The development of pediatric-specific quality measurements – especially those that focus on outcomes – has gained ground, although it is still hampered, in part, by the lack of electronic health records that are specific to pediatrics, say experts.
“Pediatric measures have historically lagged behind many of the adult measures,” said Dr. Ramesh Sachdeva , medical director for quality initiatives at the American Academy of Pediatrics and professor of pediatrics at the University of Wisconsin, Milwaukee.
In the adult population, the quest to encourage meaningful use of EHRs has spurred the blooming of a giant health IT industry, and the creation of adult-specific process and outcomes measures that populate adult-specific EHRs, said Dr. Sachdeva. Meaningful use has gained more widespread adoption among physicians treating Medicare patients – primarily adults – than among those treating Medicaid patients, which includes large numbers of children.
As of September 2014, some 431,000 eligible physicians had received incentive payments from Medicare for meaningful use since the beginning of the incentive program, according to the Centers for Medicare & Medicaid Services . By comparison, only 48,000 physicians have received Medicaid incentive payments since the start, said the CMS in a September report .
“We need to do some catch-up,” Dr. Sachdeva said in an interview.
Even among the biggest supporters of EHR use in the pediatric field, “development and implementation of functionality to promote quality of pediatric care specifically has been inconsistent,” according to a just-posted draft report on functionality of pediatric EHRs that was funded by the Agency for Healthcare Research and Quality. AHRQ, the AAP, and CMS all have issued sets of required elements for a pediatric EHR, such as immunization management; growth tracking; well-child visit tracking; medication dosing based on weight; data norms; and privacy, for adolescent populations, in particular.
“It is unclear whether pediatricians are adopting pediatric-specific tools, however,” said the AHRQ researchers. They found that only 31% of pediatricians use an EHR with basic functionality, and just 14% use a fully functional EHR. Only 8% of pediatricians are using a fully functional EHR with pediatric functionality.
A joint CMS-AAP effort – the Model Pediatric EHR – created over 700 pediatric functionality requirements. The “large number of requirements may have had a paralyzing effect on vendors,” wrote the researchers.
Jump-starting the quality effort
The federal government attempted to jump-start the measurement development process with the reauthorization of the Children’s Health Insurance Program in 2009. That law created the infrastructure and funding for the CMS and the AHRQ to establish the Pediatric Quality Measures Program .
The PQMP is made up of seven Centers of Excellence that are developing, testing, and then recommending quality measures for the outpatient and inpatient setting.
While there is increasing movement on developing both process and outcomes measures, “in order for quality measures to lead to improvement in health care, these measures must have clinical relevance to both pediatricians and families,” said Dr. Sachdeva, along with former AAP President Thomas McInerny and immediate past president AAP President James Perrin, in an article published in a recent Academic Pediatrics supplement that is devoted to the topic of quality in pediatrics (Acad. Pediatr. 2014;14(S): S10–11).
Karen A. Kuhlthau , of Massachusetts General Hospital, Boston, and colleagues from the AHRQ and the Children’s Hospital of Philadelphia, noted in another article that the value of measuring quality is no longer really questioned. “Measurement is a critical step toward achieving the triple aim of better care, better population health, and more affordable care,” they wrote (Acad. Pediatr. 2014;14(S): S1-3).
But they also discussed some of the challenges in developing those measures in the pediatric field; among those, that each Medicaid program may have a separate method of collecting data. The variety of methodologies makes it hard to standardize the conclusions and create a strong foundation for an evidence-based measure. Another avenue is patient-reported outcomes measures, which have the potential “for making measurement more meaningful by integrating the patient perspective and engaging more families in the quality enterprise,” wrote Dr. Kuhlthau and her colleagues. And yet, they have not “been extensively incorporated into quality measurement sets thus far.”
There are complications to including those viewpoints, wrote Dr. Christopher B. Forrest , a professor of pediatrics at Children’s Hospital of Philadelphia, and Dr. Jeffrey H. Silber , director of the Center for Outcomes Research at the hospital, in a separate paper (Acad. Pediatr.2014;14(S): S33-8).
“Patient and family priorities are not always aligned with clinician priorities for treatment outcomes,” wrote Dr. Forrest and Dr. Silber. In addition, “the perspective of the family varies markedly from that of society,” they said.
Ultimately, however, the value of care must include patient and family needs, Dr. Forrest and Dr. Silber wrote.
ADHD quality measure on horizon
Donna M. Woods at the Center for Healthcare Studies at Northwestern University, Chicago, and her colleagues there and at the University of Oklahoma Health Sciences Center, Oklahoma City, have been working on an outcomes measure that better assesses the quality of care for kids with attention-deficit/hyperactivity disorder – and measures what’s important to both patients and families – that is, improvement of symptoms and functionality, she said in an interview.
Dr. Woods noted that some 5 million children between ages 3 and 17 years have been diagnosed with the condition, and that the condition appears to be on the rise.
The first step was to conduct a systematic review of studies on the outcomes of ADHD treatments. That paper was published in the Academic Pediatrics supplement (Acad. Pediatr. 2014;14(S): S54-60). This type of review for ADHD therapies had never been done before, she said.
The gold standard for good quality ADHD care is improvement in symptoms, and every one of the 35 studies that met her study’s inclusion criteria showed improvement – regardless of whether it was a medication or behavioral therapy.
That literature review showed that “improvement in symptoms could provide the basis for the development of an outcome measure to assess the quality of care for pediatric patients diagnoses with ADHD,” Dr. Woods and her colleagues concluded.
Their work attracted some attention at CMS, which became interested in developing the outcome measure for stage 3 of meaningful use, Dr. Woods said.
The National Committee on Quality Assurance, along with a private consulting firm, has helped create such a measure and is now trying to test it, said Dr. Woods, who acted as an unpaid consultant for the project.
The testing has run into a bit of an obstacle – that it can’t really be incorporated into the adult-centric EHRs that are currently available.
EHRs, MOCs, ACOs all to help drive use
Even as pediatricians lag behind in use of EHRs – and as the market lags in providing a record that will allow them to measure what’s important in pediatrics – many clinicians are participating in quality through the maintenance of certification process.
There are 17 approved practice improvement modules (PIM) offered by the American Board of Pediatrics to clinicians who are maintaining their certification.
Among the ABP-approved PIMs are the ADHD initial diagnosis PIM and the ADHD follow-up PIM. Both are based on guidelines issued by the AAP in 2011.
“The maintenance of certification process is very important,” said Dr. Sachdeva, who said it was one of several things that would likely steer more pediatricians into adopting quality measures.
Also crucial is linking payment to quality, and the push toward integrated delivery systems such as accountable care organizations that will require quality documentation and improvement.
Dr. Sachdeva, Dr. McInerny, and Dr. Perrin wrote that to improve the quality of care and reduce the cost of care, it is critical “to assure that substantial numbers of these measures are adopted into the clinical practice of practicing pediatricians.”
This should not be too difficult, if they are given the right tools, said Dr. Sachdeva.
“I think the compelling argument for pediatricians is that it’s the right thing to do for children,” he said.
