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The quality of healthcare and health IT interoperability are continuing concerns among healthcare professionals. To address these concerns, the National Quality Forum and its telehealth committee met recently to discuss ways to measure healthcare quality and interoperability.
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The National Quality Forum (NQF) was asked by the Health Department to accomplish two tasks: identify critical areas where measurement can effectively assess the healthcare quality and impact of telehealth services, and assess the current state of interoperability and its impact on quality processes and outcomes.
In a media briefing last week, NQF experts and members of the committee in charge of the two aforementioned tasks discussed the thought process behind the development of healthcare quality measures and the goal the committee hopes these measures will help achieve.
"After a comprehensive literature review conducted by NQF staff, the telehealth committee developed measurement concepts ... across four distinct domains: access to care; financial impact and cost; telehealth experience for patients, care givers, care team members and others; as well as effectiveness, including system, clinical, operational and technical," said Jason Goldwater, senior director at NQF, during the briefing.
Goldwater said that, ultimately, the following areas were identified as the highest priorities: "The use of telehealth to decrease travel, timeliness of care, actionable information, the added value of telehealth to provide evidence-based best practices, patient empowerment and care coordination."
Judd Hollanderassociate dean of strategic health initiatives, Thomas Jefferson University
Judd Hollander, associate dean of strategic health initiatives at Thomas Jefferson University and a member of the NQF telehealth committee, explained that the committee wanted to begin this process of creating measures for telehealth and interoperability in healthcare by conducting an "environmental scan."
"Where is there data and where are there data holes and what do we need to know?" Hollander said. "After we informed that and took a good look at it we started thinking, what are types of domains and subdomains and measure concepts that the evidence out there helps us illustrate but the evidence we're lacking can also be captured? ... So it was a really nice way to begin the discussion."
Hollander added that the implications of the NQF report and the measures the committee is working on are "expected to inform policy across the entire spectrum of alternative payment models, government funded healthcare, and care funded by commercial payers because it's just what you should be assessing to provide quality care."
NQF's telehealth measures: Patient experience
For healthcare to truly reap the benefits of telehealth, the industry has to focus on quality first. And to improve healthcare quality, there has to be a way to measure and report it, Hollander said.
"Those of us that live in the world of telemedicine believe not only are there quality enhancements, but there's convenience enhancements that are going to make medicine easier to deliver," Hollander said.
Hollander used a personal experience as an example of the benefits telehealth can bring to patients, even if a diagnosis isn't or cannot be made via telehealth technologies.
"I had a patient who hurt his knee working in Staples, actually, at about 5:15, 5:30 in the evening. He had a prior knee injury and he had an orthopedist, but he couldn't reach the orthopedist because their offices were closed," Hollander said.
Without telehealth, this patient would have had to go to the emergency department, he would've waited hours to be seen, and then he would've been examined and had X-rays done, Hollander said.
Not only would this have taken a long time, it also would've cost this patient a lot of money, Hollander added.
Instead of going to the ER, the patient was able to connect with Hollander through JeffConnect, Jefferson University Hospitals' app that enables patients to connect with doctors anytime, anywhere.
"I was the doc on call. We do know how to examine knees by telemedicine and we can tell with over 99% accuracy whether someone has a fracture or not and he did not," he said.
Hollander explained that they then did a little "wilderness medicine." Using materials lying around, the patient was splinted with yard sticks and an ace bandage and then was able to wait to see his orthopedist the next day.
"So we didn't actually really solve his problem, but we saved him a ton of time and money; he didn't have to go get X-rays one day, [then] have them repeated by the orthopedist who couldn't see him [until] the next day because the systems aren't interoperable," Hollander said.
NQF's telehealth measures: Rural communities
Marcia Ward, director of the Rural Telehealth Research Center at the University of Iowa and also an NQF telehealth committee member, brings a rural perspective to the telehealth conversation.
"Creating this framework we had to look across all of those different aspects of telehealth and how it could be applied. I find it particularly interesting that telehealth has been thought of as an answer for increasing access in rural healthcare ... and I think that's been one of the strongest suits," she said during the briefing. "But now it's developing into an urban application and I think we'll see particular growth in that."
Ward used the concept of travel in rural areas as an example of thinking of a unique, and maybe not always obvious, issue to address when creating telehealth measures.
"Travel is a concept that is very important, particularly in rural telehealth," Ward said. "An example of that is there's a telestroke program at the Medical University of South Carolina and one of the measures that they use is how many of the patients that are seen through their telestroke program at the rural hospitals are able to stay at their local rural hospital."
This is an example of a healthcare quality measure that wouldn't normally be seen in conventional medicine but is very appropriate for telehealth in rural areas.
"That's a very important measure concept ... able to be captured. Another one particularly important in the rural area is workforce shortages and we're seeing evidence that telehealth programs can be implemented that help bridge that gap [and] be able to deliver services in very rural areas and have the backup from telehealth hub where there's emergency physicians," Ward said. And we're seeing evidence that telehealth, in terms of rural communities in particular, it's really filling a particular need."
NQF's interoperability measures
While the experts focused mainly on telehealth during the briefing, Goldwater explained that when the committee was discussing and creating measures for interoperability they conducted several interviews to help them define guiding principles.
Goldwater said that these guiding principles include:
- "Interoperability is more than just EHR to EHR;
- "Various stakeholders with diverse needs are involved in the exchange and use of data, and the framework and concepts will differ based on these perspectives;
- "The term 'electronically exchanged information' is more appropriate to completely fulfill the definition of interoperability;
- "And all critical data elements should be included in the analysis of measures as interoperability increases access to information."
Ultimately the committee developed healthcare quality measures across four domains: The exchange of electronic health information to the quality of data content and the method of exchange, the usability of the exchange of electronic health information such as the data's relevance and its accessibility, the application of exchange of electronic health information such as "Is it computable?" and the impact of interoperability such as patient safety and care coordination, Goldwater said.
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