November 2013

The Challenges of Capturing Meaningful Use Data
By Paulette Di Angi, PhD, RN
For The Record
Vol. 25 No. 15 P. 30

Acclaimed motivational speaker Earl Nightingale once said, “Don’t let the fear of the time it will take to accomplish something stand in the way of your doing it. The time will pass anyway; we might just as well put that passing time to the best possible use.” In today’s health care environment, Nightingale may have said “the best possible meaningful use.”

Meaningful use and its increasingly demanding stages have brought data reporting to the forefront of everyone’s minds across virtually every hospital department. While the program promises many benefits, the time requirements and stress on hospitals to comply cannot be underestimated. This will only increase as meaningful use progresses from stage 1 to stage 2 and as additional pay-for-performance programs such as value-based purchasing, readmission reductions, and hospital-acquired conditions are tied to penalties and require electronic reporting.

Although the shift to an electronic data format has large potential benefits, it represents a significant process change that will affect many health care workers on many levels. When it comes to quality reporting, meaningful use is, quite simply, a different animal.

A Historical Overview of Data Reporting
The Centers for Medicare & Medicaid Services (CMS) reporting on hospital quality measures is nothing new. It’s been a requirement in various forms since the organization was established in 2001 (previously known as the Health Care Financing Administration), and even before that, other associations performed some type of reporting.

The Joint Commission worked with the CMS on the acute myocardial infarction and heart failure sets that were common to both organizations. The two aligned the measure specifications for use in the 7th Scope of Work and for Joint Commission-accredited hospitals. Hospitals began collecting acute myocardial infarction measures for patient discharges beginning July 1, 2002. In November 2003, The Joint Commission created the Specifications Manual for National Hospital Inpatient Quality Measures to be used by several organizations.

Despite all of the CMS quality improvement programs, meaningful use reporting can be difficult, especially when abstractors must manually sort through file after file to determine whether patients meet required standards. This is not because core measures do not adequately reflect quality care standards. Rather, it reflects the need to improve data reporting and analysis and to make better use of new technology to enhance accuracy and feedback to medical facilities. Better feedback will enable improved workflow changes to elevate performance and patient care.

As advances in HIT have offered new options, more questions are emerging. Is manual capture and reporting of care quality the best way to manage this process? Is a more structured process better suited to meeting these objectives?

Manual Capture and Abstraction
For manual chart abstraction and CMS compliance reporting, nurses and data analysts/abstractors review patient records to identify those meeting the guidelines. The nurses or data abstractors often face challenging deadlines to review large volumes of patient binders overflowing with forms, notes, and treatment plans written in various handwriting styles. This process leaves plenty of room for human error and creative interpretation of review guidelines.

In particular, reviewers often analyze data captured through unstructured methods. This includes SOAP (subjective, objective, assessment, and plan) reporting as well as narrative charting of patient conditions and treatments. Such reporting is subjective and rarely compels caretakers to chronicle the same measurements across similar patient populations for any objective comparison of care. Additionally, finding information in charts that does not conform to a common organizational structure can be frustrating to clinicians and slow care delivery and process improvement.

Narrative information, which involves extensive human judgment, frequently is open to interpretation. Since records lack a standardized format, locating specific information is difficult. The lack of standardization across individual abstractors can make the data unreliable. In addition, the manual extraction process is time consuming and costly. It lacks the objectivity and scientific rigor needed to provide meaningful information, the structure to help drive compliance, and the change management to improve overall care quality. All of these challenges prompted the CMS and The Joint Commission to develop a better form of compliance reporting.

Along Comes Meaningful Use
That new form of reporting is meaningful use, which incentivizes hospitals to implement EHRs and capture specific data electronically. The initiative provides a highly structured method to format data so that hospitals can demonstrate compliance by extracting a concrete and objective report directly from the electronic system. This new compliance reporting will not only ensure that the hospital receives incentive payments but also that it ultimately has a process that drives best practice care delivery.

While meaningful use’s goals are to be applauded, the benefits come at a cost. The program presents hospitals with an enormous challenge in aligning their data capture and reporting with the new requirements. Hospitals not only must migrate from manual data capture and abstraction, they also must add a new layer of structure to both processes. Because these complex and difficult changes cannot be implemented overnight, many organizations find themselves operating in a hybrid world.

Today’s Hybrid Environment
In this new hybrid world, some smaller facilities continue to capture and report data completely through manual processes. However, most hospitals have introduced some electronic capabilities, with many large medical centers adopting sophisticated EHRs that allow them to convert to digital capture and reporting. Still, digital information management is an evolving process as the structure of digital data changes, driven largely by meaningful use’s revolving requirements.

A hybrid environment presents its own set of challenges. Many hospitals have portions of patient records captured digitally while others remain as hard copy. The result is confusion about specifically where to access information to create the reports required for meaningful use. It also results in ongoing process changes that affect care delivery as staff are trained and retrained on how to enter the data necessary for compliance.

How the Shift Affects Quality Management
Quality staff in particular face a broad spectrum of new challenges. In addition to navigating the difficulties of a dual-format environment, staff members must plan for a future shaped by meaningful use. Unlike current reporting that typically allows flexibility on what and how to record large amounts of narrative data, meaningful use requires that distinct and discreet data elements are stored in the electronic patient record. Eventually, this structured information is abstracted for reporting.

Setting up an EHR system to capture all the data needed to report on meaningful use can be a Herculean task. While much of that burden falls on IT, quality staff now find themselves worrying about not only improving care but also managing the data necessary to document how it was accomplished.

What does managing data quality mean to quality personnel? First, staff members must sort through the specific meaningful use reporting requirements—information more complex than most have ever before encountered. Next, they must work with IT to ensure the electronic system includes all the necessary structured data elements to meet those requirements. Some elements may already be in the system but may need modification.

It must be determined which indicators are to be measured and how. Quality staff members must help plan the user interface for data acquisition. What choices will the system present to caregivers to answer specific questions? Will information be in a drop-down list or a pop-up box?

Workflow changes likely will be required to input new information. Quality staff members need to support the storage of case details in an electronic format to support an audit. Staff members must be trained and compliance reinforced. Once all that’s accomplished, the cycle starts over again when the CMS issues changes to the requirements.

Where Does Quality Staff Begin?
Meaningful use’s effects on quality managers and staff should not be underestimated. The initiative’s requirements are the most complex the CMS has ever released, containing more inclusions and exclusions, data elements, and compliance measures than any other in history. Just reading through and interpreting its specifications is a daunting task. Speaking of which, quality staff should study the requirements in order to launch the process correctly. Understanding the variances between meaningful use and other quality programs is critical to success.

Meaningful use will transform health care. Its benefits will include not only enhanced care validation and CMS feedback but also data analysis to provide far-reaching evidence-based treatment guidelines, physician collaboration, information sharing, and more. Under meaningful use, there’s tremendous potential to boost data quality and stagnant scores. Furthermore, over time, the CMS will merge the requirements with other pay-for-performance programs with the intention of eliminating today’s hybrid world of CMS reporting to create a system that meets requirements across multiple programs. When these programs merge, the quality of care will improve, and the reporting process will be simplified.
While achieving meaningful use may seem overwhelming, wise health care organizations will heed Nightingale’s advice and make it time well spent.

— Paulette Di Angi, PhD, RN, is chief clinical information officer and product manager for IHM Services and is responsible for new product design and product updates.