The American Medical Association (AMA) would like to thank the Office of the National Coordinator for Health Information Technology (ONC) for the opportunity to provide feedback on the United States Core Data for Interoperability Plus (USCDI+) Quality - Draft Data Element List.  

 

Level of completeness

 

The ONC's draft USCDI+ Quality data elements list is a good starting point for measuring the quality of critical health processes and outcomes. However, ONC can strengthen its USCDI+ data set by including average blood pressure (ABP).

 

High blood pressure impacts more than 120 million people in the United States. It is the leading modifiable risk factor for preventing cardiovascular disease and premature death. The accurate measurement and interpretation of blood pressure for diagnosing and assessing the effectiveness of treatment is imperative to improving the health of the nation. The value and improved accuracy of an average blood pressure compared to a single blood pressure reading has been demonstrated repeatedly through clinical evidence over the last 30 years (Chen et al., 2018). Due to physiologic variability, single blood pressure readings are suboptimal for clinical decision making. It is clear and affirmed in clinical practice guidelines (Whelton et al., 2018; Williams et al., 2018), scientific statements (Muntner et al., 2019), and policy statements (Shimbo et al., 2020) that obtaining two or more BP readings and calculating the average is a more accurate and representative measurement of an individual’s blood pressure compared to a single blood pressure reading.    

 

Physicians need health IT systems that can store and exchange average blood pressure separately from individual readings. This will lay the groundwork for consistent communication of needed patient information by easing documentation and enabling physicians to use this specific information in their clinical decision making. Electronic clinical quality measurement (eCQM) and clinical decision support (CDS) are closely related but are typically implemented independently, resulting in significant duplication of effort. Including ABP in both the USCDI v4 and USCDI+ will enable physicians to leverage the same data element, i.e., average blood pressure, for both CDS and eCQM reporting. This will also support the Department of Health and Human Services’ (HHS) efforts to streamline the development and reporting of digital quality measures.

 

The AMA strongly urges ONC to adopt the Average Blood Pressure data element in the USCDI+ as it is critical for the accurate measurement of blood pressure, essential in driving clinical decisions, and will support advances in quality measurement.

 

Level of specificity

 

To guarantee consistent and precise data element capture, ONC should furnish all measure developers and implementers with a comprehensive list of data elements referencing both their technical specifications and the instructions for their implementation. A publicly published, detailed data element list, together with implementation instructions, will help ensure that the data elements relevant to quality measures are prioritized for capture in discrete fields in various EHRs.

 

Frequency of updates

 

ONC should organize its annual USCDI update schedule in conjunction with the release of Centers for Medicare and Medicaid Services (CMS) eCQM specifications to ensure optimal utilization of the revised data elements.

 

Additional considerations

 

The AMA encourages ONC and CMS to be more explicit as to the intent of USCDI+ Quality. It is difficult to comment on a data set if the intent is not clear. For example, it is unclear of this set of data elements are meant to capture and harmonize what is already being used in existing quality measures, or if the intent is to start from scratch and establish a new standard set of data elements independent of what is currently used. If it is the former—harmonizing what is already being used—the AMA encourages a more thorough evaluation of data elements currently in use in quality measures. CMS has established a digital quality measure roadmap describing an expanded set of data sources beyond what is used for eCQMs.

 

If the intent of USCDI+ Quality is instead to create a new set of data elements irrespective of what is currently being used in quality measures, we suggest that a more thorough rationale is needed. The current data elements used in quality measures are based on extensive testing by measure developers and should not be superseded without due cause. We suggest that additional clarification of the intent of USCDI+ Quality would be helpful.

 

CMS has emphasized the necessity of a parsimonious set of freestanding quality measures for each specialty to be considered digital quality measures in the future. Yet, to be of maximum utility, the data element building blocks of these measures must be thoroughly vetted. Understanding the opportunities for improvement in data collection, and the limitations of current data elements, will be key. In either case, i.e., harmonizing current data elements or creating a new set, involving medical professionals and health care specialties will be critical in ensuring HHS’ USCDI+ efforts meet the needs of physicians, clinicians, and their patients.