Taking Control of Quality Measurements

The recent creation of the ED Clinical Data Registry (CEDR) offers emergency medicine a chance to take ownership over quality measures, designing them from within

Over the past two decades the quality measurement movement has rapidly changed U.S. healthcare delivery. Recently, the pressure for more transparency and accountability in healthcare has led to an explosion of quality measures covering every specialty and setting. There are over 600 quality measures currently endorsed by National Quality Forum (NQF).  Increasingly, these measures are used in public reporting as scorecards to support patient decision-making. In the future, measures will be increasingly incorporated into value-based purchasing programs by the Centers for Medicare and Medicaid Services (CMS) and private payers.

Quality measurement has a mixed history within emergency medicine. One of the first NQF-endorsed measures designed for emergency departments (EDs) was PN-5b, a Joint Commission / CMS measure that required patients admitted with pneumonia to receive antibiotics within four hours of ED arrival. It was based on retrospective studies linking early antibiotics with better survival. The measure was met with broad resistance from the ED community with concerns of unintended consequences and doubts about the evidence. Ultimately, research proved the ED community right on both fronts, culminating in the measure’s retirement. Another example was OP-15, a claims-based measure of CT utilization for atraumatic headache. The CMS measure was developed because of concerns of CT overuse and documented wide variation in ED imaging practices. The emergency medicine community pushed back: ED researchers demonstrated major measure flaws (e.g. the measurement did not exclude many scans with clear clinical indications, such as severe headaches in patients on anticoagulants). This past summer, CMS removed OP-15 from public reporting. What did PN-5b and OP-15 have in common? Neither were developed with broad input from the ED community.

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By contrast, there are some good stories of quality measurement in ED care. After a decade of research documenting the negative impact of ED crowding, the ED community welcomed the addition of throughput metrics to CMS reporting programs. These measures were supported by the hope that public reporting would push hospitals to focus on improving ED flow. Other examples of successful ED measures are for ST-segment elevation acute myocardial infarction (STEMI), which push hospitals to deliver thrombolytic therapy within 30 minutes or percutaneous coronary intervention within 90 minutes. These measures have led to considerable hospital-based efforts to speed up care for STEMI patients, and recent research demonstrated these efforts have been life-saving.

This year marked another important success for ED quality measurement, creation of The Clinical Emergency Department Registry (CEDR). CEDR was launched by the American College of Emergency Physicians (ACEP) as the first clinical quality registry for our specialty. Emergency medicine is late to the registry game: other specialties have had registries for years such as the National Cardiovascular Disease Registry (NCDR) and the National Surgical Quality Improvement Program (NSQIP).  However, the utility of CEDR and other data registries was recently elevated by the 2015 Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), also known as the “SGR-fix”.  MACRA institutes a new program called the Merit-Based Improvement Payment System (MIPS). The MIPS redesigns provider payments around four targets: quality measures, efficiency measures to reduce the cost of care, meaningful use of electronic health records and clinical practice improvement activities. The MIPS uses federal incentives and penalties to encourage providers to join qualified clinical data registries such as the CEDR. Over the next five years, this could impact up to 18% of CMS payments to individual providers.

CEDR also fixes several challenges of the beleaguered Physician Quality Reporting System (PQRS). In PQRS, individual providers and provider groups reported quality data to CMS. While ED physicians participate in PQRS at higher rates than many other specialties, emergency physicians have been faced with a drought of useful quality metrics with many measures being retired (such as 12-lead EKG for syncope). In addition, PQRS reporting has been limited to Medicare beneficiaries who represent a minority of ED patients. (Certainly quality is important for non-Medicare patients too.) Under new regulations, data from registries reporting on patients with all types of insurance can be used. And finally, CEDR measures do not require NQF-endorsement which can be a costly, lengthy process. As a result, measures can be developed by our specialty directly and launched immediately.

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CEDR includes measures covering a broad array of conditions and allows all ED physicians to participate in the current PQRS and future MIPS program. CEDR includes 27 measures this year and will add 8 more next year.  CEDR already includes some measures taken from existing CMS programs (such as measures of ED throughput or antibiotic avoidance in sinustits) and from the PQRS program (such as performance of an EKG for chest pain) and four new measures of ED efficiency (Table 1 and 2). This may draw a mixed response from some EPs, but these measures had to be included in order to start a registry while new measures are developed. However, moving to CEDR does expand options for reporting, particularly as CEDR is not limited to Medicare patients only. This will allow reporting of measures such as Rhogam administration for women at risk of Fetal Exposure (PQRS #255) and pregnancy testing for female patients with abdominal pain (CEDR #11)—two longstanding measures that do not apply to patients over 65. Second, new regulations relax reporting requirements for providers participating in a qualified clinical data registry such as the CEDR. Emergency physicians reporting quality measures to CMS as a group will no longer have to submit data on a cross-cutting measure, which have been measures developed largely for primary care providers. Providers that participate in qualified registries also avoid having to report potentially burdensome CAHPS patient experience survey scores (Consumer Assessment of Healthcare Providers and Systems) and the assignment of a Value Modifier score by CMS for at least one year that could result in payment penalties.  As specialty societies across the house of medicine expand existing registries into qualified clinical data registries like the CEDR, most physicians and licensed professionals may see major benefits in joining.

Another key driver of CEDR’s creation was the opportunity for emergency medicine to take ownership of quality measure development. CEDR has a governance structure, including a Quality Measure Subcommittee that utilizes a standing Technical Expert Panel to review and submit registry measures to CMS for approval based on emergency physician input. The Technical Expert Panel includes over 25 members in this inaugural year and is primarily composed of emergency physicians, but also includes emergency nurses, partner specialties such as radiology, and other stakeholders (e.g. purchasers and patient advocates). This panel has guided the specification and development of 27 measures for the CEDR, including 4 ACEP-developed measures of ED affordability, and eight new measures proposed for next year. The initial four ACEP-developed measures focus on improving efficiency and demonstrating the value of emergency care including a measure of CT appropriateness for both adult and pediatric head trauma, the use of CT imaging for suspected pulmonary embolism and a measure seeking to improve the ordering of coagulation studies in the ED (Table 2). These measures were designed in concert with ACEP’s participation in the Choosing Wisely campaign.

Currently, the CEDR is asking for public comment on eight new measures to be included in the registry next year. The latest set of measures include six focused on sepsis management, a measure of Foley catheter appropriateness and two more imaging measures (Table 3). The sepsis measures are constructed much simpler than the recently released CMS SEP-1 metric as they seek to promote only the essential elements of sepsis care – fluids, antibiotics and lactate measurement – and do not require central line placement on all patients, which is in line with recent evidence.

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As CEDR develops, EPs will have several opportunities to contribute. Along with submitting comments on the eight proposed measures, ED physicians can also submit ideas for the next cycle of quality measure development starting this fall. In addition, participation in the CEDR may provide many EDs with real-time quality data and benchmarking reports through the web-interface which can be used by ED directors to guide local improvement efforts. However, many challenges remain as most current measures focus on diagnoses as opposed to clinical symptoms or chief complaints which may be a useful way to structure future ED quality measures. In addition, numerous data difficulties remain as quality measurement efforts seek to catch up with the rapid adoption of electronic health records. Ultimately, while it is still too early to report on the success and scale of the CEDR and there is much work to do, our specialty is moving forward in charting a path for acute care quality nationally.