NQF CEO Safran: Bulk FHIR Offers Potential to Ease Reporting Burden
Dana Gelb Safran, Sc.D., president and CEO of the National Quality Forum (NQF), said recently that she believes the work being done by the Office of the National Coordinator for Health IT on bulk FHIR will lead to new ways to use the clinical data in the EHR for measurement, rather than having to rely on claims data.
FHIR offers a standardized way to transmit information about an individual patient from one provider to another or from a provider to a health plan. “Bulk FHIR allows us to do that on a population,” Safran explained, “so it really begins to open up the possibility of low-burden, high-fidelity ways of using data from the clinical record to source our measurement.”
Safran was speaking at the recent Value-Based Heath Care Congress in a one-on-one discussion with Stacia Cohen, R.N., M.B.A., executive vice president for health services at Maryland-based CareFirst BlueCross BlueShield. The two discussed health equity and patient-reported outcome measures as well as measure harmonization and easing the reporting burden.
Safran took the helm at NQF in July 2021. The nonprofit organization develops measures and standards for initiatives to enhance healthcare value, make patient care safer, and achieve better outcomes.
Cohen began the conversation by asking Safran for examples of how healthcare providers have leveraged incentives from value-based care arrangements to invest in delivery system improvements that could help reduce health disparities.
Safran responded that value-based payment has accomplished the beginnings of two important shifts in healthcare. One is that providers who are now in contracts through which they had accountability for total cost of care have recognized that it is necessary to begin to integrate mental healthcare into the rest of what they were doing in in their delivery system. “We saw the integration of behavioral healthcare providers into primary care settings. I think that value-based payment was the impetus for that and it created the incentives,” she added.
The second, she said, is that the terms around social drivers of health are becoming very much common parlance in healthcare and beyond. “I also credit value-based payment for creating that awareness,” she said. “When you're accountable for total cost of care, you begin to think outside the literal and figurative clinical box of the office setting, to where patients live and work. Oftentimes the best use of the dollar has more to do with making sure that a patient has a stable housing situation than it does getting one more test or one more specialty referral.”
Including the patient perspective in measures
Cohen then asked how quality measures and measure sets are going to continue to evolve. “As you take the helm at NQF, how do we bring the patient perspective on outcomes that matter to them into the quality measurement world?”
Safran distinguished between patient-reported experience measures (PREMs), which ask patients about their experience with healthcare delivery, and patient-reported outcome measures (PROMs), which asks patients about their health, functional status, and well-being. They're very different, and both are important, she stressed. “I would say that in the measurement world, there has been much more acceptance in the past two decades of incorporating PREMs into contracts and public reporting of performance,” she said. “It is understood that one of the most important things that patients want to know if they're to use quality information to inform a choice is what other patients think.
Safran added, however, that among the most important developments that we need to have for value-based care to deliver on its promise of improving outcomes while reducing cost growth are new sets of measures of health outcomes that will include but not be limited to PROMs.
“It will include new measures derived from data in the clinical record about the control of chronic conditions or about the ability to stave off further progression of disease for patients that have it, or perhaps for patients who have the risk factors, and staving off the onset of developing those conditions,” Safran explained. “In terms of patient-reported outcomes that could be included in that next generation of measures, I think we see an emerging consensus that this is incredibly important.”
She said years ago we heard regularly from physicians: “What is it a patient can tell me about their health that I can't know better from my stethoscope and clinical tests?” Now those perspectives are beginning to change, she said, as clinicians understand that “getting at the heart of what patients can tell us about how they're feeling and how they're functioning, and holding ourselves accountable for improving those things is really what we're talking about with many conditions. I'm very excited about the development of next-generation outcome measures and the importance of value-based payment, including but not limited to the role of patient-reported outcome measures.”
Cohen noted that as an industry, we often talk about measure proliferation and the burden of measurement. “At CareFirst, as we looked across all of the market segments that we serve, every single purchaser wants to measure something different because they value something different for the outcomes of their population. To meet all of those purchaser expectations, we'd be asking providers to pay attention to at last count 67 different measures. That is a measurement burden that quite honestly isn't palatable to anybody,” she said. “Frankly, lots of times people throw up their hands and say, ‘I can't pay attention to all these things, and therefore I'm only going to pay attention to the ones that I care about.’ I don't think we've gotten to the right place yet in harmonizing.”
She asked Safran how she sees that evolving over the next five years and how we might we think more proactively about measure harmonization.
Safran responded that the issues of both measure parsimony and measure alignment have been the subjects of active conversation for several years. She noted that the measures that we have today, for the most part, are a byproduct of a fee-for-service way of paying for care, and therefore a fee-for-service mindset about measurement.
Measures representing quality and health are difficult, she said, but we can certainly move in that direction from all of the process measures being used now. “For example, if we take five clinical areas that represent more than 50 percent of spend for commercial payers, but also for Medicare and Medicaid, it's a list of behavioral health, musculoskeletal conditions, cardiovascular, oncology, and obstetrics,” Safran said. “Those five things represent more than 50 percent of spend for commercial and public payers. And we have almost no or in some cases no measures in our portfolio of endorsed measures to draw from. Moving toward the development of those big measures will allow us to measure what matters to patients, measure what matters to the payers and the purchasers. I think we will get there, and I have some ideas that we're exploring about how NQF can play a valuable role as a convener.”
The ease of reporting
Cohen noted that besides the quantity of measures, there is also the question of ease of extraction for measurement reporting. “We have to figure out how to get the data, but it has to be done in an easy, more digitally enabled way,” she said. “It can't be people having to manually extract things from charts — that continues to add to the burden.” She asked Safran to comment about measurement burden in terms of data gathering and reporting.
This is where Safran’s comments turned to technology and the potential of bulk FHIR. “For over a decade now, we have had consensus that we want to move measurement more toward data that are sourced from the clinical record,” Safran noted. “Our nation has made billions of dollars of investment in the adoption and use of health information technology, and yet we are not close today to a national portfolio of measures that draws from the clinical record.”
She noted that NQF is part of the convening of something called the Core Quality Measures Collaborative, which tries to work on this issue of alignment across payers, and has developed four measure sets. Those core measure sets include both claims-based measures and measures sourced from clinical records. “The measures that are getting used are the claims-based measures. Why is that? Well, it is because the claims-based measures are available, known, and have been tested and used for a long time,” Safran said. “While there are a lot of questions about whether we can do better at both our risk adjustment and the measures themselves, if the data are drawn from the clinical record, there's a sense that it will give us a truer and more robust view of the patient clinically, and therefore better measures of health and health outcomes. We just haven't been able to extract the data from the clinical record in that way for all kinds of reasons, including the way the clinical record is being used today really isn't designed to support measurement. It's designed to support clinical care and billing. Lots of important information is in unstructured fields, which makes that extraction for measurement purposes difficult, she added.
“I think all that gets transformed by some of the really important work that the Office of the National Coordinator is doing, including the requirement of EHR technology companies to implement bulk FHIR,” she said, adding that there is still lots of development and testing to be done before that data can be used for measurement purposes. “I'm excited about partnering with payers and others who are motivated to help solve this problem,” she added. “On the one hand, we have moved to some extent, especially CMS has moved toward this desire that providers have to use the clinical record for data sourcing, rather than claims. But the downside of that has been a reporting burden that folks are really quite upset about. We do have the possibility to have our cake and eat it, too, by leveraging bulk FHIR to get those clinical data, but we've got a lot of work to do to make sure that they're ready for prime time in terms of high-stakes measurement for payment and public reporting. and network design and all the other ways that we use measurement today.”
A magic wand
Cohen closed by asking Safran if she could wave a magic wand and make something happen that would get us to an ideal future state, what would she do?
Safran responded by saying she would advance us to that point in time that brings together each of the things they had spoken about, “where we have realized that next generation of measures that are outcomes-oriented, that are able to leverage the clinical record, and patient-reported measures,” she said. “It would mean that we now have easy technology capabilities that solve that last-mile challenge of reaching patients and engaging them to get the patient-reported information in standardized ways and easily have it returned into the clinical record so that it can be used for clinical care at the same time that it's used for population-level measurement and accountability. I do truly believe that when we have that capability of really measuring and tracking our progress against the outcomes that matter to patients, and to those who are purchasing care on their behalf, we have the makings of transformation in healthcare and true value — being able to see where we're falling short, see where the massive disparities are, track our progress against a commitment to address those disparities.”
