January 18, 2011 CBCC Conference Call

Community-Based Collaborative Care Working Group Meeting

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Attendees

• Dorina Maris
• Suzanne Gonzales-Webb CBCC Co-chair
• Mary Ann Juurlink
• Milan Petkovic
• Richard Thoreson CBCC Co-chair
• Serafina Versaggi
• Tony Weida
• Craig Winter

Agenda

1. (00 min) Roll Call, Approve Minutes & Accept Agenda (postponed to January 25, meeting)
2. (30 min) Discussion - SHIPPs Project in 'Safety Net World' view , Richard Thoreson
3. (25 min) Action Item update

Action Items

• Action1: Regarding SHIPPS outreach - Serafina to report back on MITRE Corporation- response expected on Jan 21st, 2011.
  • Update: (no change) MITRE will get back to Serafina by 1/21st; at this point it is a tentative 'yes'.
  • They continue to be interested, as they are still looking for someone who has the time to represent them. Serafina to follow up (20110208) (email exchanges with Jean Standford)
• Action2: Regarding SHIPPS outreach - Richard and Serafina to present to EHR agenda working group. Since Gary Dickinson is traveling, this may not happen until February.
  • Update: Meeting at 3 p.m. today 20110208. Meetings with CoChair previously(date??) received approval for their co-Sponsorship. (is this in writing?) The WG however did not have quorum, expected to vote in today's meeting. (outcome?)
• Action3: CBCC to discuss format of SHIPPS publication prior by February 2011
  • Update: To be discussed during presentation 20110208 meeting SHIPPSProjectOverview.ppt
• Action4: In order to send PPS to Steering Division; approve PSS as complete e.g. accept all revision markers. Outreach still ongoing. - Mary Ann will send the PSS to the Steering Division for approval and send the revised PSS to David Hamill.
  • Update: Sent PSS to Steering Committee, email to Austin Kreisler, Edward Tripp and Davie Hamill Jan 12, 2011.
  • DESD electronic vote for the SHIPS was sent out on Sunday (Jan 23, 2011). The vote will run until quorum is reached or 3 weeks have passed, which ever comes first. About all that can done to speed up the process is to encourage work groups in DESD to submit a vote so the Steering Committee can achieve quorum quickly.

Mary Ann to follow up on status, e.g. SD approved, PSS sent to TSC? (20110208)

• Action5: Touch base with Ken Salyards (Floyd) requesting copies of QDS for NQF measures (retooled or otherwise) - Completed, we have the QDS spreadsheet.
  • Update: NQF received (by Mary Ann) by Ken
• Action6: The need to make the process, value add explicit (Mary Ann)
  • Update: We will include explicit discussion regarding the changing of measuring the process to measuring the outcome (20110208)
• Action7: Mary Ann to start reviewing behavioral data sets e.g. Safety Net information from 2 states, to be provided by Richard
  • Update: Something we will keep working on, we want quality measures and as much as we can outcome measures. Closed (20110208)
• Action8: Add a section to the implementation guide to speak to the limitations of the data and reporting in relationship to behavioral health e.g. checking validity of data through self-reporting
  • Update: Closed (20110208)
• Action9: To report back on PQRI
  • Update: Goals with PQRI. Voluntary physician driven enables providers
• Action10: Serafina to send Spain ontology recording with Security
  • Update: Craig to send out recording to CBCC list. (20110208)

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Discussion - SHIPPs Project in 'Safety Net World' view

Richard cautioned where the NQF would take us. The challenge with the retooled measures is that they are still in the fee for service mode of tying the quality measures to what information we can capture during the bill paying process. This will not take us very far. We need to be working to a point where we are sharing much more of the clinical data that surround the billing data and also emphasizes the integration of services across multiple providers. The goal in the US is to bundle services trying to go to Health Homes and to understand a pattern of problems, services and outcome data that we can use in order to assess quality.

Serfina: The information modeling we are doing here is talking about how we can use data being captured during the normal course of treatment that is in an EHR and how that data can automatically be used to generate measures against the data. Regarding the concern about it being patient centric and that most of this has been done using claims data; I would like to point out that we are seeing more EHR and clinical data repository being rolled out. The ONC information exchange group meeting focused on the Provider Registry. The use case for a provider registry is that it would allow a more comprehensive quality reporting for a provider, by being able to pull together all the quality measure data that might be found in various locations. The registry service would allow all of pertinent patient data to be pulled together. There are a number of infostructure functions and capabilities that need to be in place in order to look at data that is being collected in various locations and a patient centric way across organizations.

Richard: Billing is provider centric not patient centric.

Mary Ann: The emeasures is not a total solution, it needs to be applied to the EHR. We have different codes for billing and clinical. It is the QDS that provides the coding information we are using.

Richard: We are targeting QDS by trying to look at quality that is meaningful rather than quality that is measured in bits of information.

Mary Ann: As soon as someone provides us with the requirements for the clinical coding we can use it for these measures.

Richard: I am not talking about how to use a SNOMED code. I am talking about how we put information together by patient; you see a pattern of needs, a pattern of services and eventually the Safety Net World will have a fighting chance of pulling together all the relevant records for a client. PCAST is an ambitious attempt to light a fire under the whole system. The SHIPPS proposal needs to look at the Safety Net World, within a State where there is a single public payer. This means they are already collecting all the necessary data. What we are trying to do is to look at a whole pattern of needs in a community. The domain analysis model should capture the information underlying the pattern of needs in the community that is important to see in order to evaluate the effectiveness of a community behavioral health center.

CBCC is focused on the clinical however we can’t make sense of the clinical data in the EHR unless we talk about the integration of services in the community. That’s what missing from a lot of our measures of quality and let’s face it we don’t have measures for outcomes they are all self reporting nobody believes it. The problem we have is some kind of larger context here I believe a few states that do want to look at the whole set of needs, services and outcomes. This is where I am pushing you. I am fine with working with the NQF measures at the moment but the context of ‘why am I an alcoholic’ and there will be some reasons for ‘why’ that will not be addressed in the clinic. So we won’t get there yet but we will try and establish some markers, a framework so that we can see it from a public payer point of view, this is where the value is. If we work with KP and private payers there is a problem of not seeing it from a single public payer views e.g. can’t see outcomes.

Mary Ann: What work in being done in the US in defining protocols for Behavioral types of measures?

Richard: We have a proposal and hoping to work with one or two states. We would pull together a Safety Net person e.g. it will essential pull all records on a person e.g. income tax, criminal justice, school data, training …anything the state pays for. What you see is a whole pattern of needs, services and outcomes. Now we have something.

Mary Ann: Another project separate from SHIPPS is defining the problem and requirements for tracking a delinquent.

Richard: We will just worry about the data standard level across services. So much of the data a state may have is all behavioral data e.g. reflect on how I behave, how effective I am in my job etc. If we look at all these services we can tell which provider is doing a good job and which one isn’t.

Mary Ann: These data sets already exist then?

Richard: Of course, they have them in cans all over the place in the state government.

Serafina: We can look at the Federal Health Informatio Model(FHIM)behavioral model with respect to the quality measures.

Richard: We need to define behavioral problems more broadly than DSM diagnosis. If we do that then we will be a lot further ahead of what we are doing now. People are saying they are getting better but from a point of who is paying for the treatments they want to know if it makes a difference, in terms of all these other things a state is paying for.

Mary Ann: Currently we are creating a model for NQF measures and focusing on the implementation guide in order to have a clear sense of how it all works. Maybe we should look at a whole new area e.g. the behavioral area and it might add to our information model or it might be a different model.

Richard: You are flushing out clinical work flow or concepts that are needed in order to agree on how we are going to measures these things

Serafina: Let’s talk about the triggers that we need in order to do quality measures, and yes we need to look at all the other information that is related.

Richard: You will have a placeholder for behaviors, that is relevant to why you are in treatment

Serafina: As with the NQF there are stakeholders that determine what is quality. Who really is the authorizing body that will come up with this expansive definition? Is this something SAMHSA is defining?

Richard: No no, the hope is that let’s take criminal justice e.g. I am in treatment because I am in a court aversion program maybe for mental health problem. Measures could be different level of supervision.

Mary Ann: Looking at the model thus far everything you are outlining fits into it e.g. person information, procedure information etc. Is there a behavioral reporting data set that we could have access to?

Richard: SAMHSA is terribly underdeveloped in this area.

Mary Ann: I am interested in the kinds of behavioral information and reporting and how fits into what we are already doing or if there are concepts we are missing. You also said that 2 states already have projects underway it might be something we can use to test our model.

Richard: South Carolina has a data warehouse where they combine a lot of the Health and Human Services (HSS). Washington State is doing similar work but not sure how they are pulling it together, starting to talk with Minnesota. Everybody wants to do it and some have taken first steps. This raises huge privacy issues that need to be talked about. In the single public payer world (Safety Net) you have to trust the state is going to be able to protect the data, we need rules about how the information is made available.

Serafina: The Natioal Information Exchange Model(NIME)reference architecutre already have standard information models that we can use and integrate this information. What we are really interested is the process they use.

Richard: Flush things out e.g. the concepts that we need to measure, people might think that this is intuitively obvious.

Serafina: These relationships are not obvious. The analysis will reveal gaps in functionality and how EHRs are currently working.

Richard: In the EHR world within the Safety Net bank you have a lot more information than you would have in a usual clinic. We already have this information because we are coordinating care for criminal justice.

Mary Ann: We can keep our vision big; however we do a complete run through e.g. description, information model of the NQF, QDS and calculate the measures. We also need to put our preliminary work through a Draft for Comment.

Richard: We should put something in there about the validity of the data e.g. self-reporting data to reflect subjectivity. In Behavioral Health it is harder to get concrete measures vs with heart problems indicators, which have pretty objective indicators. Need to build this into our domain analysis that even though these are reported out there are certain validation steps we need to do.

Richard: Are the EHR working groups moving to develop an information model for their each of their functional domains?

Serafina: They certainly want to be aware of the impact of SHIPPS; we anticipate gaps in EHR functionality. Significant gap in recording

Serafina: MITRE to get report back to Serafina on Jan21 so will be able to update next week. They will be able to provide a person to track the SHIPPS project, it is a tentative yes.

Richard: The MITRE connection started by Richard had to do with their Privacy work.

Serafina: I see this information model dealing with the quality measures and it will also tie in the privacy classes and attributes that are related. We want to ensure that we have an information model with relationships to everything that fits together.

Richard: In order to protect privacy somehow.

Serafina: We are talking about how to do that and it is through data segmentation.

Richard: Privacy still needs to be in the mix.

Serafina: We will also look at the FHIM behavioral model, at all those Safety Net kinds of areas that intersect directly with behavioral health e.g. education, criminal justice

Richard: The SHIPPS value add – we will make explicit what needs to go into the EHR so standardized measures can be processed. In a billing environment the information does not mean the same thing, people are gaming the systems all the time.

Serafina: The information is being collected as a byproduct of whatever information they can gather electronically for the purpose of sending a claim and whatever minimum data that people need to report for various quality reports and regulatory reporting. Often times they are being asked for information that is not captured in their systems with clear relationships between the data that allow for true value of reporting; so they report whatever they can. This is the best that there is.

Richard: Compromises are being made at the end of the day in reporting. The real thing may look different, and could affect refurbishment rate.

Mary Ann: The reporting and how they got the information may be questionable but we don’t have any control over that at this point in time. The next step with the eMeasures work we are doing is to look at behavioral scenario you describe so that the measures we look at will be applicable to self-reporting.

Richard: We can reflect gaps we are seeing now in the modeling.

Serafina: That is the purpose of this small step and the reason that the EHR working group is interested in SHIPPS e.g. we need a data profile to go along with the functional profile of the EHR functional model. We are going to show a model of how you can automatically obtain this information from an EHR based on what they are trying to report on. It may show that you cannot automate; this is where the maturity model comes in e.g. the data is not captured in a structured encoded manner or the relationship between the information isn’t being stored in such a way that you can automate the reporting as the data does not have the same meaning.

Mary Ann: We need to add a section to speak to the limitations of the data and reporting in relationship to behavioral health.

Richard: What is missing in the traditional physical health environment is a whole set of variables having to do with compliance or risky behaviors, things that are contributing to the costs / poor outcomes of care.

Mary Ann: Go forward strategy with respect to the limitations of the data itself.

Richard: Simplest thing to talk about is how we can integrate the care information of a patient overtime. Build in compliance outcomes e.g. someone is providing much better care which could relate to payment. We need to look at population care e.g. providers care of Safety Net populations.

Mary Ann: We need a driver for requirements to create a profile.

Richard: Talked to John Ritter regarding the PHR because this is where is gets consolidated e.g. a PHR within a state banking system. Data warehouse of information, every patient every client overtime. Now you have real information, you don’t have to rely on self-reports, you don’t have to rely on reports of one provider. Overtime some provider’s physical health wise do better than other providers, why is that? Perhaps they do a better follow up with the patient, establish a better relationship with the patient?

Mary Ann: This gives us something to think about certainly in forming out next steps.

Richard: Getting out of the US domain fee for service mind set, it is very constrictive.

Richard: PQRI was going to be a complement to the NQF?

Meeting was adjourned at 3:00p.m. EST