Cutting the volume of data down to size

The beast should get smaller — eventually

Every hospital quality improvement manager hears complaints about all the data that has to be collected, how much of it is redundant, the different ways you have to report it, and the increasing number of organizations that want it. Why can’t they all get together and figure out a way to work together? they ask.

That’s one of the goals of the Measurement Applications Partnership (MAP), convened first in 2011 by the National Quality Forum at the request of the federal Department of Health and Human Services. The group just completed its second report, after asking for input regarding some 500 measures under consideration for use in federal programs.

The goal is to get private and public entities on the same page as far as data collection and reporting. Eventually, it is hoped that the vast number of program requirements will be streamlined, reducing the reporting burden for your average hospital.

This round, MAP supported the inclusion of 141 of the measures for some 20 programs, generally liked another 165, and recommended that 64 of the measures be removed over time. They also added six measures that weren’t on the list submitted to MAP and its panel of more than 100 experts. They acted after receiving some 400 comments from nearly 100 stakeholders. The complete report is available at

Along with the annual review of the list of measures, MAP members also identified gaps in the measures and proposed solutions. Most of the kinds of gaps had been previously mentioned in MAP reports — creating more outcome, versus process, measures; that children and other special populations needed more measures; using patient experience measures in settings other than inpatient; using fewer check-box-type measures; too few composite measures for multifaceted topics; and a dearth of measures for specialties like behavioral health.

The next generation

The report notes that comments largely supported MAP members’ opinions on the measurement gaps, and some suggested other areas of lack as well, such as palliative care, functional status, and disease-specific measures for conditions like osteoporosis.

Members of the MAP team recommend ramping up efforts to create a “next generation” measure set. It would include things like resource use and composite measures. NQF plans to work on this during the coming year. And the report notes that there must be better collaboration, both to close the identified gaps, but also to reduce duplication and harmonization. “The resources available to fund measure development, testing, and endorsement are finite,” notes the report, “so stakeholders need to establish agreement on the highest priority measurement issues and how to overcome barriers to address them.” NQF hopes to act as a coach and coordinator of efforts, as well as a measure incubator.

The work for the coming year for MAP includes working on new measure families. Thus far, they have created families for safety, care coordination, cardiovascular disease, diabetes, cancer, hospice, and dual eligible beneficiaries. The team wants to add families for affordability, population health, patient and family engagement, and behavioral/mental health.

MAP will also work to create feedback loops to get ongoing information about existing measures, gaps that may not yet be on the radar, and unintended consequences of new measures.

One of the key findings of this report was the need for more “rigorous” performance measurement, says Tom Valuck, MD, JD, senior vice president for strategic partnerships at NQF. “As we evolve from pay for reporting to pay for performance, we have to have measures that are more meaningful to providers, purchasers, payers and patients alike,” he says. “What that means depends on the audience involved. Outcome measures may be more meaningful to patients — such as functional status. But providers are interested in measures that are fair, valid, reliable, and appropriately adjusted. That might mean more rigorous reporting of socioeconomic data to help account for readmissions. Purchasers, though, may be more interested in ensuring we don’t adjust away meaningful differences, and that we have measures that look at both quality and cost of care.”

The goal is to tie measures more closely to outcomes, Valuck says. “Having a checkbox measure that asks if you have an electronic medical record doesn’t provide any information on whether you have coordination of care or effective transfer of patient information between providers. That is what we want to move toward.”

Linking cost and quality

Valuck says MAP also intends to move toward a more overt linkage of cost and quality in its measures. What that looks like will depend on what level of data you examine — patient, provider, hospital or system level data. Good cost measures for each are still being developed, he says.

There is total cost of care for a procedure, but does that give you all the information you need if the cost is solely based on what happens in the inpatient setting? How does that help complete payer understanding if the costs associated with rehabilitation aren’t included? And if information on a hip replacement doesn’t include information on whether the patient has a better quality of life, does it have any meaning for the patient?

It could be that there will end up being some kind of index related to a particular kind of care. Under hip replacement will be data looking at the cost of implant, surgery, recovery, rehabilitation, nursing, home care, and on down the line, Valuck says. That kind of thing takes time, though.

For now, quality managers can assist in making sure that the burden isn’t high but the payoff in data is by communicating with the NQF and MAP. “We want to engage you and find out what you have difficulty with. Where are you finding unintended consequences? What data do you wish you had more of?” he says. “We are committed to streamlining data collection and reporting and decreasing the administrative burdens you face. So tell us what is redundant. Tell us if you have ideas for making it more efficient.”

Nothing MAP suggests is set in stone. HHS takes the suggestions under advisement and may or may not adjust its proposed rules. But Valuck says he thinks they understand the value of the knowledgeable group of stakeholders involved in MAP. Late this year, they will start the process again, looking at what rules and measures came to fruition and whether they are helping the healthcare system as a whole better meet its quality, safety, outcome, and cost goals.

For more information on this topic, contact Tom Valuck, MD, JD, senior vice president, Strategic Partnerships, National Quality Forum, Washington, DC. Email: