Authors: Blackford Middleton, MD, MPH, MSc - Chief Informatics and Innovation Officer, Apervita & Benjamin Hamlin, MPH - Senior Research Informaticist, Performance Measurement, NCQA
The healthcare industry has spent over a decade mandating the collection of a wide array of health data. With the advent of cloud platforms, that data is more readily available than ever before but, until very recently, it has not been incorporated into quality measurement. The digital quality renaissance has released quality measurement from the restrictions of administrative-only data sets, opening the door to the development of person-centric assessment models leveraging an array of electronic clinical information. This increased use of electronic clinical data and common specification standards helps to reduce provider burden, strengthens the validity and reliability of knowledge generated from the measurement process and reduces the variability which arises in measure implementation. The next generation of quality measurement now requires payers, providers and vendors to support new capabilities, data sets and technologies. Healthcare organizations that wait to adopt digital quality strategies will quickly fall behind industry leaders.
At the forefront of this digital quality transformation is the National Committee for Quality Assurance (NCQA), which is developing and implementing the latest technologies to measure healthcare quality. However, NCQA isn’t just digitalizing traditional Healthcare Effectiveness Data and Information Set (HEDIS®) measures. In July 2019, the healthcare quality organization released an entirely new quality reporting model: use of Electronic Clinical Data Systems (ECDS). Measures in the HEDIS ECDS ecosystem are designed around a core set of principles intended to facilitate a continuous cycle of knowledge sharing that supports quality improvement and the production of timely and actionable feedback. ECDS measures are specified to be more person specific than traditional HEDIS administrative measures, further enriching the insights they can provide to consumers and end users of the information. ECDS measures are based on existing HEDIS measures but require more robust and granular electronic clinical data coming directly from electronic health records (EHRs), health information exchanges, clinical registries and case management systems, thereby enhancing the quality insights about each individual assessed.
NCQA’s digital quality push is notable considering the scope of its reach in the industry: 190 million people are enrolled in plans that report quality measure results to NCQA.
Other healthcare industry regulatory bodies are similarly changing the way payers and providers measure, improve and report quality. In 2018, The Centers for Medicare and Medicaid Services (CMS) began mandating the submission of electronic clinical quality measures (eCQMs) in order for eligible hospitals, critical access hospitals and dual-eligible hospitals to meet interoperability requirements. Less than a year later, The Joint Commission also began mandating digital quality measures.
It is difficult to imagine in this age of technology that the majority of quality measurement in healthcare still requires substantial manual effort in coding and testing every iteration of each individual measure. Even with traditional quality measures, the coding of the specification isn’t the end of the manual process. The collection of data at the point of care requires clinical staff to check boxes and calculate clinical findings into “readable” results as specified by the measure. All this human intervention at multiple levels of the process opens up the possibility for interpretive and calculation errors at every juncture. Digitalization alone is not sufficient, the measures themselves must evolve to meet expectations of specific provisions of the 21st Century Cures Act to help improve the overall health of the population.
Digital measure innovations are enabled by new technologies and rapidly maturing standards, the most important of which is clinical quality language (CQL). CQL is a healthcare-specific logic standard developed by Health Level Seven International that is both human and machine-readable. When implemented properly and in conjunction with a cloud-based platform, CQL cuts time and effort for measure execution by upwards of 90%. For instance, a traditional quality measure typically takes 200 hours to implement. With CQL enabled on the Apervita platform, a digital measure implementation typically takes 12–14 hours. Particularly in the case of those person-specific measures whose specifications are substantially more complex, CQL now performs many of the complex query functions that were previously far too onerous to be completed manually. Standardization of the measure specifications using CQL allows for the reuse of common measure components across multiple measures which reduces the burden of maintenance and implementation.
Digital measures rely on implementors to download the CQL specifications and deploy them immediately to generate useful knowledge that empowers clinicians and informaticians to take clinically appropriate action. Traditionally, measure implementors would have to obtain the specifications, interpret each and code them to operate within their own unique data environment, seek certification to verify the accuracy of their interpreted code and then run them against their data to generate a measure report. A typical implementation and validation process requires several hundred hours of programmer time per measure, and the entire process ranges from weeks to months before a measure can be considered ready for use. In contrast, in the new digital quality ecosystem informaticians were able to successfully download, validate and run eleven HEDIS ECDS measures on the Apervita platform in less than three days from start to finish. This meant that Apervita clients were able to begin generating measure artifacts and assessing care gaps from their data within a week of the measure publication date.
Digitizing healthcare isn’t new, however digitalizing quality measurement to proactively improve clinical care is. ECDS, digital HEDIS, and CQL based-eCQMs are drastically transforming the way payers and providers work with each other and interact with regulatory agencies. These measures provide ease of use and harness the power of the vast amounts of existing clinical data in order to provide a more holistic look at patient outcomes. With the industry moving to an ever more value-based ecosystem, now is the time to be proactive about digital quality measurement transformation.
Digitizing healthcare isn’t new, but digitalizing quality measurement to proactively improve clinical care is.
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