Pamela McNutt, senior vice president and CIO of Methodist Health System in Dallas, has one word for the government’s planned requirement for electronic reporting of clinical quality measures: Folly.

“This notion that we’re going to extract every piece of data that we need to do clinical quality reporting solely from the electronic medical record is folly,” she says.

McNutt, and others who agree with her, are not on the fringes. They are not resisting change. They have long embraced health information technology as a route to better patient care and greater efficiencies. They are generally on board with meaningful use initiatives. They are leaders in promoting top patient care via health IT. But, they view this requirement of meaningful use Stage 2 as impossible – at least for now.

When it comes to clinical quality reporting, as the Centers for Medicare and Medicaid has defined it so far, EHRs are just not there yet, they assert.
The way clinical quality reporting is done today is with the help of a system called Midas, which has been certified under the government’s EHR certification program.

“So maybe they identify all people with a certain diagnosis, and they pull certain data over into Midas,” McNutt explains, “and then they have an abstractor go and look at a lot of things to try and figure out what certain values should be that are needed to compute the quality metrics. For instance, they may go read the physical and history to try and figure out if something is a pre-existing condition,” she explains. “They have to work it at all kinds of data points to make some decisions on the more complex measures.

McNutt advocates for continuing to report on quality measures as it is being done today, using Midas and abstractors who have deep clinical knowledge.

Discreet data elements needed

CMS is calling not only for electronic submission of quality metrics, but also for all the information to be entered and reported via the EHR.

But, some of the information required might be buried in a progress note or other narrative piece of a doctor’s notations, such as the history, McNutt explains.
What she and others say are needed are more “discreet” data elements – structured data fields – within the EHR.

Charles E. Christian, CIO of Good Samaritan Hospital in Vincennes, Ind., says many quality measures are not easily digitized. Moreover, they need to be reviewed to determine whether they are the right measures.

“Are we making sure that the things we’re tracking, gathering and reporting on really are truly indicative of high quality patient care?” he asks.

The metrics address both quality of care and reimbursement, Christian points out.

“All those things go back to value-based purchasing,” he says, “and if the intent is to have an automated generation of the quality measures, which is going to impact your future reimbursement, if we don’t get those right – and we don’t have good mechanisms together of ensuring that we’ve documented in the electronic systems appropriately – we’re going to have a problem with reimbursement down the road.”

At Rady Children’s Hospitals in San Diego, Albert Oriol, vice president and CIO, says, “There’s no doubt in my mind that long term, discreet is better.”

But, not everyone will be able to turn on a dime.

“I think assuming that you can start there, it's a hard assumption because what we’re dealing with here is really a mindset of change, of behavioral change process,” he says. “People get there, but I think attempting to get them there in one big jump may end up curtailing some of these initiatives. So some organizations have taken the approach of concentrate first on getting people using the system. Once they get comfortable using the system, then let’s introduce this more granular way of documenting instead of setting ourselves up to be able to pull out the data.

“I think the goal is right. How fast we’ll be able to get there is going to vary.”

Halamka’s plan

Perhaps the CIO with the most sway with the federal government on these matters is Beth Israel Deaconess Medical Center CIO John Halamka, MD, who is vice chair of the Health IT Standards Committee, which exists to advise the federal government on these matters.

“The Clinical Quality Measures (CQMs) are certainly one of problem spots, using standards that are not yet mature, and requiring computing of numerators and denominators that are not based on data collected as part of clinical care workflow,” he writes in his Nov. 6, 2013, blog.

“There is a chasm between quality measurement expectations and EHR workflow realities causing pain to all the stakeholders – providers, government, and payers,” he continues. “Quality measures are often based on data that can only be gathered via manual chart abstraction or prompting clinicians for esoteric data elements by interrupting documentation.”

That is exactly, McNutt’s point.

“You can only report things that were natively taken out of an EHR,” she says. “You cannot accept any abstracting to meet this measure. Now, Midas still has a whole other module that everybody uses to do all the abstracting stuff. But, [CMS] is saying for this particular piece, you can’t do that anymore. You can’t take any of the abstracted data and fill in the blank. It’s only going to count if that main electronic record system produced it.”

“We are so far off from being able to do that,” McNutt concludes.

If McNutt had her way, she would continue to report as she did in Stage 1, a mix of discreet data and abstracted data.

“You take out of your EMR all the data elements that you can take out of it – and you can identify patients – but you still have to go fill in some of the gaps,” she says. “Well, naturally over time, as we progress, we’re going to try and close those gaps. But let it happen naturally rather than try and force it.”

It’s more of less what a report commissioned by the American Hospital Association and published last July, concluded after visiting four case study sites. The hospitals were large and small, urban and non-urban, and each with significant experience with EHRs prior to meaningful use. Each employed an EHR from a different vendor.

“Despite extensive EHT implementation experience, each organization quickly learned that the eCQM implementation would be more challenging than anticipated,” AHA wrote. “The actual eCQM implementation required mu;tiple iterations of workflow redesign, data capture, eCQM calculation and validation.”

For his part, Halamka has a three-point plan for easing the pain of reporting requirements, which includes realigning expectations, adding data elements and structured data fields to EHRs over time, and greatly reducing the number of measures required.

Oriol has a suggestion that would almost surely have support from CIOs across the country.

Have all the agencies that collect metrics from hospitals collect the same measures and collect them in the same way.

“It would be incredibly helpful if there was a common set of standards of what needs to be submitted,” he says. “I suspect that many organizations – most organizations – are devoting an incredible amount of time tweaking information that they are collecting, but this group wants it this way; this group wants it calculated this other way; this group wants it submitted this other way, and it’s just so inefficient. So, if these agencies could get together and agree this is what we’re going to collect and this is how we’re going to collect it, I think the efficiency would be tremendous.

“Goals and objectives have to be meaningful and realistic,” he adds. “Otherwise, it’s so tempting to throw in the towel.”

No word yet from CMS, but McNutt and others remain optimistic that agency officials will understand the complexity and difficulty of what it has planned, and will be willing to adjust some of the requirements.

“We have a very aggressive timeline in order to get to electronic quality reporting,” Christian observes.” I think it’s going to be an iterative process. We’re going to learn as we go along. We’ll learn what works and what doesn’t work.”