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Introduction to Quality Improvement and Health Information Technology
- 1. Quality Improvement Introduction to Quality Improvement and Health Information Technology Lecture a This material (Comp 12 Unit 1) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/
- 2. Introduction to Quality Improvement and Health Information Technology Learning Objectives — Lecture a • Identify the current challenges in health care quality. • Examine the components of the health care system that have an impact on quality. 2
- 3. Current Health Care Landscape: Affordable Care Act (ACA) • Became law on March 23, 2010. • Increases health coverage for children. • Mandates health insurance. • Ends lifetime and most annual limits on care. • Allows young adults under 26 to stay on their parents’ health insurance. • Gives patients access to recommended preventive services without cost. • Other benefits: – 50% discounts on brand-name drugs for seniors in the Medicare “donut hole.” – Tax credits for small businesses that provide insurance to employees. 3
- 4. Systems and Health Care Reform • “Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed … It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it” (Berwick, 2009). • “The performance of a system — its achievement of its aims — depends as much on the interactions among elements as on the elements themselves” (Berwick, 2009). • “The improvement of health and healthcare depends on systems thinking and systems redesign … ‘Reform’ without systems thinking isn’t reform at all” (Berwick, 2009). 4
- 5. Current Health Care Landscape Meaningful Use Providers show they’re using certified EHR technology in ways that can be measured significantly in quality and in quantity. Patient-Centered Medical Home Providers organize care around patients, working in teams, coordinating care, and tracking over time. Accountable Care Organization Provider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients. 5
- 6. Meaningful Use and QI — 1 “Even hospitals with fully functioning EMRs still make extensive use of digitized scans of manually completed forms and textual checklists. With no forms or screens to capture data in a structured way, hospitals fail to report quality measures as a routine byproduct of the practices, relying instead on a retrospective chart abstracting process” (Holland, 2010). 6
- 7. Meaningful Use and QI — 2 • The American Reinvestment and Recovery Act (ARRA) of 2009 “authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming ‘meaningful users’ of certified electronic health record technology.” • The Health Information Technology for Economic and Clinical Health Act (HITECH) establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge. 7
- 8. Goals of Meaningful Use • Improve quality, safety, and efficiency. • Engage patients and their families. • Improve care coordination. • Improve population and public health; reduce disparities. • Ensure privacy and security protections. 8
- 9. Stages of Meaningful Use in 2016 Source: ONC website. 9
- 10. The Patient-Centered Medical Home (PCMH) The Patient-Centered Medical Home is “an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family” (Patient-Centered Primary Care Collaborative). 10
- 11. Joint Principles of the Patient- Centered Medical Home • American Academy of Family Physicians (AAFP). • American Academy of Pediatrics (AAP). • American College of Physicians (ACP). • American Osteopathic Association (AOA). • Seven Principles of the PCMH. 11
- 12. Seven PCMH Principles — 1 1. Personal physician. 2. Physician-directed medical practice. – Collective responsibility. 3. Whole person orientation. – All stages of life, all sites of care. 4. Coordinated and integrated care. – Assures smooth, continuous, and culturally appropriate care. 12
- 13. Seven PCMH Principles — 2 5. Quality and safety. – Optimal patient-centered outcomes, evidence-based practice, CQI, use of CDS, measuring achievement of outcomes, etc. 6. Enhanced access. – Ease of access to providers. 7. Payment. – Recognizes value of the PCMH. Coordination, Health IT, Remote Monitoring, Attention to Case Mix, Physician Share in Cost Savings, Payment for Quality. 13
- 14. PCMH Content and Scoring Tool Source: National Committee for Quality Assurance. Used with permission. © 2014 National Committee for Quality Assurance. 14
- 15. Accountable Care Organizations (ACO) • ACO: providers and suppliers (e.g., hospitals, physicians, and others involved in patient care) work together to coordinate Medicare covered services. • Goal: Medicare beneficiaries receive lower cost, higher quality, and better coordinated care. • Patient-centered care decisions are joint between patient and providers. • Under the proposed rule: – Medicare would continue to cover Medicare services. – Benchmarks developed by CMS for each ACO. – ACO performance measured to determine if they receive shared savings, or held accountable for losses/poor performance. 15
- 16. Introduction to Quality Improvement and Health Information Technology Summary — Lecture a • The quality of care received in the U.S. needs improvement. • In the current health care environment there are a number of initiatives that aim to improve the care for all Americans through the use of HIT. – Meaningful Use. – Patient-Centered Medical Home. – Accountable Care Organization. 16
- 17. Introduction to Quality Improvement and Health Information Technology References — Lecture a — 1 References Affordable Care Act. Available from: www.healthcare.gov/law/index.html Berwick, D. October 30, 2009, speech, Harvard School of Public Health. Center for Medicaid Services. Shared Savings Program. Available from: https://www.cms.gov/sharedsavingsprogram/ Endorsing national consensus standards for measuring and publicly reporting on performance; California Academy of Family Physicians Diabetes Initiative Care Model Change Package originally developed by Lumetra. Holland, Marc. In Health Information Exchange: From Meaningful Use to Healthcare Transformation. The National Coalition on Health Care (NCHC, 2007). Available from: http://nchc.org/ Patient-Centered Primary Care Collaborative. What We Do (PCMH). Available from: http://www.pcpcc.net Patient Protection and Affordable Care Act (PPACA). Available from: http://www.healthcare.gov/law/index.html 17
- 18. Introduction to Quality Improvement and Health Information Technology References — Lecture a — 2 References U.S. Department of Health and Human Services. (June 22, 2011). Up to $500 million in Affordable Care Act funding will help health providers improve care. Available from: https://innovation.cms.gov/files/x/partnership-for-patients-funding-solicitation-press- release-06-22-2011.pdf Charts, Tables, Figures 1.1 Table: PCMH 2014 Content and Scoring. Produced by the National Committee for Quality Assurance. Retrieved March 24, 2016, from: https://www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/PCMH%202014%20 Intro.%20Training%20Slides%20Part%201%20-%20Standards%201-3%20- %2011.26.pdf Images Slide 5: Meaningful Use, Patient-Centered Medical Home, Accountable Care Organization. Courtesy of Dr. Anna Maria Izquierdo-Porrera. Slide 9: Stages of Meaningful Use. Office of the National Coordinator for Health Information Technology. Available from: https://www.healthit.gov/providers- professionals/meaningful-use-definition-objectives 18
- 19. Quality Improvement Introduction to Quality Improvement and Health Information Technology Lecture a This material (Comp 12 Unit 1) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. 19
Editor's Notes
- Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture a. This course has been designed to examine the critical relationship of health care quality and health information technology (HIT). We will explore the concept of health care quality and the role of health information technology in advancing the quality of health care.
- The Objectives for Introduction to Quality Improvement and Health Information Technology are to: Identify the current challenges in health care quality. Examine the components of the health care system that have an impact on quality.
- The U.S. health care system is large and complex. While the system excels at providing technologically sophisticated health care, according to many experts, it is also plagued by exorbitant spending, quality, and safety concerns. The National Coalition on Health Care (NCHC) reported that total health care expenditures make up 16 percent of the gross domestic product and are expected to reach $4.2 trillion in 2016. The NCHC also reported that there were more than 47 million uninsured Americans and that the number had risen by almost 9 million people since 2000. As a response to these problems, the Affordable Care Act (ACA, also known as Obamacare) was signed into law by the President on March 23, 2010. This law has brought insurance coverage to almost 16 million uninsured Americans and set in motion a fundamental transformation from a volume- to value-driven payment system. Some of these changes include: Increased health coverage for children. Health insurance mandate. Ends refusal of coverage for preexisting illness, lifetime, and most annual limits on care. Allows young adults under 26 to stay on their parents’ health insurance. Give patients access to recommended preventive services without cost. The Act includes other benefits, such as: 50% discounts on brand-name drugs for seniors in the Medicare “donut hole” Tax credits for small businesses that provide insurance to employees.
- Dr. Donald Berwick, a former administrator at the Centers for Medicare and Medicaid Services (CMS) and a founder of the Institute for Healthcare Improvement (IHI), has stated that system performance depends not only on the elements of the system, but also on the interaction among these elements. Dr. Berwick has dedicated his career to improving patient outcomes and providing better health care at lower cost, which are components of his well-known “Triple Aim.” According to him, health care improvement depends on systems thinking and redesign, and that health care reform without attention to the nature and nurture of health care as a system is doomed. To quote Dr. Berwick, “It will, at best, simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families and their communities experience it.” The U.S. Federal Government is one of the largest stakeholders in health care. It is by far the single largest payer of the health care system and has regulatory authority as well. The Affordable Care Act and the ARRA/HITECH legislations have brought health information technology (HIT) to the forefront as an indispensable tool to improve quality and reduce cost. The following few slides discuss some key programs that have resulted from implementation of these legislations.
- We will review three programs that have already had profound impact both in the use of HIT and in the quality of health care. The Meaningful Use program is designed to enable providers to implement and “meaningfully use” certified Electronic Health Records technology (CEHRT). The Patient-Centered Medical Home (PCMH) incentivizes providers to organize care around patients, working in teams, coordinating care, and tracking over time. Finally, the Accountable Care Organization (ACO) program moves provider reimbursements from fee-for-service to more value-based care. Quality measures are integrated in each of the three programs listed here.
- It is generally understood that rarely will organizations be able to become completely electronic. According to Marc Holland, an expert in HIT and health-data exchange, “even hospitals with fully functioning EMRs still make extensive use of digitalized scans of manually completed forms and textual checklists. With no forms or screens to capture data in a structured way, hospitals fail to report quality measures as a routine byproduct of the practices, relying instead on a retrospective chart abstracting process.” The complexities of quality measure reporting have not been completely understood, and much of your effort as HIT professionals will be directed toward finding ways to manage this complexity. The new system of measuring quality using electronic clinical quality measures (eCQM) is still evolving and holds great promise of reducing provider burden of quality reporting and making quality measurement more real-time linked with clinical decision support (CDS).
- The American Reinvestment and Recovery Act (ARRA) of 2009 authorized the Centers for Medicare and Medicaid Services (CMS) to provide reimbursement incentives for eligible providers and hospitals who can demonstrate that they use certified electronic health records in a meaningful way. This act has Health Information Technology for Economic and Clinical Health (HITECH) provision to establish programs under CMS in coordination with the Office of the National Coordinator (ONC). The majority of the Meaningful Use incentive dollars have been spent, and the system is evolving from incentives to penalties.
- Meaningful use of Electronic Health Records means that use of these records improves quality, safety, and efficiency of care; engages patients and families in their care; improves coordination of care, improves population and public health and reduces disparities; and ensures privacy and security protections for all. To qualify for federal incentives or avoid penalties, users of certified EHRs must demonstrate that they meet these criteria.
- Meaningful use criteria have been released in three stages. Stage 1 (2011–2012) criteria are directed toward capturing and sharing data. The objective of stage 2 criteria (2014) is to advance health care processes with decision support, and in stage 3 (2016 and beyond), meaningful use criteria were targeted at improving outcomes. Stage 1 criteria address the priority of improving quality, safety, efficiency, and equity of health care. The goals of stage 1 criteria are four-fold. First, in order to meet the stage 1 criteria, health information must be electronically captured in a structured and coded format by both hospitals and eligible providers. Then, they must be able to demonstrate that they use that information to track key clinical conditions for quality improvement purposes. Third, providers and hospitals must be able to communicate that information to other care providers to ensure coordination of care. Then they need to lay the foundation for reporting clinical quality measures and public health information. Criteria have been divided into two sets: a core set that must be met by all eligible providers, hospitals, and critical access hospitals in order to qualify for incentives, and a menu of additional criteria from which they must select any five choices to receive incentives.
- The Patient-Centered Primary Care Collaborative (the PCPCC), a group that includes consumer groups, hospitals, providers, large employer groups, and many others, joined together to focus on the Patient-Centered Medical Home (PCMH). This group has formed to advance the concept of the PCMH and puts forth the following definition, “an approach to providing comprehensive primary care for children, youth, and adults. The PCMH is a healthcare setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.”
- The American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA) in 2007 created a set of joint principles that outline the characteristics of the PCMH. These four groups have a total membership of more than 33,000, and have a vested interest in the PCMH. The Joint Principles document can be found on the website of the American Academy of Family Physicians. There are seven principles that have been put forth by this consortium of four groups for the PCMH. We will briefly describe these seven principles.
- Here are the first four of the seven PCMH principles. The first principle asserts that each patient has a personal physician who becomes the captain of the ship, taking total responsibility for a patient’s care. The second principle is the physician-directed medical practice. This principle espouses that there is a team of individuals, led by a physician, who take total responsibility for a patient’s care. A whole person orientation — the third principle — means what it says. The person is viewed as a whole, not a collection of systems or illnesses. In the PCMH, this principle means that all aspects of the patient’s health care needs, across all stages of life, is the personal responsibility of the primary physician. The personal physician must also assume responsibility for arranging and coordinating care for a given patient. The fourth principle assures that care is coordinated and/or integrated across all sites of care, including acute care, home care, long-term care, in the community, and the like. Such care assures smooth, continuous, and culturally appropriate care. Of course, the ability to provide such continuity and coordination is reliant on health IT, mechanisms for health information exchange, and a patient-centered focus that takes into account culturally and situationally appropriate plans of care.
- The final three dimensions start with quality and safety — which are the fundamental and defining characteristics of the PCMH. The goal of the PCMH is to support and encourage attaining patient-centered outcomes. These are not the outcomes decided by the provider; instead these are commonly derived goals between the care team, the patient, and his family. It requires compassion and strong relationships between all members of the patient-centered team. It also requires that the patient and family expectations for the care process and the outcomes are being met. Quality and safety measures also include adhering to evidence-based practice and the use of robust clinical decision support tools to guide optimal decision making. Achieving quality and safety also requires that all members of the team, with the feedback from patients and families, participate in continuous quality improvement and voluntarily participate in quality improvement measurement and reporting. Interestingly and quite relevant for health IT professionals, these guidelines (under the Quality and Safety header) require the use of health IT to facilitate high-quality communication, for measurement of performance and outcomes, to support superior patient care, and for patient and family education. Finally, demonstration that the practice has the capacity and wherewithal to provide patient-centered care consistent with the PCMH, determined by a voluntary recognition process conducted by a non-governmental entity, is required. The sixth principle of enhanced access to care is directed at assuring that patients are able to reach providers and care staff with a minimum of effort. This can be achieved via the use of health IT (such as online scheduling, emailing with providers — much in the way that the Veterans Affairs My HealtheVet web portal works) or by other methods such as weekend hours, evening hours, and the like. The seventh and final principle focuses on payment. The payment principle is premised on the acknowledgement of the value that is derived from patients who are participating with the PCMH. A payment structure has been derived as part of this framework and includes aspects such as payment for care coordination, financial incentives for adoption of health IT (recall, these principles were developed in 2007, long before the HITECH Act), payment for remote monitoring activities and the use of alternative telecommunications with patients and families, attention to case mix, allowance for enhanced cost sharing across providers for cost savings derived from the PCMH, rewards for achievement of high-quality and low-cost services, and several other aspects. The entire payment framework can be found by accessing the reference at the end of this slide deck from the AAFP. In addition, these entire Seven Principles of the PCMH are very clearly outlined in the same reference for students to examine in closer detail.
- The principles just outlined translate into specific elements that health care delivery sites have to put in place to be part of this system. This slide presents an example of elements and their scores necessary for the National Committee for Quality Assurance (NCQA) certification. This is one of many PCMH certifications, and it presents a good example of the specific elements. Twenty-seven elements across the following six standards are shown in the slide: Enhance Access and Continuity Team-Based Care Population Health Management Plan and Manage Care Track and Coordinate Care Measure and Improve Performance Total scores determine the following three levels of certification achieved: Level I = 35-59 points Level II = 60-84 points Level III = 85-100 points The following items are “Must Pass”: 1-A: Patient-Centered Appointment Access 2-D: The Practice Team 3-D: Use Data for Population Management 4-B: Care Planning and Self-Care Support 5-B: Referral Tracking and Follow-up 6-D: Implement Continuous Quality Improvement
- ACA also created accountable care organizations. Accountable Care Organizations (ACOs) refer to physicians, hospitals, other providers, and service suppliers that have agreed to work together to coordinate patient care under the original Medicare program. Some private payers have also set up ACO-type plans. While working to provide these coordinated services for Medicare beneficiaries, the provider groups establish a mechanism for shared governance, and strive to provide high-quality and coordinated care. ACOs are recognized legal entities at the state level and are therefore bound by state law. The Centers for Medicare and Medicaid Services (CMS), the entity that administers Medicare, will enter into three-year agreements with an ACO, and the ACO then assumes responsibility for the coordination, cost, quality, and overall care for assigned Medicare beneficiaries. Any cost savings are to be shared across the ACO partners. Overall, the goal of the ACO is to reduce the cost of care while improving quality and care coordination for beneficiaries. Care decisions are shared between the providers and the patient in an ACO — thereby, in addition to improving quality and increasing cost efficiency, an ACO would also contribute to a patient-centered orientation to care.
- This concludes Lecture a of Introduction to Quality Improvement and Health Information Technology. In summary, the quality of care received in the U.S. needs improvement. In the current health care environment there are a number of initiatives that aim to improve the care for all Americans through the use of HIT. Meaningful Use, Patient-Centered Medical Home, and the Accountable Care Organization are three of these programs.
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