1. The 2nd P in P4P: Towards a Hybrid Data Strategy
Irene Fraser, Ph.D.. Director
Center for Delivery, Organization and Markets
Presentation to
Mini-summit on HIE and P4P
National Pay-for-Performance Summit
March 10, 2009

2. Accurate Measures and Data Are Fundamental for P4P
System Reform
and Redesign
for Quality
& Value
Incented
by payment and other incentives
Documented Results
Quality
Patient Safety
Efficiency
Access
ROI
For ALL Americans
Informed
by evidence and
models of successful
design strategies
Facilitated
by improved
HIT

3. Achieving Good Measures and Data Requires Multiple Bridges
Between…
HIT World
EMR World
Clinical data
Health Info. Exchanges
Measure developers
Medicare and Medicaid data
And…
Quality world
Claims data world
Claims data
State data orgs.
Data developers
Private payer data

4. AHRQ Work to Strengthen EMR Measures and Data
Work w/ NQF to add measures to EMR
Supporting HIEs
Grants to improve ambulatory care measures
Facilitating use of e-prescribing

5. Working from the Other Side: AHRQ Work to Strengthen Claims Data
Healthcare Cost and Utilization Project
Quality Indicators
Efficiency Measures
Public Reporting Template
Portals with software for local use

6. A Voluntary Federal-State-Private Sector Collaboration
The HCUP Partnership:
A Voluntary Federal-State-Private Sector Collaboration WA MT VT ND ME MN OR NH ID WI SD MA NY WY MI RI IA PA NV NE CT OH UT IL IN NJ CO DC CA WV MO VA KS DE KY NC MD TN AZ OK
One of the most fundamental things to understand about HCUP – one of the things that distinguishes it from most other data collection efforts – is that it is a partnership, a voluntary partnership.
This partnership model is unique and is an incredible strength. We (AHRQ) leverage the very substantial investments that are made by each of the statewide data organizations that contribute their data to HCUP. So for a relatively small investment, we are able to work in unison to create a national data resource.
But this also adds complexity. First, and foremost, it means that we work within the constraints set by our partners’ needs, rules and requirements. AHRQ and the statewide data organizations sign a MOA, which documents both of our responsibilities, as well as the intended and appropriate uses of the data. While AHRQ provides the resources (get back to this), ($ and staff) to support the project, HCUP must also provide value to our state partners. Statewide data organizations participate for a variety of reasons, but each must see a benefit to belong in the partnership. The benefit they see often resonates with their own capacities, mission, visions and budgets. We interact with our state partners regularly, and we bring them together yearly to update and discuss the project in person with them. (skin in the game)
Describe slide. We often are asked why not all the states – more than one answer to the question. NM AR SC AL GA AK MS
Legend TX LA
HCUP Partner FL
Potential Partner
Does Not Collect
Statewide
Inpatient Data
40 states in partnership
90% of all discharges HI
Not a Partner

7. HCUP Databases State Ambulatory Surgery Databases (SASD)
State Inpatient Databases (SID)
State Ambulatory Surgery Databases (SASD)
State Emergency Department Databases (SEDD)
As a quick review – you can see from this slide that the NIS is produced from HCUPs state-level databases. The NIS contains a stratified, random sample of community hospitals from all the SID in a single data year. All of the discharges (not a sample of discharges) from the selected hospitals are included. This database approximates a 20% sample of community hospitals in the U.S.
Nationwide Inpatient Sample (NIS)
Kids Inpatient Database (KID)
Nationwide Emergency Department Sample (NEDS)

8. What is HCUP? And what is it not?
HCUP is...
HCUP is not...
Discharge database for health care encounters
A survey
All payer, including the uninsured
Specific to a single payer, e.g. Medicare
Hospital, ambulatory surgery, emergency department data
Outpatient visits, pharmacy, laboratory
All hospital discharges
A sample
Accessible multiple ways: raw data, regular reports, on-line (HCUPnet)
Just another database
It is important to understand what HCUP is...and, what it’s not. (Read slide)
The raw data are the ascii flat files of the NIS and SID.
The regular reports are the SBs, Fand F, methods series technical reports
Online is the HCUP tools and software, HCUPnet, HCUP-US database, the TA

9. AHRQ Quality Indicators (QIs)
Developed at behest of state partners
Use existing hospital discharge data
Incorporate severity adjustment
Current modules: Inpatient, Patient Safety, Pediatric and Neonatal, Prevention
Include composites
Growing use for reporting and P4P
NQF endorsement for 40+ so far
CMS using 9 under new Inpatient Payment rule
Evidence-based public reporting template available
14 states use AHRQ QIs for public reporting

10. 14 States Use AHRQ QIs for Public Hospital Reporting
Wisconsin
(parts of state)
Vermont
Iowa
NewYork
Oregon
Ohio
Massachusetts
New Jersey
Kentucky
California
Utah
Colorado
Florida
Texas

11. Next Frontier: Measuring Cost and Efficiency
Evidence Review on Efficiency Measurement
Workshops on hospital efficiency measurement and physician-level public reporting
HSR issue on “Improving Efficiency and Value in Health Care”
New efficiency chapter in Nat’l Healthcare Quality and Disparities Reports
National admissions and costs for aggregate PQIs
Relative hospital cost efficiency index

12. Study Shows Cost-effective Enhancements to Admin. Data*
Assessed impact of incrementally adding more complex clinical information
Administrative data can be improved at relatively low cost by:
Adding present on admission (POA) modifiers
Adding numerical lab data on admission
Improved coding
AHRQ Awarded pilots in VA, FLA, MN, planning contract in WA to show proof of concept
We conducted a study under contract with Abt and Michael Pine and Associates, to identify the most cost-effective clinical data elements that could be added to administrative data for the purpose of publicly reporting hospital quality of care.
What we found was that:
Adding POA information (CMS rule – October 2007)
Adding lab data from the day of admission and
Improved ICD coding
Added nearly as much information to mortality models as full clinical information at a fraction of the cost.
* Pine M, Jordan HS, Elixhauser A, et al. Enhancement of claims data to improve risk adjustment of hospital mortality. JAMA 2007, 267 (1):
Jordan HS, Pine M, Elixhauser A, et al., Cost-effective enhancement of claims data to improve comparisons of patient safety. Journal of Patient Safety 2007, 3(2):
Fry DE, Pine M, Jordan HS, et al. Combining administrative and clinical data to stratify surgical risk. Annals of Surgery 2007 (forthcoming).

13. Administrative/Hybrid Data: The Future
Improve timeliness
Provide on-line all-payer market-level data on cost, quality, efficiency, price.
Add clinical detail, data links for accuracy, credibility
Expand outpatient reach (e.g. physician, episode)
Pilot cross-site data, new data links
New tools for expanded data
Additional states, as feasible
Develop, validate, maintain, deploy measures in priority areas
Expand data elements to align with levers of change
Tools for change
Some ideas that AHRQ will be exploring for this “joining forces” effort are:
Use HIT to improve the timeliness of the reporting of data to state Partner oraganizations
Add clinical detail to improve quality measurement, including an indicator of whether each diagnosis was present before admission to distinguish complications of hospital care from patient comorbidities. And a recent AHRQ-funded study shows that there are 20 lab test values that would greatly enhance the accuracy of the claims data for hospital quality reporting.
Expand statewide outpatient data, develop new data analysis tools for outpatient and clinically enriched data, and do this with continued vigalence of patient privacy and data security,

14. Frontier in All-Payer Claims Data: Data ACROSS Sites:
Hospital Data
ED Data
A. Surg. Data
Cross-site
Data

15. QI Reporting Template(s)
Challenge: Presentation Matters!!
Approach: Two Model Templates
Composite scorecard
Health topic/disease
Report Sponsors Choose:
Overall approach
Topics, composites, & measures to report
How scores will be calculated
The medium to be used
Model reports are based on:
Literature review and analysis
Interviews with experts
Focus groups with different populations
Cognitive interviews
The idea for the reporting template originated as a request from the QI user community. These reports are designed specifically to report comparative information on hospital performance based on the AHRQ QIs. There are two model reports, one developed in mid-2006, that groups individual indicators together and organized them into Health Topics. This first model is known as the Health Topics Model Report. The second model, known as the Composite Model Report was developed later in 2006, and is based on a set of four composite measures using a substantial portion of the IQIs, the PSIs, and the PDIs. These composites were created on the basis of substantial statistical analyiss as well as an expert review. 15

16. Preventable Hospitalization Costs: A County-level Mapping Tool
Potentially Preventable Hospitalizations cost over $30B a year.
Maps show the admission rates for health problems by county.
Calculates cost savings if admissions are reduced.
Can add information about local populations show number of persons at greatest risk for health problems in each county.

17. NEW! Portal for States, Communities, Others to Display, Analyze Data
Query paths currently in HCUPnet
Results based on AHRQ QIs
Preventable Hospitalization Costs mapping tool
New ways of presenting information
Beyond tables
QI Reporting Template
Other AHRQ tools? Other information?
Strategies for Improvement
The first version of EQUIP, which should go into beta-test early next year will contain some of the most popular AHRQ tools:
The query paths currently in HCUPnet
Results from the AHRQ QIs
And the Preventable Hospitalization Costs mapping tool
The intent is to present the information in an accessible, user-friendly way that relies on helpful use of graphics and reporting characteristics based on the best evidence currently available.
We hope to add more AHRQ tools in the future – such as CAHPS – and perhaps other information such as process measures from Hospital Compare.

18. Sites for Implementing Measures and Data: Chartered Value Exchanges

19. Coming Up Next: Starting some Bridge-Building
Janet Marchibroda – National View on Improving HIE
J. Marc Overhage – HIE and Pay for Performance
Linda Davis – Direct Submission of Clinical Data
Discussion