Phreesia appreciates the opportunity to submit comments to the Office of the National Coordinator for Health Information Technology (ONC) regarding the US Core Data for Interoperability Plus (USCDI+) Quality – Draft Data Element List. Phreesia is the steward of the Patient Activation Measure® (PAM®), the only National Quality Forum (NQF) endorsed performance measure (PM) for gains in patient activation. Research and practice have shown that patient activation helps patients become more empowered in their care and increases the likelihood of the adoption of new healthy behaviors and engagement in self-management, ideally improving care outcomes, cutting health care spending, and ultimately reducing provider burden.

Level of Completeness

If the intent is to categorize PROs in the Health Status Assessment Data Class, Phreesia strongly recommends creating data elements within the Health Status Assessments Data Class that outline additional pertinent Data Elements related to Patient Reported Outcomes (PRO). Currently Health Status Assessment only includes Assessment Type, Value, and Time. However, this lacks the specificity that is needed for many PRO instruments and their associated performance measures. Alternatively, some PROs may be more appropriate depending on the nature of the PRO.

Phreesia suggests the following to improve the Health Status Assessment Category:

• For many reporting measures using PROs it is essential to understand what specific version and definition of the PRO is being used. For example, if Phreesia were to work with clients reporting the PAM Scores at 12 months, it is important to know which version of the PAM is being utilized for that measure, e.g., the PAM-10 or PAM-13. For this reason, Phreesia recommends that “Assessment Version” of the PRO be added to the Health Status Assessment as well.
• Phreesia recommends that a second data element should be added to specify whether an initial evaluation or a subsequent evaluation is being performed. Many PROs like the PAM allow providers to learn more about their patients over time as they track the scores and trend them. If the “Assessment Time” Data Element, is intended to capture this, that should be clarified.
• The current individual value approach does not allow for trending over time, which would reflect an increase or a decrease in two values collected at separate times. Phreesia recommends the addition of so “Assessment Trend” to capture this information.
• Phreesia recommends that the “Assessment Value” data element be further categorized to capture both a raw score and an interpretive value. For example, the PAM has a score on a 100-point scale, as well as a level of 1-4.
• Another Data Element to consider is whether the information is truly Patient Reported or is assumed by the provider. The gold standard of collection for race, ethnicity, language and PRO’s is collection from the patient, not through the lens of the provider or whomever else may be putting information in the electronic health record system. Therefore, adding an additional Data Element to each category that would reflect how the information was collected is recommended.

Inclusion of these new Data Elements to support PROs is important for several reasons. Most importantly, as a dedicated data class, it will disambiguate patient-reported information that has a distinct structure that should not be changed from the original questionnaires that are more about general history or assessment. This will prevent deviation from the structured tools that were designed to measure specific information, protecting the license holder as well as assuring data element fidelity for measurement.

Additionally, creation of the Data Elements to support Proms aligns with The Centers for Medicare and Medicaid Services (CMS) objectives. CMS has emphasized the importance of PROs to collect and measure valuable information to improve the quality of care. “...Ensuring that patients and families are engaged as partners in their care—one of the CMS priorities— can also be an effective way to measure the quality of patient care.”¹ PAM is an excellent example of why PROM collection is so vital for improved health outcomes. The information measured by the PAM is directly relevant to the process and outcomes of patient care as well as the success of the patient/provider relationship. Increased patient activation has repeatedly been shown to be associated with better patient clinical outcomes, mental health outcomes, medication adherence, disease self-management, and treatment satisfaction across several clinical specialties and chronic disease states. In fact, PAM scores predict most health-related behaviors, regardless of health status or conditions. Improved patient outcomes and experiences lead to decreased costs and provider burden as activated patients require less clinical intervention.

Lastly, creating a new additional Data Elements related to PROs in the Health Status Assessments is necessary to support the advanced applications of PROs. The PAM performance measure is currently utilized in two Center for Medicaid and Medicare Innovation Center (CMMI) model programs, Kidney Care Choices (KCC) and Maternal Opioid Misuse (MOM). Within the KCC program, one large provider group has seen a decrease in hospital admissions and readmissions which they attribute largely to increases in patient activation. ² Most recently, the PAM performance measure was recommended for CMS rulemaking for inclusion in the End Stage Renal Disease program as well as Merit-Based Incentive Payment System (MIPS) by the National Quality Foundation’s (NQF) Measures Application Partnership (MAP) following the review of the 2022 Measures Under Consideration (MUC) list.

Phreesia appreciates the opportunity to submit these comments for the addition of PROM specific data elements as a new Data Elements to the USCDI+ Quality Draft Data Element List. The PAM is an excellent example of a PROM that can be implemented at the point of care to improve patient outcomes and experience. We believe the addition of more detailed data elements that can be leveraged by PROs like the PAM would enhance the collection of data within the other elements on the USCDI+ list to further improve health outcomes through patient-centered care. We are happy to provide additional information and serve as a resource for ONC regarding patient activation and quality of care.

Sincerely,

Sarah Duggan Goldstein, DrPHc, MPH                                 Kasey McCreery NP-C MSHI

Director, Policy and Clinical Programs                                  Director, Clinical Documentation

1. https://mmshub.cms.gov/sites/default/files/Patient-Reported-Outcome-Measures.pdf
2. https://www.prnewswire.com/news-releases/somatus-achieves-certification-from-validation-institute-for-decreasing-cost-for-medicare-patients-with-improved-patient-activation-measures-pam-301679789.html