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2. Tales from the Measurement Front featuring the American College of RadiologyJune 28, 2018 Judy Burleson, MHSA Jason Itri, MD, PhD

3. Reminders • Today’s webinar is being recorded • The slides and a link to the recording will be posted on the PCPI website - http://www.thepcpi.org/?page=Webinarslist • Questions will be addressed during the Q&A following the presentation • Please submit questions during the presentation via the chat • Lines will be opened following the presentation

4. Today’s Speakers Jason Itri, MD, PhD Associate Professor, Wake Forest Baptist Medical Center Vice Chair, American College of Radiology’s Quality Measures Technical Expert Panel Judy Burleson, MHSA Senior Director, Quality Management Programs American College of Radiology

5. Drivers of New Measure Development Issues with existing measures: • Continued suitability • Low impact or variability in care • High CMS PQRS benchmarks • Identified as “topped out”

6. Drivers of New Measure Development Issues with existing measures: • Limited scope • Very specific, individual process of care • Dependent on administrative code sets • Relevance and meaningfulness questioned

7. Drivers of New Measure Development Issues with existing measures: • Narrow band of clinical topics • Radiologist sub-specialization limits applicability • Broader array needed • Allow flexibility to choose most meaningful measures

8. Topic Selection • Link to outcomes • Rigorous clinical evidence • Focus on developing measures based on strongest guideline recommendations based on the highest level of evidence • Address gaps/variations in care • Confirm importance of measure topic, potential for improvement • Address gaps in measurement • Avoid duplication, where possible • Identify opportunities to harmonize • Feasibility of data collection (ie, specification) and implementation

9. Topic Selection • Areas of impact for radiology • Appropriate use of imaging studies • Optimization of radiation exposure • Diagnostic accuracy • Effective and timely communication • Care coordination

10. Addressing the topics • Radiology report – rich source of clinical data for performance evaluation • Measure examples: • Interpretation of CTPA for PE - specificity of level of embolus • Appropriateness of follow up imaging recommendations for (pulmonary nodules) (benign adrenal masses) (cystic renal masses) (separate measures) • Surveillance imaging for liver nodules in patients at risk for hepatocellular carcinoma (US vs CT) • Use of low dose cranial CT or MRI for patients with ventricular shunts

11. Next steps • Specifications • Goal is to develop eCQM specifications but limitations with available electronic code sets and unstructured report text complicate the process. • Working to develop hybrid specifications with a combination of standardized codes (SNOMED, LOINC, et) and “registry data elements” – data element definitions, format, structure and values • Testing • Reliability and validity testing with PCPI support • May be one measure at a time depending on site commitment, resources and interest • Multiple sites have been identified • Submission to CMS under call for measures • Inclusion in QCDR

12. Challenges during the measure development process • Variability among members in understanding the process of quality measure development Multidisciplinary Technical Expert Panel Public Comment High priority area Environmental scan Gap analysis Measure development Measure testing Implement • Evaluate for existing measures • Eliminate disparities • Track to measurable outcomes and impact • Safeguard public health • Cost savings • Improve access for rural communities • Reduce burden • Specify numerator and denominator • Exclusions and exceptions • Data sources • Data extraction methods • Quality Improvement • NQF endorsement • MAP recommendation • Inclusion in CMS quality payment programs • Clinical practice guidelines supporting measure • Evidence of gap in care • Feasibility • Reliability • Validity • Importance • Unintended consequences

13. Challenges during the measure development process • Discussed measures before researching clinical practice guidelines supporting measures and evidence of a gap in care or variation in practice Background research on quality measures with practice guidelines and evidence of gaps TEP meeting – groups presented measures with evidence and rationale for discussion Specialty-focused subgroup

14. Challenges during the measure development process • No evidence of a gap in care or variation in practice (even though we know one exists!)

15. Challenges during the measure development process • Difficulties with measure specification – particularly with eCQMs Available only as free text within a radiology report

16. Challenges during the measure development process • Public comments sometimes reflected a lack of understanding about the purpose of measures

17. Key lessons Positives • It is deeply rewarding to be involved in quality measure development, knowing that the measures we develop now will influence practice in a way that improves the quality provided to patients by radiologists across the country • Changes in reimbursement to account for quality is a positive force • It gets easier over time!

18. Key lessons Negatives • The traditional approach to research, e.g. performed in a highly controlled setting, designed to minimize bias, and focused on determining optimal performance, does not reflect routine clinical practice and is often not designed to identify gaps in care or variations in practice • There is a clear need for more research in the quality measure domain, particularly when it comes to evidence of gaps in care and variation in practice • Constituents may not understand the requirements for quality measures or the reasoning behind specific measures

19. Final comments • Partner with someone who has been involved in the measure development process. Working with experienced ACR staff and PCPI support has been crucial to our success in developing 11 new quality measures for diagnostic radiologists • It is important that members have adequate time to learn the quality measure development process and perform the background research necessary for developing valid quality measures • The process has to be managed in a way that members don’t become frustrated with inefficient meetings and conference calls

20. Thank you! Questions?