Clinical Quality Measure Exchange is Not Easy

INTRODUCTION

Family physicians provide nearly 20% of all clinical outpatient visits, nearly 200 million visits in the United States annually.¹ Frontline clinicians continue to report failures of certified electronic health records (EHRs) to meet federal certification requirements and to meet electronic reporting needs, the latter of which is estimated to cost them $15 billion per year.^2-11 Reducing reporting burden and enhancing the portability and utility of clinical data for quality improvement is an American Board of Family Medicine (ABFM) goal that is aligned with federal policy.^12,13 In 2013, the ABFM began development of a Qualified Clinical Data Registry to assist practices whose EHRs were not serving their quality reporting needs and to reduce reporting burden. That registry, called PRIME, launched in 2016 and now actively extracts data from EHRs in more than 800 practices in 47 states (https://www.primeregistry.org).

Beyond reducing reporting burden, the ABFM aims to help practices easily access their own data for quality assessment and improvement and to reduce continuous certification burden. The ABFM recognized that many primary care physicians would not be able to connect directly to PRIME and that another passive data path was needed by which an EHR vendor, institution, or clinic system could send aggregated quality measures to the PRIME registry.^12,14,15

The objective of this study was to assess whether quality measure reporting could be made a by-product of clinical care and quality improvement. We report here on the functional testing of quality measure exchange, that is to say, a test of the reliable exchange of whole-panel, quality measures from clinical networks. This component of the study was integral to a broader effort called the TRial of Aggregate Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ).^14,16,17 The study partners were 4 health systems with mature, established clinician quality-measurement and tracking systems. All 4 systems were willing to test ways to automate direct transmission of clinical measures.

METHODS

While TRADEMaRQ was a randomized, controlled trial, we report on the descriptive study component of the measure exchange testing experience.

RESULTS

DISCUSSION

This paper reports on a test of exchange of whole-panel, standardized quality measures from clinical networks and health systems with mature internal quality measure processes, all of whom reported to HEDIS and Centers for Medicare & Medicaid Services (CMS). Of 19 measures that the 4 agreed were common and standard, only 5 measures were used by all 4. Dozens of identified errors or hazards in measure calculation, data management, data delivery, and physician inclusion occurred. These problems often required human intervention and manual repair, precluding fully automated file transfers. In the end, there was a steady stream of reported data and most of the enrolled physicians were able to interact with them on the secure ABFM website. We conclude that it was really a test of system-level breakdown in measure definition, process, capture, and transmission rather than about the particulars of individual clinician quality; it is a symptom of the bigger system problem.

The “passive” data reporting path that TRADEMaRQ sought to test was related to the intentions of the Health Information Technology for Economic and Clinical Health Act.¹⁸ Specifically, it promoted the Office of the National Coordinator for Health Information Technology (ONC) Direct Project which aimed to create a simple, secure, scalable, standards-based way to transmit health information from a sender to a trusted recipient over the Internet.¹⁹ Direct Project priority 2 specifically mentions reporting of quality measures to a variety of potential recipients. The TRADE-MaRQ aims also aligned with the ONC Nationwide Health Information Exchange intentions, namely to support secure health information exchange for measuring and improving quality tied to incentives for improvement and required reporting.^20,21 This study reconfirms an important problem, namely, that despite continued growth in health information technology adoption and calls for interoperability, most clinical practices struggle to produce standard quality measures from their clinical data and to meet a growing number of reporting needs.²² Several large-scale, federal demonstration and research efforts have run headlong into this problem and are struggling to get measure data out of participating practices.¹¹ Although many clinicians are now reporting to the federal Quality Payment Program and hardship exceptions are made for small practices, they are at increasing risk of being left behind because NCQA’s patient-centered medical home recognition program is moving to annual electronic measure reporting, and many public health registries and even some payers are also requiring electronic measure submission.⁵ Quality reporting is unlikely to disappear but the reliability of what is reported is unclear, meaningfulness uncertain, and the cost high.^6,7

A major limitation of our study is that the problems identified may not generalize to other health systems.

CONCLUSION

TRADEMaRQ and other recent studies suggest that we remain far from clinical data liquidity goals of federal agencies. The ABFM’s goals to help physicians make reporting a by-product of care and ongoing quality improvement, and reduce physicians’ reporting burdens, remain aspirations. While small and independent practices struggle with turning their EHR data into reportable measures, large health systems also struggle with managing measure definitions, internal vs external quality processes, and costly processes for managing reporting.