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The American Journal of Managed Care October 2015
Scalable Hospital at Home With Virtual Physician Visits: Pilot Study
Wm. Thomas Summerfelt, PhD; Suela Sulo, PhD; Adriane Robinson, RN; David Chess, MD; and Kate Catanzano, ACNP-BC
Health Coaching by Medical Assistants Improves Patients' Chronic Care Experience
David H. Thom, MD, PhD, MPH; Danielle Hessler, PhD; Rachel Willard-Grace, MPH; Denise DeVore, BA; Camille Prado, BA; Thomas Bodenheimer, MD, MPH; and Ellen H. Chen, MD
The Path to Value Through the Use of Holistic Care
Roy A. Beveridge, MD, Chief Medical Officer, Humana
Delivering Value by Focusing on Patient Experience
Paula Chatterjee, MD, MPH; Thomas C. Tsai, MD, MPH; and Ashish K. Jha, MD, MPH
Medication Adherence and Healthcare Disparities: Impact of Statin Co-Payment Reduction
Jennifer Lewey, MD; William H. Shrank, MD, MSHS; Jerry Avorn, MD; Jun Liu, MD, MPH; and Niteesh K. Choudhry, MD, PhD
Integrated Medicare and Medicaid Managed Care and Rehospitalization of Dual Eligibles
Hye-Young Jung, PhD; Amal N. Trivedi, MD, MPH; David C. Grabowski, PhD; and Vincent Mor, PhD
Solutions for Filling Gaps in Accountable Care Measure Sets
Tom Valuck, MD, JD, MHSA; Donna Dugan, PhD, MS; Robert W. Dubois, MD, PhD; Kimberly Westrich, MA; Jerry Penso, MD, MBA; and Mark McClellan, MD, PhD
The Impact of Kaua'i Care Transition Intervention on Hospital Readmission Rates
Fenfang Li, PhD; Jing Guo, PhD; Audrey Suga-Nakagawa, MPH; Ludvina K. Takahashi, BA; and June Renaud, BEd
Are Chronically Ill Patients High Users of Homecare Services in Canada?
Donna M. Wilson, PhD, RN; Corrine D. Truman, PhD, RN; Jessica A. Hewitt, BScKin; and Charl Els, MBChB, FCPsych, MMedPsych, ABAM, MROCC
Request of Acute Phase Markers in Primary Care in Spain
Maria Salinas, PhD; Maite López-Garrigós, MD; Emilio Flores, PhD; Joaquin Uris, PhD; and Carlos Leiva-Salinas, MD
Antibiotic Use for Viral Acute Respiratory Tract Infections Remains Common
Mark H. Ebell, MD, MS; and Taylor Radke, MPH
Clinician Considerations When Selecting High-Risk Patients for Care Management
Vivian Haime, BS; Clemens Hong, MD, MPH; Laura Mandel, BA; Namita Mohta, MD; Lisa I. Iezzoni, MD, MSc; Timothy G. Ferris, MD, MPH; and Christine Vogeli, PhD
Currently Reading
"Meaningful" Clinical Quality Measures for Primary Care Physicians
Cara B. Litvin, MD, MS; Steven M. Ornstein, MD; Andrea M. Wessell, PharmD; and Lynne S. Nemeth, RN, PhD

"Meaningful" Clinical Quality Measures for Primary Care Physicians

Cara B. Litvin, MD, MS; Steven M. Ornstein, MD; Andrea M. Wessell, PharmD; and Lynne S. Nemeth, RN, PhD
Recommendations from primary care Meaningful Use "exemplars" are that clinical quality measures likely to improve outcomes should be evidence-based, high priority, actionable, and minimize burden.
Objectives: To systematically solicit recommendations from Meaningful Use (MU) exemplars to inform Stage 3 MU clinical quality measure (CQM) requirements.

Study Design: The study combined an electronic health record (EHR)-based CQM performance assessment with focus groups among primary care practices with high performance (top tertile),
or “exemplars.”

Methods: This qualitative exploratory study was conducted in PPRNet, a national primary care practice–based research network. Focus groups among lead physicians from practices in the top
tertile of performance on a CQM summary measure were held in early 2014 to learn their perspectives on questions posed by the Office of the National Coordinator related to Stage 3 MU CQMs.

Results: Twenty-three physicians attended the focus groups. There was consensus that CQMs should be evidence-based and focus on high-priority conditions relevant to primary care providers.
Participants thought the emphasis of CQMs should largely be on outcomes and that reporting of CQMs should limit the burden on providers. Incorporating patient-generated data and accepting
locally developed CQMs were viewed favorably. Participants unanimously concurred that platforms for population management were vital tools for improving health outcomes.

Conclusions: Using a series of focus groups, we solicited Stage 3 MU CQM recommendations from a group of physicians who have already achieved “meaningful use” of their EHR, as demonstrated by their high performance on current MU CQMs. Adhering to the standards deemed to be important to high-performing real-world physicians could ensure that the MU Incentive Programs achieve their ultimate goal to improve outcomes.
Am J Manag Care. 2015;21(10):e583-e590
Take-Away Points
Through a series of focus groups, we solicited recommendations from high-performing Meaningful Use (MU) “exemplars” on clinical quality measures (CQMs). 
  • The evolution of MU CQMs is not consistent with the exemplars’ recommendations. 
  • “Exemplars” recommend reverting to at least some core CQMs and ensuring that CQMs focus on high-priority conditions, are evidence and guideline-based, and do not require additional documentation. 
  • Population management should be incorporated into the MU objectives.
Reporting of clinical quality measures (CQMs) has been a required component of both Stage 1 and Stage 2 of the CMS Electronic Health Record (EHR) “Meaningful Use” (MU) Incentive Programs. These CQMs are intended to promote the capabilities of EHRs to calculate measures that inform providers, and eventually the public, about their clinical performance.1,2 Several groups, including the American College of Physicians,3 argue that CQMs are the most important part of MU; others have stated that a focus on health outcomes is the critical requirement for reengineering our healthcare system.4 CMS notes that CQMs are tools that help us to “measure and track the quality of healthcare services.”1 Accordingly, MU CQMs are now aligned with other CMS programs, including the Physician Quality Reporting System and the Value-Based Payment Modifier.5,6

Furthermore, the evolution of MU CQMs supports this notion. For Stage 1 MU, eligible professionals (EPs) were required to report on 3 core CQMs: blood pressure, tobacco status, and adult weight screening and follow-up. EPs also chose to report on 3 additional CQMs from a menu of 38 measures. In 2014, for both Stage 1 and Stage 2 MU, reporting on 9 of 64 CQMs was required. These CQMs are organized by the 6 National Quality Strategy (NQS) domains representing HHS priorities for healthcare quality improvement. There are recommended core sets for both adults and children based on high-priority conditions and a requirement that the selected measures cover at least 3 of the 6 NQS domains.7 The Table lists the 6 NQS domains along with CQMs relevant to primary care within these domains.

CQMs for Stage 3 MU, which has been delayed and is now scheduled to begin in 2017, are now under consideration.8,9 In late 2012, the Office of the National Coordinator for Health Information Technology (ONC) issued a Request for Comments (RFC) for Stage 3 MU which included questions related to CQMs, focused on ensuring that the CQM set improves the “quality of care and experience of care for providers and patients” consistent with the ultimate goal for MU.10 In February 2013, the Agency for Healthcare Research and Quality (AHRQ), working in partnership with the ONC and CMS, solicited rapid cycle research projects to provide evidence to inform the development of Stage 3 MU objectives.11 The purpose of this study, in response to this request, was to systematically solicit recommendations from high-performing primary care MU exemplars to help inform the Stage 3 MU CQM requirements for EPs. The final rule for Stage 3 MU was released by CMS in October 2015.8,9,12


This exploratory qualitative study was conducted in Primary (Care) Practices Research Network (PPRNet), a national EHR-based primary care practice-based research network, and an AHRQ Center for Primary Care Practice-Based Research and Learning.13 At the time of the study, all PPRNet practices used the same EHR (McKesson Practice Partner, San Francisco, California). PPRNet maintains a longitudinal clinical database, derived from regular EHR extracts from participating practices, which is used for quality reporting and research. Reports provide feedback on the practice, provider, and patient level for more than 60 quality measures encompassing primary and secondary prevention, disease management, and safe medication prescribing and monitoring, as well as summary measures.14 Twenty-one of the PPRNet measures are comparable to 2014 MU CQMs.7

All PPRNet practices whose providers had attested for Stage 1 MU were eligible for the study. Practices were recruited through a series of e-mail messages in the fall of 2013. Enrolled practices that submitted an October 1, 2013, PPRNet data extract were included in the study.

EHR-Based CQM Performance Assessment

The PPRNet approach to CQM performance assessment has been described in detail elsewhere.15 For this study, we assessed performance for each practice as of October 1, 2013, on the Summary Quality Index (SQUID),14 the quotient of the number of eligible measures the patient met, and the total number of MU CQMs for which the patient was eligible. Seventy-one PPRNet practices were eligible for performance assessment; the practices with the 27 highest SQUID-CQMs (approximately the top tertile) were deemed exemplar practices.

Focus Groups Among Exemplar Performers

Lead physicians from each of the 27 designated exemplar practices were invited to participate in 1 of 3 focus groups held on consecutive Saturdays in geographically separate cities in late January and early February 2014. Participants provided verbal consent to participate and have the discussions recorded for analysis. Two of the study authors (CL and SO) moderated the focus groups using a detailed slide presentation; each focus group lasted 2.5 hours. Although each of the 3 focus groups was conducted similarly, minor clarifications in the questions were made based on experiences from the first group. During a 15-minute introduction, ground rules for the focus groups were established and an overview of prior and current MU CQM requirements was provided. The introductory presentation refreshed the group about the overall intent of MU CQMs to improve the quality of care.

Questions from the ONC’s RFC for Stage 3 MU CQM were used to guide the discussion. Participants were asked to identify which CQMs (Table) should be a high priority, discuss how to reduce the burden of CQM reporting on providers, and compare the value of process versus outcome measures. The significance of incorporating patient-generated data into CQMs, the appeal of aligning MU CQMs with MU functional objectives, the feasibility and desirability of locally developed measures, and the importance of population management platforms were also explored with participants. All focus group members were encouraged to respond to each question and participate in the general discussion. Two other research team members (LN and AW) observed the groups and took detailed notes in a structured observational template to supplement the audio recordings. The observational template was developed to document the responses, agreements, and contrary views among the participants of each focus group, adapted from a micro-interlocutor approach.16

A professional transcription service was used to transcribe digital records of all focus groups. Transcripts and focus group observation notes were imported into NVivo International, Pty (QSR International, Doncaster, Australia) by a qualitative researcher (LN) for thematic analysis based on the ONC RFC questions. Two of the study authors (CL and LN) independently reviewed transcripts and notes from all focus groups to identify themes related to MU CQMs. The transcripts were then used to locate specific comments and context for clarification. The 2 qualitative analysts reconciled discrepancies through a process of immersion and crystallization which were, for the most part, consistently interpreted.17

Lead physicians from 23 of the 27 practices selected as exemplar practices attended the focus groups. Five of these physicians were female, 2 were Hispanic, and all were white; the median age of these physicians was 56 years. Five physicians were general internists, 2 were internal medicine/pediatrics physicians, and the remainder were family medicine physicians. The physicians came from practices in 18 US states, and all practices reported using their EHRs for over 6 years: 9 practices had been using their EHRs for 6 to 10 years, 7 for 11 to 15 years, 5 for 16 to 20 years, and 2 for over 20 years. Analyses from focus group discussions have been organized into 8 themes, discussed in more detail below.

1. CQMs should be evidence-based, focused on high-priority conditions, and relevant for primary care physicians. Participants were asked to provide feedback on measures from each NQS domain. For all domains, there was general consensus in each focus group that CQMs should be evidence-based, noncontroversial, and based on national guidelines when available. They also believed that the measures should be “the ambulatory-sensitive ones—the ones that we can control ought to be measured in every office.” Participants emphasized the need for CQMs to be flexible and rapidly evolve to reflect changes in evidence or new guidelines. For example, many participants were concerned that current CQMs regarding dyslipidemia are not concordant with the recently released American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol,18 and argued that these CQMs should be quickly updated to reflect the new guidelines. One participant stated, “Keep it simple. Whatever you do, use things that have been vetted as indicators or results or processes that are valuable and proven they make a difference, and keep the flexibility.”

Participants generally agreed that CQMs in the Clinical Process/Effectiveness domain should reflect highly prevalent conditions with long-term consequences and for which improved performance on the CQM could have considerable impact on morbidity and mortality, such as hypertension, hyperlipidemia, and diabetes. All participants believed CQMs in the Population/Public Health domain should be a high priority—particularly those with broad public health implications. At one focus group, there was near unanimous consensus that CQMs should be limited to measures only in this domain, while participants in the 2 other focus groups agreed that, although important, CQMs in other domains also reflected high-priority chronic conditions and should be included.

Many argued that adherence to all US Preventive Services Task Force (USPSTF) Grade A and B recommendations and recommendations from the Advisory Committee of Immunization Practices be included as CQMs, while others favored selecting specific USPSTF recommendations with a considerable impact on mortality. Participants universally agreed that CQMs related to hypertension, obesity, and smoking cessation were of utmost importance. One participant stated, “I would put my energy into blood pressure, blood pressure, blood pressure. Smoking, smoking, smoking. Exercise, exercise, exercise.”

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