You can't improve what you don't measure; you can't measure what you don't understand; and you can't understand what you don't collect. And, it's at this intersection of understanding where the National Quality Forum (NQF), measure stewards, "meaningful use," "retooling" and "eMeasures" meet.
NQF has played a key role in setting national priorities and goals for performance improvement and for endorsing national consensus standards for measuring and publicly reporting on performance. To date, most performance measures have been developed and are available in a paper-based format. This means data collection to understand performance, compare outcomes, and define key data inputs and outputs requires manual review and abstraction.
In 2009, HHS, motivated by the HITECH Act and the meaningful use regulations, requested that NQF manage the "retooling," or conversion, of a set of 111 measures from the traditional paper-based format to the electronic measure, or "eMeasure," format that is readable by electronic health records. Working in close collaboration with its measure steward partners, NQF is 61 measures down the path toward completion and expects to complete all measures by the end of 2010. This conversion should ensure that performance measure data are consistently defined, implemented, and usable in the context of an EHR and support the meaningful use requirements.
The 'So What' of Retooling
Today, plugging quality measures originally produced in a paper or PDF format into EHRs is a burdensome process. Tedious programming is required at each hospital or physician office for each new or updated measure, local implementations are not consistent and the process does not scale well without significant additional resources.
While most measures for quality improvement and public reporting are paper based, EHR-readable measures have the potential to make performance measurement more cost-effective, less burdensome for providers, and easier to compare across settings and conditions. Retooling also sets the stage for the future of quality improvement where measurement is automated and quality data are available at the point of care. The use of health IT (and eMeasures as a component) will provide unique and new opportunities for performance measurement and quality improvement. Health IT will:
- Allow clinicians to routinely capture information on patient preferences and enable shared decision making and consumer empowerment;
- Promote greater consistency in measure development and in measuring and comparing performance results;
- Reduce costs and time for measure developers and vendors and drive greater standardization and specificity across the measures and data collection (For example, eMeasures provide more exact requirements, or "specifications," about where information should be collected; therefore, less interpretation about what information fits the measure requirements will be necessary.);
- Promote greater confidence in comparing outcomes and overall provider performance in the long term;
- Reduce the workload, time and overall burden for data abstractors, vendors and measure developers, which will ultimately save money for the health care system;
- Reduce ambiguity within measures and provide a clearer understanding of what is being measured and what data are necessary;
- Enable implementation of clinical decision support to improve care concurrently by using the same data elements; and
- Ultimately improve care by providing access to better, more comprehensive and accurate performance information.
Retooling and Me
eMeasures can be applied to real data and defined in very specific terms for all patients. The availability and use of eMeasures will directly impact many health care stakeholders. It will impact how, how much and what type of care providers deliver; what care and how much of it payers (e.g., health plans, employers) pay for; and what kind of care (e.g., evidence based, guidelines) patients receive and how good that care is.
Providers will understand, in real time, if they are delivering appropriate, evidenced-based treatment and will be more aware of their own performance, as well as that of their peers. Payers can be more confident and informed about providers' care delivery and payment for appropriate care. In addition, patients will know they are receiving the most appropriate care based on guidelines and current evidence.
Eventually, measures will begin as eMeasures, and conversion or retooling will be an unnecessary step. NQF is developing a software tool that measure developers will use to create the eMeasure. The tool, expected to be online in mid-2011, will be Web-based, easy to use and maintained over time for use in NQF's measure submission process. The authoring tool will allow measure developers to define the information needed in a manner that informs EHRs how to capture and express it.
The use of standard codes for each data element will reduce variability in reporting and allow greater consistency in meaning as these same concepts are used when information is shared during the clinical care process. Such sharing will improve the meaningfulness of EHR use within and among settings of care.
Ultimately, we expect this tool and process to be a "well-oiled machine" for how measures are developed, endorsed, automated and implemented.