:
- Measurement should be patient-centered.
- Measurement should be supported by end users’ education and collaboration.
- Measurement should be aligned to national priorities.
- Measurement should be actionable and built to work within a system of quality improvement.
- Measurement should leverage available technologies.
The report goes on to delve deeply into issues around managing two separate phenomena that overlap in practice: quality measurement and improvement activities, and the ongoing development and implementation of information systems, especially clinical information systems. It provides guidance at the conceptual level to healthcare leaders considering, planning, or already implementing both types of activities and systems.
Shortly after the publication of the report, Dr. White, who conceived the report and oversaw its publication, spoke with HCI Editor-in-Chief Mark Hagland regarding its content and implications. Below are excerpts from that interview.
What was the strategic goal of the agency in developing and publishing this report?
There are a lot of federal programs looking at health IT; ONC [the Office of the National Coordinator for Health IT] is helping to guide providers on health IT, and CMS [the Centers for Medicare & Medicaid Services] is providing incentive payments. AHRQ’s job is to provide the best evidence possible and to make sure that providers have good tools at their disposal that are evidence-based. There’s a lot of stuff happening now, and it’s a very exciting time. We wanted to have a sense of what the questions were to ask, not only now, but in five or ten years from now. And to do it in a thoughtful way, you need to stop and look at the current landscape. So first, we wanted to ask what the big questions were that we ought to be asking our people to think about now. And as a secondary goal, we wanted to find out what things people say they have a need for, and can begin to work on, in terms of processes or infrastructure, that can help them get where they want to go.
P. Jon White, M.D.
We all need for the federal agencies to be pulling in the same direction in these areas, right?
I agree completely. No one person or organization will be able to do this well; everybody has to be able to communicate clearly, regularly, and effectively, in order for this to work. They’ll have to communicate about what’s going well and not; you can’t leave anyone behind.
How do you see the areas around data aggregation, integration, and exchange?
I see it in two ways. On the one hand, things are very exciting. Part of the putting together of this report was that a background report was put together, and then an RFI [request for information] and focus groups. And there’s a lot of enthusiasm for and involvement in, this area. Organizations are putting together these systems, and more importantly, using them to guide care. That’s tremendously exciting for me. What’s more, the folks who want to do this are really interested in incorporating data from a lot of different sources that touch on people’s lives and health, in ways that we hadn’t seen previously. Previously, the focus was just on what we can capture in the EHR and codify; but we really need data from patients’ activities of daily living, information about patients’ lives, etc., via monitoring and devices. And that can be so much more meaningful data than me sitting in my office and asking how you’re doing.
There’s a tremendous amount of data, but the challenge is, how do you derive data from that information? And the data will come from different places and have different levels of truth from it and be incomplete, and you’ll be comparing apples to oranges. So both the methods you use and the levels of meaning you assign to that data, will be different. So, can we get our heads around “big data,” as it were? Ultimately, I want people to live longer, suffer less, and live better lives. And how do you get there from a sea of big data?
What are some of the biggest challenges to gathering data and making sure it’s meaningful? If you could especially address what CIOs and CMIOs need to be doing as they work in this area, that would be very helpful.
One is to figure out the best ways to get meaning from data. The other is, what’s important? And that relates to what processes can create change. Healthcare is not a narrow sector; it serves everybody. And you could go out and try to boil the ocean; but we’ve got limited people and resources. So everybody to a certain extent has to decide what’s important for them. And per CIOs and CMIOs and what they should be thinking, on one level, those folks need to focus on the fundamentals. I’ll offer you two metaphors for this: in baseball, you’ve got to catch the ball, hit the ball, and throw the ball. And in order for them to do their jobs well and serve the people in their organizations and ultimately their communities, they’ve got to execute. And they’ve got to do some fundamentals well, and a really key part for them is engaging in dialogue.
You’ve got to engage, certainly, with their clinicians, and ask them what they need. If you go to them and say, here’s what’s going to be done to you, you’re going to founder beneath the angry waves! But you need to engage with them. And the clinical folks also need to engage in productive dialogue with vendors around where you’re trying to go and how you’re going to get there. And the good and thoughtful vendors will listen well and do what needs to be done. Another big element in this is the dialogue with senior leaders. CIOs and CMIOs get executive sponsorship for what they do, and they need to provide good, honest feedback to the leadership on what they’re doing and how it’s going on. And finally, they need to engage with patients, with caregivers in the community, and how what they do serves them. That sounds very platitudinous; but you can see it in the people who are doing their jobs well.
Overall, in your view, how are we doing as an industry right now as we move forward in these important areas of activity
That’s a great question. I grew up in a medical household; my dad’s a doctor. So I’ve been around this for a while. And there’s a real sea change going on. It is no longer about eminent-space medicine, I’m the doctor and what I say goes. It’s about creating better health and engaging with patients, and people are used to asking for and getting information in many elements of their lives, and they’re asking for that information in healthcare, and are starting to get good information. And that trend won’t stop. And I think that’s what underlies this happy engagement in this area right now. And per better harmonization, what we heard from folks as we prepared the report, as much as we’d like for it to have happened yesterday, harmonization doesn’t just happen; getting everybody on the same page is going to take time and take patience. And ultimately, people need to not unplug; they need to stay engaged in the process.