Joe Rotella, MD MBA HMDC FAAHPM
Before giving a talk to her local medical community on how to discuss hospice with patients, a hospice medical director asked a physician’s assistant what he thought about his electronic health record (EHR). He said he saw up to 40 pre- and post-op surgical patients a day, and each time his EHR required him to document their response to the question “are you depressed?” He understood that his group practice was reporting the depression screening measure to the Centers for Medicare & Medicaid Services (CMS) under the Physician Quality Reporting System, but he hoped his patients all said no, because he didn’t have the time or training to talk to them about it. The hospice medical director thought about the Medicare quality reporting requirements that would apply to her growing community-based palliative care practice and wondered how she could avoid a similar exercise in futility.
What can we do to make sure that clinicians in hospice and palliative medicine don’t waste time and effort managing quality measures that won’t make a difference for their patients?
When the leaders of Measuring What Matters (MWM), a joint initiative of AAHPM and HPNA, published their expert consensus recommendations for the 10 top-ranked measures for quality improvement (QI) in hospice and palliative medicine (HPM) in 2015, they emphasized that quality measurement in HPM was in an early stage of development and the measures were not ready for use in pay-for-performance accountability programs(see sidebar, MWM Top Ten Recommended Measures for Hospice and Palliative Medicine).1
They identified serious limitations with the best available measures, including narrowly defined populations and care settings (eg, only patients with invasive cancer or those receiving hospice care), missing domains of palliative care (eg, no measures for cultural aspects of care), and no validated way of identifying the entire population of patients with serious illness appropriate for palliative care that could be included in the denominator of a broader measure. The passage of the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) accelerated the drive to value-based purchasing and linked future clinician payments under Medicare Part B to performance on measures of quality, cost, and use of certified information technology (IT), as well as to performance of clinical practice improvement activities under a program called the Merit-Based Incentive Payment System (MIPS). It also encouraged clinician participation in high-quality, high-value alternative payment models (APMs). When CMS finalized policies for implementing these reforms under the new Medicare Quality Payment Program (QPP), few quality measures relevant to HPM were included, yet many HPM clinicians now must either report quality measures of limited value or potentially face cuts in payment. Although quality improvement is critical for ensuring the delivery of the best care possible to patients with serious illness and their families, if HPM clinicians have to report quality measures that are irrelevant, ineffective, or beyond their control, the added burden is unlikely to benefit their patients.
To gauge the impact of this rapidly evolving quality and accountability environment on HPM clinicians, AAHPM and HPNA recently surveyed their members on the structure and limitations of their QI programs and how they were using MWM measures and IT for collecting and reporting quality data.
The survey received more than 1,000 responses and identified major challenges for HPM programs, which often lack resources, access to facilitative IT, and training in QI (see sidebar, Key Findings from the MWM Survey). Lisa Lindley, PhD RN, assistant professor at the University of Tennessee, Knoxville, College of Nursing and co-chair of the MWM eCQM Working Group that conducted the survey, noted a major theme: “There is a disconnect between QI efforts and the electronic measurement systems available to hospice and palliative care services, highlighted by the finding that one-quarter of respondents were not on one of the top five EHRs and used more than 50 different systems, including paper.” Most respondents could not collect MWM measures directly from their EHRs (see Graph 1). Demographic results also were striking; only one-third of respondents were younger than 50 years and although most reported more than 20 years of experience in health care, one-half had less than 10 years of experience in hospice and palliative care. This trend concerns Marianne Matzo, PhD APRN-CNP AOCNP FPCN FAAN, clinical professor in the Department of Family Medicine at the University of Oklahoma Health Sciences and director of research at HPNA: “Given the age and palliative care experience reported in the survey, I wonder if we will have the people with expertise to work with palliative care patients, let alone to measure what matters.”
Although most survey respondents indicated that their organizations reported quality measures to CMS through the Hospice Quality Reporting System, Physician Quality Reporting Program, or another mechanisms, most did not indicate that their organizations partnered with payers on quality initiatives, participated in multisite QI collaborations, or had access to quality registries or databases (see Graph 2). Perhaps most concerning, at least one-third of the respondents indicated that they did not know whether their organizations participated in Medicare quality reporting or any of these collaborative activities, suggesting significant gaps in knowledge and engagement around quality imperatives.
The Medicare Quality Payment Program represents a fundamental shift in accountability for quality, cost, and other measures for clinicians who submit more than a minimum threshold of claims under Medicare Part B. Most HPM clinicians also are included in this framework, but those who provide services to patients not enrolled in hospice care and who are not employed by a hospital or the Veterans Administration may be most affected by these changes in their daily practice. Phil Rodgers, MD FAAHPM, co-director of the Adult Palliative Care Program at the University of Michigan and chair of the AAHPM Alternative Payment Model Task Force, urges HPM practices to embrace this development: “The Medicare Quality Payment Program is critical to the future of our field. Focused on the ‘triple aim’—better care of patients, better care for populations, and lower costs—the QPP is moving quickly, and palliative care teams need to be transforming their practices now to survive and thrive in the value-based payment present and future. The good news is that palliative care is well positioned to succeed, given its proven ability to improve quality and control cost for seriously ill patients. The challenge is to understand the opportunities (and risks) in specific communities and markets and adapt accordingly.”
To minimize the burdens to clinicians and QI staff associated with having to enter data in multiple places or perform manual workarounds for data entry and extraction, it is ideal for quality measures to be integrated seamlessly with clinical documentation in an EHR. Because HPM practices use a wide range of vendors and customized EHRs, that calls for the development of electronic clinical quality measures (eCQMs) with precisely specified and standardized data elements (eCQMs) that can work interoperably in various IT systems. Although it is tempting to blame any difficulties on the technology component of IT, Arif Kamal, MD MBA MHS, physician quality outcomes officer at the Duke Cancer Institute and co-chair of the eCQM Working Group, suggests that pinning down the information one wants to capture may be the bigger challenge: “We need to develop a common language to describe palliative care populations, processes, and outcomes and view IT more as a helper than a barrier.”
“Look at the example of air traffic safety: all around the world pilots communicate with air traffic control in English and use terms that are very precisely defined,” he adds. “That’s because accidents are more likely to be caused by a misunderstood communication than a faulty radio. In hospice and palliative care, if we wanted to create an electronic clinical quality measure on whether a goals-of-care discussion was documented, its usefulness would hinge on how well we standardize what is meant by a ‘goals of care discussion.’ We won’t be able to make meaningful comparisons if, in one place, it means a family meeting was conducted with a specialized interdisciplinary palliative care team structured around Physician’s Orders for Life Sustaining Treatment but somewhere else, it just means somebody asked about code status.”
Laura Hanson, MD MPH, professor of geriatric medicine, director of the University of North Carolina Palliative Care Program, and co-chair of the AAHPM Quality and Practice Standards Committee, recommends participation in a clinical data registry, a system that collects and analyzes patient-level data from many programs: “Clinical data registries are a terrific tool for allowing us to track how we deliver palliative care by collecting data on what we do and how well we do it. Working in our own organizations, we can collect data to make sense out of what we are doing for patients and families, and whether we are living up to our own ideals for best practices. But a registry takes this to the next level altogether by allowing us to see how our practices and outcomes compare to other palliative care organizations.” She adds: “I personally learn so much when I talk with my colleagues about how they are doing things elsewhere, but I learn much more when those impressions are backed up by comparing what we learn from data on quality metrics and team structure.” Some clinical data registries that receive special qualification by Medicare for use in the QPP have another advantage: they may enable clinicians to meet requirements by reporting quality measures that are more germane to their practices but not included in MIPS.
To position the HPM field to thrive under value-based health reforms and deliver the best quality care possible to patients with serious illness and their families, AAHPM is working with hospice and palliative care leaders and organizations, foundations, and other stakeholders on a broad range of projects, including
- Measure development: AAHPM, in collaboration with the American Medical Group Association, OptumLabs, and the National Quality Forum’s Measure Incubator project, has been awarded grant funding from AARP to develop and test new pain treatment and other outcomes measures in a seriously ill population using a commercial clinical and claims database.
- Registries collaborative project: Supported by a grant from the Gordon and Betty Moore Foundation, AAHPM has partnered with organizations that currently offer HPM specialty registries, including the Center to Advance Palliative Care, National Palliative Care Research Center, Global Palliative Care Quality Alliance, and Palliative Care Quality Network, to explore models for unifying the registries and expanding the academy’s role as the supporting national medical specialty society.
- APM development and patient and caregiver support for serious illness: Following nearly a year of intensive study, development, and input from a broad range of subject matter experts, stakeholder organizations, CMS leaders, and the Academy’s governing body and members, the Alternative Payment Model Task Force submitted a proposal for an APM to support palliative care teams who serve patients with serious illness in the community to the Physician-Focused Payment Model Technical Advisory Committee, which was established under MACRA to review proposals for new models. The proposed accountability for quality includes surveys of the patient’s or caregivers’ experience of care, process measures based primarily on the MWM recommendations, and measures of hospice and intensive care utilization at the end of life.
Katherine Ast, MSW LCSW, director of quality and research for AAHPM, describes how MWM has evolved: “It’s critical that we maintain the momentum to measure what matters to patients, families and providers. AAHPM has created two working groups in collaboration with HPNA to build on the MWM project. One is the Technical Specifications for electronic Clinical Quality Measures (eCQMs) Workgroup, whose goal is to partner with EHR vendors and other stakeholders to develop eCQMs for the indicators that matter most for patients with serious illness and their families. The other is the Quality Improvement (QI) Education and Strategies Workgroup, whose goals include development of QI Education tools, webinars and education modules to improve patient care and meet new requirements for value-based reimbursement while also meeting Continuing Medical Education and Maintenance of Certification (MOC) requirements whenever possible.”
Amy Davis, DO MS FACP FAAHPM, clinical assistant professor at Drexel University School of Medicine and co-chair of the MWM QI Education and Strategies Workgroup, has advice for clinicians who are just getting started with QI: “Let those in leadership know that you are interested, and you are likely to get a warm welcome. Or, you may prefer to focus on QI at a more personal level. Pick one important area you think you do well and one or two that might need improvement. Have someone run a report or review a random sample of charts to see if the data match expectations. You may be surprised to find you’re doing better, or not as well as you thought. Explore how you might improve something and try a change. After sufficient time, re-examine the data and adjust accordingly. Some QI projects start small, but, when they work, it is very satisfying to know you have made things better for your patients and their loved ones.”
Quality in HPM has come a long way in the last few years, and there is good reason for optimism. Ast believes the time is ripe to leap forward: “I have hope that we can truly improve care for people with serious illness and their families because we finally are seeing funding opportunities to create quality metrics, educational tools, and implementation programs that address the needs we identified in the MWM survey. I feel confident that in the next couple of years we’ll have a lot more to offer our members to support meaningful quality improvement and make headway in our quest for eCQM integration and interoperability.”
- Dy SM, Kiley KB, Ast K, et al. Measuring what matters: top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. J Pain Symptom Manage. 2015;49(4):773-781.
MWM Top Ten Recommended Measures for Hospice and Palliative Medicine
- Palliative care and hospice patients receive comprehensive assessment (physical, psychological, social, spiritual, and functional) soon after admission.
- Seriously ill palliative care and hospice patients are screened for pain, dyspnea, nausea, and constipation on admission.
- Seriously ill palliative care and hospice patients who screen positive for moderate or worse pain receive treatment within 24 hours.
- Patients with advanced or life-threatening illness are screened for dyspnea, and if present at moderate or worse degree, should begin on a plan to manage it.
- Seriously ill palliative care and hospice patients have documented discussion regarding emotional needs.
- Hospice patients have documented discussion of spiritual concerns or preference not to discuss them.
- Seriously ill palliative care and hospice patients have documentation of surrogate decision-maker’s name and contact info or absence of surrogate.
- Seriously ill palliative care and hospice patients have documentation of their preferences for life-sustaining treatments.
- Vulnerable elders with documented preferences to withhold or withdraw life-sustaining treatments have their preferences followed.
- Palliative care and hospice patients or their families are asked about their experience of care using a relevant survey.
Key Findings from the MWM Survey
- Most respondents could not collect performance measures from the MWM Top 10 Recommended Measures directly from the more than 50 EHR systems in use.
- Respondents were primarily older, experienced healthcare clinicians, but most had less than 10 years of experience in hospice and palliative care.
- Nurses or pharmacists led QI initiatives more often than physicians did.
- Many respondents seemed to lack a working understanding of payment reform and its relationship to quality measurement and reporting.
- The primary barriers to QI implementation were insufficient time and infrastructure.
- There was a critical need for coaching and education regarding how to perform effective QI.
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