Quality measures that a federal advisory panel recommended but which were dropped from proposed rules for the meaningful use of health IT represent a missed opportunity to significantly improve patient care, according to members of the Health IT Policy Committee.
In its proposed rule for meaningful use, announced Dec. 30, the Centers for Medicare and Medicaid Services incorporated many of the suggestions for quality objectives and measures that the Committee recommended be included in the rule.
But CMS dropped from the list recommendations that physicians generate progress notes for each patient visit, document the recording of advanced directives for the elderly and develop information resources that are easy for patients to understand.
Some committee members believe by rejecting the suggestions CMS is missing opportunities to generate significant and useful care information that will be difficult to obtain otherwise.
"It's probably a moment in time when we have an opportunity to fundamentally change the kind of quality reporting that is done," said Dr. Paul Tang, co-chairman of the committee's meaningful use work group, who spoke at a committee meeting Jan. 13.
Tang, said, for example, that most of the quality measures approved by CMS still rely on claims data rather than the richer, more immediate clinical data that an electronic health record could collect.
"We have been tethered to whatever data has been available, and that data typically has been claims and administrative data," said Tang, who is also chief medical information officer of the Palo Alto Medical Foundation. "Most of the existing endorsed quality measures are based on that kind of data."
Tang also said he disagreed with CMS's decision to drop progress notes from the list of required quality measures. "The rationale from CMS was that it wouldn't contribute to care coordination, (but) there certainly is a lot of feeling (in the meaningful use workgroup) that it may," he said.
Another of his concerns was CMS's decision to include a large group of optional quality measures from which providers could choose to report depending on their specialties. A better approach might have been to have physicians focus on a few quality measurements that could be documented well, Tang said.
The workgroup also took odds with CMS about how often problem list reports should be updated in the EHR. The workgroup understood the original recommendations to mean that "to maintain a problem list, it was every time you see that patient" Tang said. "In the NPRM, it's one time that there must be one or more problems."
Tony Trenkle, director of CMS' Office of e-Health Standards and Services, said CMS made some changes and deletions from the policy committee recommendations, fine-tuned others but made sure each objective had a measure.
"They were our best shots," he said.
In considering comments by individuals and organizations on the proposed rule, CMS will look for detailed explanations why a meaningful use definition or requirement needs to be clarified or changed, Trenkle said.
He advised those who wished to comment on the proposed rule to include detailed, logical explanations for why they believe a requirement needs to be clarified or changed.
"You need to explain why it's a bad idea and what would accomplish the same or better result," he said. For instance, if the definition for a hospital eligible physician is wrong, the commenter should provide the reason on a national scale, describe the better alternative and back it up with data if possible. "You can't take what's in the NPRM and modify it. If it's not a logical extension, we cannot change it in the final rule," he said.
The policy committee will submit comments to CMS by March 1.
