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Contributing Writer · Aug 24, 2010

Hospital EMR usage can help achieve new Joint Commission accreditation standards

Measuring quality of care in hospitals is undergoing change. Two interrelated factors are fueling this change: changes from the Joint Commission as they accredit hospitals, and changes in what is expected from hospital Electronic Health Records(EHRs) for Meaningful Use.

In an article published August 12th in the New England Journal of Medicine, Mark Chassin, MD (president of the Joint Commission) and colleagues described how several measures of hospital quality used in the accreditation process miss their targets and fail to truly measure quality and reward “gaming.” In the article, four criteria that all measures of hospital care processes should meet are defined: (1) there should be strong evidence showing that the care process leads to improved outcomes; (2) the measure accurately captures whether evidence-based care has, in fact, been provided; (3) the measure addresses a process that has few intervening care processes that must occur before the improved outcome is realized; and (4) implementing the measure has little or no chance of inducing unintended adverse consequences.

Of the 28 Joint Commission “core” measures also used by CMS, 22 of them met all four criteria for useful accountability metrics – the remaining 6 measures did not. The Joint Commission promised to get rid of metrics the didn’t work. New measures would likely take their place. The authors stated that “fortunately, as the science has advanced, we now have a surfeit of measures that meet all four accountability criteria with which to populate accreditation, public reporting, and pay-for-performance programs.”

These criteria are not a “grading on the curve,” with the intent of failing a certain percentage of “students” – the measures become a standard of care for hospitals. If every hospital did well, then the quality of hospital care everywhere would be advanced. And most do – according to 2009 data, 85.9% of the 3,123 hospitals providing data to the Joint Commission had more than 90% compliance with these measures.

Simultaneous with the changes envisioned for Joint Commission hospital-accreditation, the Meaningful Use criteria for in-hospital EHR technology includes a set of Clinical Quality Measures (CQM). We previously commented on the CQM criteria for ambulatory EHRs – with reporting on 3 core measure (or 3 alternate core measures) and 3 of 38 “menu” measures being needed for Meaningful Use bonus money beginning in 2011. On the hospital-EHR side of the fence, there are 15 CQMs, all of which need to be implemented. Interestingly, 13 of these 15 measures are authored by the Joint Commission themselves, and coincide with Joint Commission accreditation criteria.

The CQMs for hospital-side EHRs fall into 3 categories: (1) measuring Emergency Department throughput processes; (2) measuring the management of patients with stroke; and (3) measuring the management of patients with a venous thromboembolism (or at risk for such). The simple measurement of Emergency Department throughput (the first domain of hospital EHR CQMs) has been shown to reduce wait times by 22%! Stroke management – using specific medications, engaging patients in true health education, and discharge planning about this condition – as well as prevention or treatment of venous thromboembolism are steps that reduce the cost, hospital readmission, and improve the quality of lives of patients with these conditions.

The evolution of quality metrics – both on the ambulatory side, as well as on the hospital side – are resulting in an evidence-backed array of process measurements that will, in fact, result in improvement of the health of Americans across the country. These measures are emerging as the de facto standard of care, which all settings of health care should achieve.

The onus is on developers of tools (EHRs and associated and interconnected health IT apps) to create products that are easy to implement, and accurately display performance on all these quality measures. For hospitals, it is a more onerous task, as they are often heavily invested in legacy technology that may not adapt very quickly – in fact, such hospitals will like assemble a collection of health IT Modules in order to achieve hospital-side Meaningful Use. On the ambulatory side, where web-based technology is more emergent, development of these kinds of tools and platforms may occur much more quickly.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR