1

SAFTINet)R/QI)Committee)Scope)Document:)Refining)the)UDS)

Adult)Weight)Screening)and)Follow)Up)Measure)to)be)More)

Actionable) ) ) ) ) ) ) ) )

Table&of&Contents&Project(Goal( 2!

Background( 2!

Problem(Statement( 2!

Conceptual(Framework(for(Evaluating(Validity(and(Utility(of(Clinical(Quality(Performance(Measures( 3!

Methods( 3!

Current(Measure( 4!Reported(Elements(for(Current(UDS(Adult(Weight(Screening(and(Follow(Up(Measure((UDS(Table(6B,(Section(F,(Row(13)( 4!Data(Elements(Needed(to(Create(the(UDS(Report(As(Currently(Reported( 4!

Table!1:!Data!Elements!Required!for!Defining!the!Relevant!Population! 4!

Table!2:!Data!Elements!Required!for!Defining!and!Computing!Current!UDS!BMI!Measures!Using!Electronic!Data! 5!

Limitations(of(the(Current(Measure( 6!

Proposed(Improved(UDS(Adult(Weight(Screening(and(Follow(Up(Measure( 7!Rationale(for(Proposed(Changes( 7!Table(3:(Added(Elements(to(Help(Enhance(the(Actionable(Value(of(the(UDS(Report( 7!

Clinical(Quality(Performance(Reports:(options(for(pilot(project( 8!Care(Quality(Measures( 8!

Care(Quality(Ancillary(Reports(( 8!

Data(Quality(Ancillary(Reports( 9!

Key(to(Abbreviations( 9!

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Project&Goal&The)goal)of)this)pilot)study)is)develop)and)assess)one)or)more)quality)of)care)measures)that)address)overweight/obesity)

screening)and)management,)and)to)develop)the)ancillary)reports,)such)as)data)quality)reports)and)patient)registries,)that)

support)dataHdriven)quality)improvement.)The)primary)assessment)outcomes)for)this)project)include)1))utility)or)

“actionability”)of)the)quality)measures)and)ancillary)reports,)and)2))feasibility,)and)3))reliability)of)measure)computation,)

including)data)quality)for)data)elements)required.)

)

Background&The)Research)and)Quality)Improvement)Committee)of)the)Scalable)Architecture)for)Federated)Translational)Inquiries)

Network)(SAFTINet),)a)practiceHbased)research)network)of)FQHCs,)identified)care)quality)priorities)and)collaborated)to)

identify,)specify,)and)pilot)the)relevant)measure(s))and)ancillary)measures)deemed)of)greatest)value)to)SAFTINet)

member)FQHCs.)SAFTINet’s)distributed)data)network)infrastructure)is)positioned)to)support)practices)in)design,)

implementation)and)use)of)quality)reporting)tools.)Our)methods)include)the)following)steps:)

Problem&Statement&Federally)Qualified)Health)Centers)(FQHCs))and)other)health)center)programs)defined)in)Section)330)of)the)Public)Health)

Service)Act)are)mandated)to)report)Uniform)Data)Systems)(UDS))measures)to)the)Health)Resources)and)Services)

Administration)(HRSA).)SAFTINet)partners)report)that)administrators)and)providers)at)these)health)centers)often)find)

the)UDS)measures)to)lack)value)in)assisting)them)with)quality)improvement)initiatives)and)program)evaluation,)while)

the)data)needed)to)compute)the)measures)are)burdensome)for)the)practices)to)gather.))Given)the)effort)in)reporting)the)

measures,)SAFTINet)partner)would)like)to)report)measures)that)have)value)to)their)practices)(such)as)for)quality)

improvement))and)HRSA)(such)as)for)performance)benchmarking).)SAFTINet)partners)note)the)following)specific)

problems)related)to)UDS)measures)for)BMI/Weight)Counseling:)

)

1.! The)data)elements)may)not)readily)available)in)structured)fields)in)administrative)and)clinical)databases.)Health)centers)lack)resources)to)extract)electronic)medical)record)(EMR))data)for)reporting)even)if)properly)codified.)In)

the)event)the)require)data)elements)are)not)electronically)available,)the)current)UDS)2013)Adult)Weight)Screening)

and)Follow)Up)measures)(UDS)Table)6B,)Section)F,)Row)13))require)manual)review)of)70)charts.&2.! The)UDS)measures)lack)value)to)practices)as)they)are)not)actionable:&

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a.! Due)to)the)complexity)of)the)composite)measures,)which)combine)age,)BMI)and)followHup)into)a)single)binary)measure,&

b.! They)do)not)segment)the)results)at)the)level)of)practice)and)provider.&&3.! The)UDS)measures)do)not)capture)the)essence)of)quality)of)care)for)patients)with)obesity)and)the)range)of)things)that)can)be)done)to)manage)obesity)in)primary)care.)&

Conceptual&Framework&for&Evaluating&Validity&and&Utility&of&Clinical&Quality&Performance&Measures&1.! Relevance)2.! Scientific)soundness)3.! Feasibility)

&

Methods&)

R/QI)working)group)will)(1))specify)new)BMI)measure(s);)(2))ancillary)report)to)enhance)actionability)(3))

complementaory)DQ)report;)build)and)deploy)1,2,)and)3)

)

1.!We)engaged)practices)in)the)design)of)ancillary)reports)for)UDS)measures)related)to)obesity)management,)including)breaking)down)composite)measures)into)their)component)parts,)and)enabling)options)for)viewing)the)

data)at)various)levels)of)granularity)(by)patient)type,)practice,)and/or)provider).))

2.! Create)the)corresponding)ancillary)care)quality/data)quality)reports)using)the)SAFTINet)infrastructure)a.! Revised)measures)including)linking)patients)to)a)specific)practice)or)provider)b.! Ancillary)reports)methods)e.g.,))c.! –))Evaluate)feasibility)and)value)of)1,2,)and)3)

3.!We)will)use)data)visualization)techniques)to)aid)in)the)interpretation)of)the)data)and)enhance)actionability.)We)will)then)randomly)assign)providers)to)receive)only)care)quality)reports)or)care)quality)+)data)quality)reports)on)a)

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monthly)basis)for)6)months;)we)will)then)assess)whether)there)was)a)difference)in)care)quality)and)data)quality)

metrics)over)time)between)the)two)groups.))

4.!We)will)use)(interviews?)Surveys?))to)assess)acceptability)and)perceived)utility)to)providers)and)administrators.)

)

)

Current&Measure&&

Reported&Elements&for&Current&UDS&Adult&Weight&Screening&and&Follow&Up&Measure&(UDS&Table&6B,&Section&F,&Row&13)&Column!A.! Number!of!patients!18!years!of!age!or!older!during!the!measurement!year!(18th!birthday!was!on!or!before!December!31!of!reporting!year)!AND!

had!at!least!one!medical!visit!during!the!reporting!year!after!their!18th!birthday!at!the!health!center,!excluding!pregnant!women!and!the!terminally!ill!

(this!is!the!same!as!the!criteria!in!the!first!column!of!the!Population!table,!above)!

Column!B.! Number!of!charts!sampled!(i.e.,!70!charts!for!manual!chart!review)!or!EHR!total!(equal!to!Column!A,!immediately!above)!

Column!C.! Of!those!in!the!denominator!(equal!to!Column!A,!immediately!above),!the!number!of!patients!who!had!their!BMI!(not!just!height!and!weight)!

documented!during!their!most!recent!visit!OR(within!six!months!of!the!most!recent!visit!AND(if!the!most!recent!BMI!is!outside!parameters,!a!followVup!

plan!is!documented.!!Parameters!for!BMI!are!as!follows:!!

a.! were!under!age!65!AND(their!BMI!was!over!25!OR!b.! were!age!65!or!older!AND(their!BMI!was!over!30!OR!c.! were!under!age!65!AND(their!BMI!was!under!18.5!OR!d.! were!age!65!or!older!AND(their!BMI!was!under!22.!

Suggested!codes!for!evidence!of!BMI!are!CPTVII:!3008F!(BMI!documented),!and!for!followVup!plan!V65.3!(dietary!surveillance!and!counseling)!

Data&Elements&Needed&to&Create&the&UDS&Report&As&Currently&Reported&&

Table&1:&Data&Elements&Required&for&Defining&the&Relevant&Population&&UDS 2013 Definition SAFTINet Adaptation Inclusion 18 years of age or older during the measurement year (18th birthday was on or before December 31 of reporting year) AND

> 18 years during the measurement period (year, quarter) AND

Had at least one medical visit during the reporting year after their 18th birthday at the health center (“In a clinical setting”)

Had > 1 medical encounter at the practice after their 18th birthday during the measurement period

Exclusion

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Pregnant women Women with a diagnostic code for pregnancy and/or a diagnostic/procedure code for a delivery during the measurement period

Terminally ill patients (no definition is provided) Patients who die during the measurement period, ICD-9 codes or procedure codes indicative of terminal illness [e.g., 799.3 (Debility, unspecified), V66.7 (Encounter for palliative care)]

Table&2:&Data&Elements&Required&for&Defining&and&Computing&Current&UDS&BMI&Measures&Using&Electronic&Data&& Measure

Description

Definition SAFTINet Fields or Concepts Needed

Denominator Inclusion of Patients Eligible for Measure by category: •! Under!age!65!AND(BMI!

over!25!

•! !Age!65!or!older!AND(BMI!

over!30!!

•! Under!age!65!AND(BMI!

under!18.5!!

•! Age!65!or!older!AND(BMI!

under!22.!

•! All!

•! Age!>!18!years!during!the!

measurement!year!

•! >!1!visit!during!the!

measurement!year!after!

their!18th!birthday!

•! DOB,(date(of(end(of(reporting(period,(age(at(end(of(reporting(period(•! Date(of(service(for(all(visits(to(practices,(DOB(

Denominator Exclusion Pregnant women during reporting period

Diagnostic and procedure codes and associated dates Women with a diagnostic code for pregnancy and/or a diagnostic/procedure code for a delivery during the measurement period

Denominator Exclusion Terminal illness, indication during reporting period

Diagnostic and procedure codes and associated date; Patients who die during the measurement period, V66.7 (Encounter for palliative care)]

Numerators Number with BMI documented at most recent visit or within 6 months of most recent visit for those in the following categories: •! Under!age!65!AND(BMI!

BMI documentation by categories of age and BMI

CPTVII:!3008F!=BMI!documented!or!BMI!value!is!not!null.!

Age!during!reporting!period

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Measure

Description

Definition SAFTINet Fields or Concepts Needed

over!25!

•! !Age!65!or!older!AND(BMI!

over!30!!

•! Under!age!65!AND(BMI!

under!18.5!!

•! Age!65!or!older!AND(BMI!

under!22.!

•! All!

BMI follow-up plan documented for those in the following categories: •! Under(age(65(AND(BMI(

over(25(•! (Age(65(or(older(AND(BMI(

over(30((•! Under(age(65(AND(BMI(

under(18.5((•! Age(65(or(older(AND(BMI(

under(22.(•! All(

BMI plan documented by categories of age and BMI

BMI documented and associated date FollowVup!plan!V65.3!(dietary!surveillance!and!counseling)

Limitations&of&the&Current&Measure&!! Feasibility:!chart!review!of!70!charts!from!across!the!organization!is!resourceVintensive,!especially!with!elements!like!documentation!of!a!weightVrelated!

followVup!plan.!

!! Reliability:!What!constitutes!a!weightVrelated!followVup!plan!may!vary!between!chart!reviewers,!especially!as!this!item!involves!examining!free!text!for!

evidence!of!a!followVup!plan.!

!! Utility:!The!current!measure!is!not!useful!for!targeting!patientV,!providerV,!or!practiceVlevel!needs.!!It!cannot!identify…!

"! Which!providers!or!practices!provide!better!care!quality!(and/or!data!quality)!

"! Which!patients!are!out!of!compliance!and!why?!!Is!it!mostly!poor!rate!of!measurement!of!BMI!or!poor!rate!of!providing!counseling!for!high/low!BMI?!

"! Which!patients!are!just!barely!overweight!and!which!are!immensely!so!

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"! Which!patients!are!overweight!and!which!are!underweight!

!! Data!quality:!If!generated!from!the!EHR,!the!current!reports!would!have!a!lot!of!missing!data!because!providers!are!not!documenting!follow!up!plans!(some,!

because!there!is!no!dedicated!field!for!this)!and!the!EHR!may!not!be!able!to!demonstrate!whether!the!calculated!BMI!value!is!visible!to!the!provider!at!the!

time!of!visit.!!Manual!review!of!70!charts!provides!no!information!about!how!to!remedy!the!data!quality!issues.!

!

Proposed&Improved&UDS&Adult&Weight&Screening&and&Follow&Up&Measure&

Rationale&for&Proposed&Changes&!! Feasibility:!The!new!measure!would!permit!derivation!from!each!organization’s!existing!administrative!and!EHR!data!sources.!

!! Data!Quality!and!Reliability:!Reports!generated!by!the!new!measure!parameters!would!provide!feedback!to!organizations,!practices!and!providers!regarding!

practiceV!and!providerVlevel!completion!rate!in!documentation!of!BMI!and!of!a!followVup!plan.!The!organizations,!practices!and!providers!could!then!target!

areas!for!improvement!in!reporting!reliability.!

!! Utility:!The!new!measure!would!help!provide!feedback!on!patientV,!providerV,!or!practiceVlevel!care!quality.!!It!can!help!identify!!

"! Which!providers!and!practices!provide!better!care!quality!(or!data!quality—the!practices!would!need!to!work!on!distinguishing!issues!with!quality!of!care!

from!issues!related!to!data!quality)!

"! Which!patients!are!out!of!compliance!and!why?!!!

#! Is!it!mostly!poor!rate!of!measurement!of!BMI!or!poor!rate!of!providing!counseling!for!high/low!BMI?!!

#! Which!patient!groups!based!on!the!UDS!parameters!(four!groups!defined!by!age!and!BMI!noted!above!under!instructions!for!Column!C!for!the!

current!measure!

#! Which!patients!are!higher!priority!for!rectifying!a!missed!followVup!opportunity!based!on!parameters!determined!by!evidence!or!by!practice!

preference—e.g.,!target!patients!who!have!BMI!over!35!as!highest!priority!for!providing!followVup!!

"! Which!patients!are!overweight!and!which!are!underweight!

Proposed Measures (adults >=18, not pregnant) 1. % of those with BMI >=30, % missing BMI, n, subgroup 18-64, >=65 2. % of patient with BMI =30 or greater, and no diagnosis of obesity 3. % of patient with BMI =30 or greater, and nutrition referral or group obesity encounter or …. Proposed Measures BMI<18 – as above

Table)3:)Added)Elements)to)Help)Enhance)the)Actionable)Value)of)the)UDS)Report& Additional Element

Rationale for Added Value

Sex Can help check to make sure there are no males excluded for pregnancy

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Additional Element

Rationale for Added Value

Indicator for BMI parameter category

Can help practices better understand which of the four BMI parameter categories experience poorer compliance with follow-up measure

Indicator for BMI in- or out-of-parameters

Can help practices determine which patients were compliant with UDS measure because of BMI in-range and which because of follow-up documentation

Type of follow-up documented If this degree of detail exists, patients who had exercise- or diet-related follow-up documented might help practices figure out which follow-up category needs improvement in either care quality or data quality

Height, weight Can help determine whether BMIs are missing because of an EHR calculation issue or because height is missing (or weight); can verify cause of unrealistic BMI values

Practice Practice associated with the most frequent visits in the measurement period. This can help partners link measure performance to specific practices

Provider identifier Provider associated with the most frequent visits in the measurement period. This can help partners link measure performance to specific providers

Patient identifier Practices can identify patients in need of either a BMI measurement or a follow-up action for an out-of-range BMI

Missing values For each element in Tables 2 and 3, report the proportion missing. This can help identify data quality gaps that are impacting the measure of care quality

&

Clinical&Quality&Performance&Reports:&options&for&pilot&project&&

Care&Quality&Measures&The new measure is care quality

Care&Quality&Ancillary&Reports&& [Bethany—can you put in what you had outlined/drawn in our session after the last R/QI meeting?] Some ideas for types of ancillary reports: !! Report!summary!value!as!required!by!UDS!

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!! Report!akin!to!the!DI!reports,!allowing!partners!to!compare!at!the!practice!level,!varying!parameters!such!as!those!in!Table!2!

!! Report!akin!to!the!DI!reports!with!providerVlevel!metrics,!with!only!the!partner’s!data!available!to!that!partner,!including!variables!from!Tables!2!and!3!

!! Registry!of!all!patients!in!Column!A,!including!variables!from!Tables!2!and!3!

!! “Slice!&!Dice”!care!quality!!! Broken!down!into!component!parts!!!

!

Data&Quality&Ancillary&Reports&!

1.! By!Practice!(this!is!really!not!done!at!provider!level),!for!those!>18!years!of!age!at!end!date!of!measurement!period,!with!one!visit!during!measurement!

period!

a.! Gender=males!with!pregnancy!code,!#/%!

b.! Ht!–!DQ!range!check,!acceptable!range!0V90!inches:!missing!and!out!of!range,!#/%!{if!eventually!more!granular!<60,!60V71,!72V!78,!79V84,!>85!}!

c.! Ht!value!where!units!are!not!inches,!#/%!

d.! Wt!–!DQ!range!check,!acceptable!range!0V500!pounds,!missing!and!out!of!range,!#/%,!!{<100,!101!V150,!151V200,!201V250,!251V300,!>300!}!

e.! Wt!value!where!units!are!not!pounds,!#/%!

f.! BMI!range!check,!acceptable!range!0V40,!missing!and!out!of!range,!#/%!

g.! !Age!–!DQ!range!check!

2.! By!Organization,!Practice,!Provider!for!those!>18!years!of!age!at!end!date!of!measurement!period!

a.! #/%!missing!BMI!documentation!

Key&to&Abbreviations&•! BMI Body Mass Index •! EHR Electronic Health Record •! MU Meaningful use •! PCMH Patient centered medical home •! PCP Primary care provider •! UDS Uniform Data System

!

!

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Remaining!work!to!be!done:!

1.! Conceptual!framework!for!evaluating!the!validity!and!utility!of!clinical!quality!performance!measures.!Does!one!exist,!or!should!we!create!one?!

a.! Are!these!measures!ever!evaluated?!How!are!they!established!and!evaluated?!!

b.! What!concerns!do!partners!have!about!existing!measures?!!

i.! Not!actionable!

ii.! Time!consuming,!a!lot!of!effort!to!create!(if!not!in!EHR,!must!do!chart!audit)!

c.! What!should!be!the!goals!for!the!health!care!system!in!developing!and!evaluating!the!validity!and!utility!of!clinical!quality!perf!measures?!

2.! Define!“actionable”!

a.! What!makes!a!measure!more/less!actionable?!

i.! What!makes!BMI/weight!counseling!more/less!actionable,!specifically?!

ii.! How!generalizable!to!other!UDS,!meaningful!use!measures?!!

iii.! Questions!to!ask:!Is!the!information!true?!Is!the!information!useful?!Is!it!relevant!to!the!way!I!practice,!e.g.!adult!weight!screening.!

Does!it!inform!a!particular!action!that!would!improve!care,!general!quality!of!care?!!

b.! What!kinds!of!actions!would!they!take?!How!would!we!detect!action/followVup?!

c.! What!features!of!a!measure!or!a!report!would!affect!actionability?!

i.! Granularity!

ii.! Data!quality!assurance!(validity,!reliability)!

iii.! “slice!and!dice”!unit!of!analysis!

3.! Define!scope!of!the!work!for!SAFTINet!pilot!

a.! How!to!prioritize?!

b.! What!research!questions!will!we!answer?!

!