Tuesday, July 24, 2012

Real Time Quality Measurement as Clinical Decision Support

The topic of "Real Time Quality Measurement" as "Clinical Decision Support" has come up recently in three different forums.  In the AHRQ RFI which I mentioned earlier today, in a previous face-to-face meeting of the HIT Standards Committee, and just now in the agenda for the Clinical Quality Workgroup for tomorrow's montly call.  I'm a member of that workgroup, but won't be able to attend the meeting, given that I'm in an all-day training teaching about standards for quality measurement.  As always in cases where I cannot attend the call, I read the materials and respond ahead of time to the workgroup, so that at least they have my input.  After rereading, I decided to share it as this post:

On the topic of conceptualizing CDS as real-time quality measurement, you’ve hit one of my favorite discussion topics.

Quality measurement is intended for process improvement. One of the first steps in process improvement is documentation of quality processes. The second step is to build measurement into those processes so that progress against quality can be measured as early as possible. In clinical care, the process is a care guideline, and when that guideline is instrumented to that it can be measured, it can also be instrumented so that it can be executable. An executable clinical guideline operating against measurable inputs is clinical decision support in a very real sense.

My post on Gozinta and Gozouta is nearly three years old, yet most of what I have to say in it still applies in the current day.

What has changed in the past three years is that HQMF is now in its second release cycle, and there are significant initiatives using it, including the Measure Authoring Tool, and Query Health. There are yet more opportunities to use it to define not just how a quality measure is computed, but also to define the inputs (and possibly even outputs) of a clinical decision support process. Just being able to describe the inputs to a CDS process in a way that would allow Health IT systems to automatically generate an appropriate interface to a CDS implementation would be a tremendous game changer.

This should be a consideration of the ONC S&I Framework Health eDecisions project. I have some ballot comments on HQMF Release 2.0 that HL7 will soon be publishing that will enable this kind of use, based on some earlier standards work that IHE did. That never got adopted, I think in part because a standard like HQMF was missing from the protocol. There is emerging work in the CDS space from the Clinical Decision Support Consortium (an active participant in the Health eDecisions project) that could readily take advantage of synergies between it, and HQMF as a description of the inputs it is expecting. The CDSC work takes a CCD document from an EHR and develops from it, a list of needed interventions for a patient, which it returns to the sending EHR.

The Data Criteria section of HQMF owes its existence in part to some of that early IHE work on Care Management. The idea was that the “data of interest” to the system (in the case of HQMF, data of interest to the measure) needs to be well defined. And having defined it well, and in a computer readable format, it could be used to automatically generate an input for a clinical decision support system. That input could be a CDA Document, implemented using the CCD specification, or one of the documents specified in the CCDA specifications. It need not contain all of the specified data of interest, just that data of interest that is available to the provider, in order to be useful.

Knowing what data is of interest can also be used on the EHR side to prompt the provider to ask good questions. This is yet another form of Clinical Decision Support.

One of the missing points will be trying to figure out how to specify what the outputs of the Clinical Decision Support system would look like. Here, I believe we need to do more work on care planning. The output of the CDS system can be a care plan that specifies further diagnostics, interventions or goals which might be appropriate for the patient. Specifying what the outputs look like in a way that is actionable is important. But it need not be so detailed as to suggest exactly what needs to take place and in what order, as that is a case where systems might innovate.

  -- Keith


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