10 "Must Haves" in a CQMS

#2: Problems documented in a structured and coded manner, using clinical terminology.

Throughout the country, clinics and practices are tackling the problem of quality improvement - not only to meet new pay-for-performance standards, but also to provide a higher level of care. Many providers are finding that a well-chosen clinical quality management system (CQMS) supports their efforts and greatly improves their success. This ongoing series will highlight ten essential features for any clinical quality improvement system.

The Must Haves

An all-problem, all-patient registry of clinically-verified information not dependent on billing optimization
Problems documented in a structured and coded manner, using clinical terminology
A sophisticated rules engine of clinical care guidelines that thinks like a physician, not like a computer system
Point-of-care functionality to provide easy identification of due items and increase visit efficiency
Tools to reach patients due for services but not scheduled for a visit
On-demand reporting providing actionable data for quality improvement
Features to allow the entire care team to focus on quality
Extensibility to other HIT systems to share relevant clinical information
Vendor-supported, secure and scalable technology
A customizable framework to meet the unique needs of a practice

Any technology supporting clinical quality improvement must be built upon a database of clinical information that is accurate, accessible and relevant. Consider quality improvement technology as a vehicle to support increased care quality. Data is the dashboard for that vehicle — it provides the information you need to make care decisions.

To effectively inform care decisions, clinical quality data must be captured in a structured, clinically-relevant and coded manner. Without structure, the data cannot be used for reporting, analysis, and population management. And, without clinical relevance, it cannot be captured effectively in a busy practice.

Currently, many practices rely on administrative data to drive their clinical quality improvement efforts. Yet, this data is highly optimized to meet payors' requirements for ensuring accurate reimbursement to a clinic. As such, this information is usually documented in an unstructured manner, making it unusable for tracking episodes of patient care, as well as for managing and reporting on care quality.

There are many services (as opposed to software systems) that also attempt to construct structured and coded clinical data from billing information. While such services may prove beneficial in meeting some scorecarding and pay-for-performance initiatives, they are not truly building the foundation for sustainable quality improvement, depriving practices of a base that will support increased quality of care and an improved bottom line.

A clinical quality management system should capture patient information in a structured, clinically-relevant and coded manner. Data should be entered using a consistent and controlled clinical vocabulary that acts as a thesaurus. This allows the use of natural and standardized clinical language, making the process of recording the information unobtrusive to the operations of the practice. As an example, there are many terms for Type II Diabetes ("Diabetes Mellitus," "Type II Diabetes," "Non-Insulin Dependent Diabetes Mellitus"), but in the end, they all describe the same condition. A CQMS should allow problems to be captured with various terminology, however, these terms must be mapped to a single coded problem ("Diabetes Mellitus") to allow for easy analysis and reporting.

Use of a clinical classification system allows a CQMS to map individual terms consistently, in a coded manner to support reporting and analysis. The classification system should support reasons for the encounter as well as symptom and lifestyle diagnoses. Coding systems such as ICD-9 often do not capture such diagnoses, requiring the care provider to find the "closest fit." As an example, ICD-9 has no capability of recording the symptom of "feeling sad" or "depressed mood." Instead the care provider is forced to choose a diagnostic term of "depression." While this may be acceptable for reimbursement, it can drastically affect care delivery since a diagnosis may be assigned before an evaluation is complete.

The use of a structured and clinically-relevant, coded, classification system is vital to a sound CQMS and provides numerous benefits to a practice, as such a software system:

Greatly reduces the effort needed to generate disease-specific quality reports (such as HEDIS^®) by simplifying denominator calculations. Savings of over $100,000 have been documented using this approach.
Provides the ability to report on quality improvement and care metrics that are simply not trackable through ICD codes or billing records alone. Many of these metrics are the ones required for pay-for-performance programs.
Allows providers to accurately record all symptoms and diagnoses for a patient, providing a true picture of a patient's health. Care reminders must be based on complete information if they are to be timely, relevant, and correct.
Creates systems for recording individual patient episodes of care, the standard for quality-of-care evaluation.
Provides an easy way to identify and manage different patient populations. Using a coded database, a simple, unique identifier can be assigned to denote a given patient population. Without such a system, all phrases that could possibly be used to describe the condition (including typos) need to be included in the query.

Choosing an effective system of documentation.

When choosing a CQMS for use in a practice, be sure to evaluate the methodology used for documenting problems. First of all, in addition to coding for reimbursement, ensure that a classification system exists for capturing problems in a clinical manner — ICPC (International Classification of Primary Care) is an example of such a system. Furthermore, verify that a standardized vocabulary is in place for capturing problems, one that provides synonyms and a description for all reasons for an encounter — ENCODE^TM (Electronic Nomenclature and Classification Of Disorders and Encounters) is one such vocabulary.

The quality of the documentation system used by a CQMS will directly affect the quality of the information it manages. Since a busy practice cannot manage what it does not measure, be sure to select a system that will support a broad range of needs — from detailed problem recording to patient care and quality metrics reporting.

Next Issue: A sophisticated rules engine of clinical care guidelines that thinks like a physician, not like a computer system.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Clinical Quality News

Volume 1 Issue 2 - June 2008

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Family Practice's Performance is 20% Better than Reported

10 "Must Haves" in a CQMS

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