Measuring Quality in Wound Care

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Caroline E. Fife, MD, FAAFP, CWS

Editor’s Note: This article serves as a follow-up to Dr. Fife’s article:
“The Changing Face of Wound Care: Measuring Quality” published in October 2012. Dr. Fife shares an affiliation with Intellicure Inc. and US Wound Registry.

  Healthcare reform has major implications for the wound care industry. Transitioning to a value-driven payment model that focuses on better care at lower cost necessitates reconsideration of physician and hospital financial incentives. As a way to improve patient care, measure the benefits of specific interventions, and incentivize clinicians for providing them, there is a national initiative to develop and report specific clinical “quality measures.” Previously, I explained the various incentives (and penalties) that apply and detailed those measures relevant to wound care physicians under the Physician Quality Reporting System (PQRS) — formerly the Physician Quality Reporting Initiative (PQRI).1 Wound care clinicians are glad to have some measures to report, even if it is not clear how well these particular measures will improve the outcomes of patients living with chronic wounds. We are going to need more quality measures in wound care, particularly measures that can be reported directly from electronic health records (EHRs) since the Center for Medicare and Medicaid Services (CMS) intend for all data to be reported this way — meaning wound care practitioners must decide what constitutes quality care and how it is to be measured … before it’s decided for us.

How Quality Data Gets Reported

  More than 40 years ago, the late Avedis Donabedian proposed models for measuring almost every aspect of quality in healthcare. Widely regarded as the first to formally study healthcare quality, Donabedian defined an “outcome” as a change in an individual as a result of the care received. Patient outcomes can be characterized by clinical endpoints (eg, amputation), functional status (eg, ambulation), or general well-being (eg, pain). It is also possible to measure the appropriateness of clinical interventions that are known to improve a desired outcome (eg, diabetic-foot offloading). Although CMS prefers outcome measures to “process” measures, assessing compliance with clinical practice guidelines such as offloading may be easier to determine than a more subjective clinical endpoint such as “wound healing.” Most medical societies (ie, the American Medical Association’s Physician Consortium for Performance Improvement® and the National Quality Forum [NQF]) have spent years developing quality measures for the majority of specialties and major disease states.

  One of the nation’s first quality incentive programs, the PQRS (also known as pay for performance) began in 2007. Since the use of EHRs was not widespread at the time, reporting was facilitated via qualified patient registries that reviewed data via claim forms before transmitting it to CMS on behalf of eligible providers. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 mandated the adoption of certified EHRs, changing the dynamics of the reporting process. HITECH also made stimulus money available to clinicians who demonstrated the “Meaningful Use” of their EHRs through a number of metrics including participation in quality reporting. To make electronic data-sharing possible, all certified EHRs must use Health Level 7 Clinical Document Architecture, which consists of a mandatory “textural” component (to ensure human interpretation of the document) and “structured” components for software processing, which allows data to be shared. In order for eligible providers to obtain their HITECH-adoption bonus money, they must meet certain program requirements that are still being developed by CMS. Under stage II of Meaningful Use (beginning in 2014), providers must share data with a public health agency or a specialty registry by transmitting “directly from an EHR.” Accomplishing this will require transfer of structured data (not “free-text typing” or dictated notes). Medicare is also driving the PQRS program toward transmission of quality data directly from EHR to CMS via “e-Measures.” The clinician will transmit clinical performance data to CMS, and CMS will calculate the “pass” or “fail” rate of the quality measure to determine subsequent bonus (or penalty) payments. So, while EHRs may change the method of reporting, the real question remains: What, exactly, are we going to report in order to demonstrate wound care quality?

A Real Example in Wound Care

  As executive director of the US Wound Registry (USWR), a nonprofit organization that has been a CMS-approved patient data registry since the PQRS launched, I have been involved in performance reporting for four years. Registry responsibilities include: validating eligible providers (EPs), collecting medical data needed for EP reporting measures, acquiring attestation from EPs (permission from the clinician to report data to CMS), calculating measures (including de-identifying data), and transmitting secure data to CMS. PQRS data submission is a daunting task, particularly since some measures are highly complex to calculate. Initially, there were no PQRS measures directly relevant to wound care physicians, but by 2009 one of the 153 measures pertained to wound care specifically — “percentage of patients over age 18 with a diagnosis of venous ulcer who were prescribed compression therapy within the 12-month reporting period.”

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