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Accessing Clinical Information to Enrich Performance Measurement: The Wisconsin Experience

By: Christopher Queram, MA

Over the past several years, there has been a significant increase in the public reporting of comparative performance information on ambulatory care providers (medical groups and physician clinics). To a large degree, this information has been generated by local/regional/state initiatives which rely on administrative (claims) data, typically submitted on a voluntary basis by health plans and then pooled ("aggregated") together to form a multi-payer database. Even with a large number of plans contributing data, the performance measures generated via this method represent, by definition, a subset of the patient population managed by the medical group or clinic. Moreover, because the reliance on administrative data alone for performance measurement raises many clinical and statistical issues, national thought leaders have advocated for the development of a measurement model that integrates clinical information needed to portray outcomes for an entire patient population (insured as well as self-pay and uninsured) receiving or eligible for care within the practice.

The Wisconsin Collaborative for Healthcare Quality (WCHQ) has developed such a model. The mission of WCHQ is to improve healthcare quality in the state of Wisconsin through the development and public reporting of a comprehensive range of healthcare performance measures. The WCHQ currently facilitates public reporting for an estimated 50 percent of Wisconsin primary care physicians through a membership that currently includes a significant majority of the medium-sized and large multi-specialty groups in Wisconsin. The members of WCHQ have tested and verified reliable methods of data collection and data aggregation within a broad range of physician group practices, successfully demonstrating that investments in health information technology, though beneficial, are not required for successful public reporting. Indeed, while many of WCHQ's large clinic members are implementing electronic records, each is at a different phase of functionality; as a result, it would be most accurate to characterize WCHQ as a blend of primarily "low" and a few "high" tech sites.

WCHQ has acquired extensive experience in performance measurement at the physician group level, including the complexities of measurement testing, data aggregation, and public reporting displays. One of the greatest challenges to quality measurement in the outpatient setting is that physicians and physician groups care for multiple patients from multiple payers, so data from any one source is incomplete. Moreover, patients often maintain a relationship with their physician through several changes in insurance coverage. Under this construct, measurement performed by health plans relies on a definition of "eligibility" that is tethered to insurance coverage, thus requiring that a new approach be devised for measuring quality among physicians and physician groups. The physicians, data analysts and quality specialists from the WCHQ membership have accomplished this goal by developing ambulatory care measure specifications, which marry administrative data with clinical results. This "bottom up" method of data collection makes it possible for a health system to collect and report quality of care results on all patients under its care. More specifically, the WCHQ method begins with the identification of the measure's denominator, both for process measures (such as a mammography exam every two years) and outcomes (such as blood sugar [A1c] control). For each measure, parameters of the denominator are carefully constructed to define relevant patients cared for by the physician group. For this denominator to be meaningful, it must identify every patient, not just those who were served by a particular payer. The distinctive method developed by the WCHQ uses a standard three question algorithm (for diabetes, the questions are: is this a patient with a diagnosis of diabetes?; is this a patient that our group manages?; and, is this a patient that is current in our system?) that, when applied sequentially, reveals a finite, clearly defined group of patients—in other words, a population-based denominator.

This approach yields several distinct benefits:

Because the denominator is defined up front, data (e.g., was the mammography performed?) need not be collected about patients who will later be excluded. All exclusions are built into the three-question denominator-building methodology.
Because all qualifying patients are "counted," regardless of payer, physicians can trust that the resulting measures reflect actual performance.
These carefully constructed, population-based denominators overcome many of the sample size issues experienced by insurance companies.
Denominators constructed this way can also be used as a registry of patients with chronic, episodic or preventive care needs and, in addition, point out patients with immediate care needs ("check patient's LDL at tomorrow's visit") or those who may need further attention ("contact patient to schedule follow-up").

WCHQ's founding physician leaders understood the need to deploy measures that align with nationally recognized data sets in order to gain credibility and support with their physician colleagues and the business community, as well as to provide a smart, easy-to-use methodology for data identification and capture. This model demonstrates that the capability and capacity to reliably and accurately report both process and outcome measures exists today, with the potential to inform the evolution of the country's ambulatory quality measurement strategy.

Performance measurement experts and others who have been introduced to WCHQ's model invariably ask two questions: one, how was it possible to achieve consensus among providers, purchasers, and others to pursue this initiative collaboratively?; and two, how is it that electronic health records (EHRs) are not necessary to generate measures with clinical data? The answer to both is leadership, vision, and will. The executive and clinical leaders who formed WCHQ recognized that the benefits of transparency out-weighed the risks and invited businesses to partner together to translate the often competing aims of accurate data and urgency into a shared vision. The provider organizations supported that vision by committing the resources needed to generate measures that delivered on this promise. While the selection of any approach to performance measurement involves trade-offs (for example, the number of measures being reported), the model adopted by WCHQ demonstrates the achievements that are possible through collaboration among stakeholders.

Author

Christopher Queram, MA
Wisconsin Collaborative for Healthcare Quality, Madison, Wisconsin

Disclaimer

The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Quality Measures Clearinghouse™ (NQMC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor ECRI Institute.

Potential Conflicts of Interest

Mr. Queram reports that he is a Member of the Board of Commissioners -- The Joint Commission; Member of the Board of Directors -- Delta Dental of Wisconsin; Ex-officio Member of the Board of Directors -- Wisconsin Collaborative for Healthcare Quality; Principal -- Quality Alliance Steering Committee; Principal -- Hospital Quality Alliance; and Member, Steering Group of the AQA Alliance.

Mr. Queram states no personal financial interests, family member conflicts of interest, or additional disclosures.

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