TECH CORNER: May/June 2013

Challenges in Quality Measure Reporting

Dictionary.com has a host of definitions for “quality.” Among these definitions you will find “character with respect to grade of excellence” and “providing products or services of high merit.” You likely have a definition that comes to mind when you think about quality in products or services that you purchase or experience in your personal life. For example, we all recognize quality craftsmanship in furniture and in automobiles, or quality food service at a dining establishment. These definitions focus on attainment or excellence in regard to internal or external standards of performance.

But how do you define “quality” in your practice? Might it be measured by the average wait time your customers experience, by the percentage of patients offered additional clinical services, by the hundreds or thousands of prescriptions accurately filled between misfills, by the percentage of patients receiving medication doses outside of recommended doses, or by some other measures?

Maybe you have mental metrics that you use to continuously evaluate your practice. These metrics may focus on customer experience, while others focus on financial issues, and yet others focus on the employee experience. You can bet that even if you have not given these metrics much thought, your patients have. While their perspective may be different from yours in many ways, they still want a quality experience from your pharmacy.
Other groups are closely examining the concept of quality in community pharmacies. One group is aptly named the Pharmacy Quality Alliance (PQA). Established in 2006 and composed of over 100 member organizations, PQA’s stated mission is to improve patients’ medication outcomes by developing and implementing performance measures directed at quality in pharmacy practice (www.PQAalliance.org). The impetus behind PQA is to put pressure on and raise expectations of health plans to demonstrate that their covered patients are receiving quality care. The sources of this pressure include the federal government, employers, and patients themselves. In particular, the Centers for Medicare and Medicaid Services is evaluating all Medicare Part D plans on medication-use quality, and this is generating significant attention by the prescription drug plans. PQA’s member organizations represent virtually all groups associated with pharmacy, from professional organizations and the large community pharmacy chains to health information technology vendors and health plans.

Performance Measures The guiding philosophy behind PQA’s efforts is that a collaboratively constructed set of performance measures can reflect high-quality pharmacy practice. PQA’s performance measure development focuses on national priorities as defined by the National Quality Strategy, which is an 
effort to align public and private interests to improve the health of Americans. Priorities are general in nature but are consistent in that they apply to all Americans. The initial six priorities can be found online at http://www.ahrq.gov/workingfor quality/about.htm#develnqs and are listed verbatim below. You can find much more information about the National Quality Strategy at http://www.ahrq.gov/
workingforquality/index.html.

  • Making care safer by reducing harm caused in the delivery of care.

  • Ensuring that each person and 
family is engaged as partners in their care.

  • Promoting effective communication and coordination of care.

  • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

  • Working with communities to promote wide use of best practices to enable healthy living.

  • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models.

While these priorities are general in nature, one current area of more intense focus for PQA is medication adherence. We all know that medication adherence is a significant problem that simply has not yet been solved. So what might the efforts in this area mean for community pharmacy practice? We have spoken with some of your colleagues, and many have been largely unaware of PQA’s work. After learning about the alliance’s efforts, the general consensus is in agreement that much work remains to be done to improve medication-related outcomes for patients in the community. Adherence is considered to be a good place to start. 

A quick scan of the PQA site (http://pqaalliance.org/
measures/default.asp) reveals what constitutes the measures of adherence. The site, in an apparent spirit of transparency, lists all current measures as well as those under consideration. Other measures address medication use quality in terms of the presence of drug-drug interactions, the use of medications in high-risk populations, and clinical guideline adherence. Like us, those who review the measures will likely find them sound and to reflect goals that we should strive for in community pharmacy practice.

The Challenges 

We anticipate two primary challenges with the measures. One is technical and the other is not. The technical challenge is the development of a mechanism to efficiently and accurately capture, analyze, and share the data that make up the measures. If the goal is to look at quality in a broad swath of community pharmacy practice, then quality measurement data must of course come from a diverse representation of practice. Put another way, if quality measurement data are going to reflect practice, they should originate in a variety of practice settings. Additionally, these data would ideally be captured, stored, and transmitted, in a structured manner that allows interoperability between the systems where they originate and the analytic and reporting systems where they become meaningful. Understandably, users (payers, pharmacists, etc.) must have confidence in the system’s security. 
PQA has developed a platform to perform these tasks. Visit www.equipp.org to learn more about the Electronic Quality Improvement Platform for Plans & Pharmacies. On the site, you will see that the platform is designed to provide standardized, unbiased performance data on agreed-upon quality metrics. Benchmarking is provided to allow participants to identify where they fit compared to their peer group. As we write this on the 20th birthday of the World Wide Web, we have to smile at the capabilities provided by the most important graphical user interface the world has known.

As is often the case with technology-based solutions for practice-related issues, the larger challenge may not be technical. PQA describes a future state in which the EQuIPP system will help providers and payers identify and strategize methods to address deficiencies in quality of medication use. The goal is to create an efficient quality feedback system that enables pharmacists to identify opportunities for quality improvement and track their performance as they implement changes in their practice. This approach fits with the move toward value-driven care and the growing trend of performance-based payments for providers. Community pharmacists should anticipate that a portion of their payment in the future would be dependent on achieving quality targets related to medication adherence and safety. The concern expressed by some is that the platform could simply be additional “paperwork” (albeit electronic) for pharmacies, and that the system will be used to penalize pharmacies for not achieving quality instead of rewarding for quality that is achieved. Many of the measures we have mentioned can be gathered as a byproduct of analyzing the transactions performed by your pharmacy management system, and flags can be generated in exception reports. EQuIPP does not require any additional paperwork or reporting by pharmacies, since the measures are calculated with existing data.

Our crystal ball does not tell us what will happen. Available information suggests broad stakeholder participation in the initiative. Our hearts truly hope that the initiative will lead to advanced status for pharmacists and new avenues of reimbursement. Active involvement in one (or more) of the participating organizations is the best way to have your voice heard. We also encourage you to let us know what you think. CT

Bill G. Felkey, M.S., is professor emeritus, and Brent I. Fox, Pharm.D., Ph.D., is an assistant professor, Department of Pharmacy Care Systems, Harrison School of Pharmacy, Auburn University. They can be reached at felkebg@auburn.edu and foxbren@auburn.edu




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