In a Q&A at the recent Primary Care Transformation Summit, CMS executive Michelle Schreiber, M.D., touched on several forward-looking topics related to quality measurement, including measure alignment, measures related to health equity, and digital clinical quality measure reporting using FHIR.
Schreiber is the deputy director of the Center for Clinical Standards and Quality for the Centers for Medicare and Medicaid Services. In addition, she serves as the Group Director for the Quality Measurement and Value-Based Incentives Group. She is responsible for executing the quality strategies of CMS including quality measurement, and value-based incentive programs to encourage the transition to value-based care.
She is a general internal medicine physician with over 25 years of health care experience. Prior to her work with CMS, she was the senior vice president and chief quality officer of Henry Ford Health System (HFHS) in Detroit. At Henry Ford, she also previously served as senior vice president of clinical transformation and IT integration, where she was the clinical lead of the system-wide Epic implementation. The Epic implementation and use earned HFHS a Davies Award in 2018.
A focus on alignment
Schreiber began by noting that the CMS National Quality Strategy focuses on outcomes, equity, safety, digital transformation, and resilience in the workforce. Another key principle is alignment, she added, “because we recognize that there are a lot of different measures that sometimes are just a little different, but different enough to make it difficult for organizations to report. We're working very hard on aligning measures across all of our programs. In addition, we want to align the programs. There's the MIPS program, which is now transforming to MIPS Value Pathways, then the MSSP or the ACO programs. The innovation models in each of these have sometimes had somewhat different, not only operations, but measures,” she explained. “All of us are working hard to make MIPS MVP the launch point for physicians, but to make it such that clinicians can feel successful in the same measures that are going to be used in ACOs, and the same measures that are going to be used in the model programs so that clinicians can gain confidence and so that we also continue to build incentives for primary care physician to move into value-based programs.”
The future of eCQMs
Schreiber began talking about electronic clinical quality measures (eCQMs) by saying she has implemented many EHR systems, and recognizes the burdens and the pitfalls, “but I also recognize that healthcare has to transform into the digital age like every other industry has. If COVID taught us nothing else, it's that we have to have coordinated, interoperable data that will help drive real-time quality measurement and clinical decision support. There's really no other way to do it than through digital data.”
She added that CMS is working closely with ONC and the CDC in trying to drive digital quality measures. “At CMS, we are committed to moving toward our quality measures all being digital and ultimately reported that way, probably through FHIR APIs,” Schreiber added. “We recognize that the ACOs have had a number of challenges, particularly when it came to data aggregation. We are providing additional time and additional flexibilities to allow ACOs to make that transition, but that transition will come.”
Schreiber recommends becoming very familiar in your EHR with the workflows and what drives data reporting, because this should be seamless data that is taken from the EHR that was part of the clinical workflow as opposed to an add-on. Second, she stressed, get very familiar with reporting through FHIR.
“Having FHIR and FHIR APIs is now a mandate not only for healthcare systems, but for payers, and this is really a way of the future. There is really no other good way of moving healthcare forward than through the digital transformation,” she explained. “I encourage everybody to really get engaged around this, because this certainly will be the future of digital quality reporting, but it's actually the future of healthcare as well.”
Health equity
Schreiber was asked about the intersection of health equity efforts and quality measurement.
She noted that the Biden administration is really committed to putting equity front and center, and working to eliminate disparity gaps in care. “We haven't traditionally had a lot of quality measures that support equity,” she noted, but there are more that are coming forward. On the MIPS side, CMS has introduced several measures around screening patients for five social determinants of health: food insecurity, transportation insecurity, housing insecurity, difficulty in paying utility bills, and personal safety.
“The question is, are clinicians screening their patients for this? What's the percent positivity rate? And in the long run over the next few years, we'll also likely be introducing measures that close that gap,” she said. “In other words, if you found an issue, what are you doing in terms of planning to close that gap? And there are other measures that we've seen being developed by other organizations that are coming down the pipeline, and NCQA also is working on tailoring some of their measures around equity as well in a very similar vein around social drivers of health.”
Another strategy involves stratification of the current performance measures – for instance, readmissions or immunizations, she said. “You can stratify measures in many, different ways, she noted. “Across CMS, we're having those conversations now. Is it race, ethnicity, culture, language, SOGI status, disability status, dual eligibility, area deprivation index, or other geocoding? We're looking at all of those to make a determination across the agency and across government, what are the best stratification models. We're looking at some of our performance measures that are stratified. The plan will be to provide confidential feedback information, both to clinicians and to facilities about their performance, so that they can be looking themselves at what their data is actually showing. Over time, you can imagine that we will link that to payment and to public reporting. But I think that will take time because we all need to get used to seeing this data first, to making sure that the data that we're providing is correct.”
Beyond screening, she asked, what programs are you putting in place either in your ACO or in your personal practice to get engaged in quality improvement around equity?
“One of the lessons learned from COVID was the extreme disparities of care,” Schreiber said. “For me, this is really very personal. I've been a primary care physician largely in the City of Detroit for most of my career. This affected my patients, this affected my practice, this affected me watching that. And we owe it to every single patient to make sure that they get the best care that they can possibly achieve, so we're very excited about this direction going forward.”
