June 29, 2023

Dear Office of the National Coordinator:

On behalf of the American Academy of Family Physicians (AAFP), representing more than 129,600 family physicians and medical students across the country, I write in response to the draft quality data element list for United States Core Data for Interoperability Plus (USCDI+). USCDI+ is a service ONC provides to federal and industry partners to establish, harmonize, and advance the use of interoperable data element lists that extend beyond the core data in the USCDI in order to meet specific programmatic and/or use case requirements, such as quality measurement. We appreciate the Office of the National Coordinator’s (ONC) effort to seek feedback on this initial data element list in the quality domain.

The AAFP is very supportive of the USCDI and USCDI+ efforts to standardize the essential data elements to support care delivery. We also support ONC’s effort to establish and advance a core data set focused on quality measurement. The cost and burden on physicians and practices to capture, aggregate, synthesize, and report quality data is significant.[1]^,[2],[3],[4] We believe the goal for USCDI relative to quality should be that the essential quality measures are truly interoperable and EHR data can be systematically mapped to the quality data elements without effort by physicians and other health care professionals. Family physicians consistently report that quality measure reporting is a significant source of administrative burden, taking time away from direct patient care and worsening moral injury. The AAFP appreciates ONC’s efforts to address these burdens by supporting the standardization and interoperability of clinical data elements needed to advance digital measurement and reporting.

For essential quality measures, we refer ONC to CMS’s Universal Foundation[5]  and the Core Quality Measures Collaborative (CQMC)[ ACO/PCMH/Primary Care|https://p4qm.org/cqmc/core-sets] core measure set with future consideration for new measures focused on the four core functions (4 C’s) of primary care such as the Primary Care Measures that Matter. We believe measures that are used should be essential and interoperable. As highlighted in our Guiding Principles for Value-based Payment for Primary Care, “…performance measures should focus on processes and outcomes that matter most to patients and have the greatest impact on overall health, and unnecessary spending. VBP measures, as well as the mechanisms of measurement, should be parsimonious and aligned across payers to reduce unnecessary administrative burden.”

Level of Specificity and Usefulness of Companion Guidance

As we reviewed the adjunct materials provided by ONC, while helpful, the USCDI+QUALITY – Electronic Clinical Quality Measure (eCQM) USE CASE MAPPING is not sufficient to determine if all data elements within an essential quality measure are covered. What is needed is a list of all data elements required for each essential measure and a map to data elements within the USCDI+ quality data element list. This type of mapping would provide ONC and the public a clear understanding of which quality measures are fully supported by USCDI+ and therefore have a chance to be truly interoperable.

The CQMC Digital Measurement Workgroup is a multi-stakeholder effort working to translate quality measure data elements to FHIR.  This group published a report in September 2022 with multiple goals, one being to increase use of digital quality measures (dQMs) within the CQMC core sets, which are intended to encourage alignment in measurement for value-based payment programs and alternative payment models across the nation. Transitioning the core sets to dQMs will ensure they remain relevant in the future. As a leading force for measure alignment, the CQMC has the opportunity to help ensure the transition to FHIR addresses standardization of the data needed for the highest-priority quality measures. This group is already working to prioritize the measures that are essential to primary care quality and performance measurement and then identify every data element needed to translate those measures to FHIR-based dQMs. We encourage ONC to collaborate with this skilled multi-stakeholder group that is already undertaking this work. Together, we can all support this collaborative effort to leverage the USCDI+ Quality standards to allow physicians to focus their energies on patient care over measurement tasks.

While we await the result of the in-depth data element identification of the CQMC Digital Measurement Workgroup, we still see some opportunity for additional UCDI+ quality data elements to add. These include but are not limited to the following:

• Data element(s) to represent the reason patient discontinued a medication or treatment
• Regarding social drivers of health, there should be data elements to document patient declined screening and/or declined intervention. These data elements should be harmonized with the HL7 Gender Harmonization work and the new data elements in the HTI-1 proposal.
• Data element to document occurrence and results of shared-decision making with the patient.
• Data elements to support patient-reported vitals by adding source and provenance attributes with clear value sets to represent “patient reported.”
• Data element to represent date of death in Patient Demographic or other appropriate data class.

Additionally, for measures that are not fully supported by USCDI+ or otherwise fully interoperable, we encourage ONC and CMS to either discontinue their use altogether or to accelerate work to map them to digital measures. 

 

Frequency of Updates

The AAFP recommends that the ONC organize its annual USCDI updates schedule in conjunction with the release of updated eCQM specifications for CMS programs to ensure optimal utilization of the revised data elements.++

In summary, we must move to a quality and performance infrastructure that is interoperable and robust to ensure we can measure what is meaningful to patients and physicians in a way that does not burden clinicians and health care organizations.

Sincerely,

Sterling N. Ransone, Jr., MD, FAAFP

Board Chair, American Academy of Family Physicians

 

[1] Halladay JR, Stearns SC, Wroth T, Spragens L, Hofstetter S, Zimmerman S, Sloane PD. Cost to primary care practices of responding to payer requests for quality and performance data. Ann Fam Med. 2009 Nov-Dec;7(6):495-503.

[2] Abraham JM, Oldenburg N, Eder M, Luepker R. Organizational Costs and Benefits of a Health System Quality Improvement Intervention to Increase Aspirin Use for Primary Prevention of Heart Attack and Stroke. Am J Med Qual. 2021 Sep-Oct 01;36(5):297-303.

[3]Casalino LP, Gans D, Weber R, Cea M, Tuchovsky A, Bishop TF, Miranda Y, Frankel BA, Ziehler KB, Wong MM, Evenson TB. US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures. Health Aff. 2016 Mar;35(3):401-6.

[4] Saraswathula A, Merck SJ, Bai G, Weston CM, Skinner EA, Taylor A, Kachalia A, Demski R, Wu AW, Berry SA. The Volume and Cost of Quality Metric Reporting. JAMA. 2023 Jun 6;329(21):1840-1847.

[5] CMS.gov. Aligning Quality Measures Across CMS – the Universal Foundation. https://www.cms.gov/aligning-quality-measures-across-cms-universal-foundation. Accessed June 22, 2023.