Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives
Appendix C. Glossary
Aligning Forces for Quality (AF4Q): AF4Q, sponsored by the Robert Wood Johnson Foundation, helps participating communities achieve sustainable health care quality through multi-stakeholder local alliances. These alliances focus on three intersecting program areas: (1) developing local quality improvement resources to help health professionals improve care, (2) helping the public to use appropriate information in making health care decisions, and (3) working to increase performance measurement and public reporting of those measures. AF4Q communities actively promote nurse leadership in the effort and also focus on reducing disparities in care for racial and ethnic groups.
Better Quality Information to Improve Care for Medicare Beneficiaries (BQI): The BQI Project is a Centers for Medicare & Medicaid Services (CMS)-funded project in which the Delmarva Foundation for Medical Care subcontracted with six community collaboratives as pilot sites. These pilot sites tested methods to aggregate claims data from Medicare, commercial health plans, and, in some cases, Medicaid. The data were used to calculate and report quality measures for physician groups and, in some cases, individual physicians.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®): Supported by AHRQ, the CAHPS program is a public-private initiative to develop standardized surveys of patients' experiences. The surveys cover ambulatory care (medical groups, individual clinicians, mental health providers, and health plans) and facility-level care (hospitals, nursing homes, and dialysis centers). Surveys consist of core and supplemental questions concerning access and wait times, patient-doctor communication, trust, continuity of care, coordination between primary care physicians and specialists, referrals, preventive care, experiences with office staff, and demographic characteristics. Health care organizations, public and private purchasers, consumers, and researchers use CAHPS results to assess patient-centered care, compare and report on performance, and improve quality of care. CAHPS survey results can be obtained through AHRQ's national CAHPS Benchmarking Database, the National Committee for Quality Assurance, the HQA Hospital Compare Web site, and other public report cards.
Chartered Value Exchange (CVE): A CVE is a multistakeholder community quality collaborative composed of public and private payers, health plans, providers, and consumers so designated and supported (in-kind) by the Department of Health and Human Services (HHS) and AHRQ. In aggregate, the 24 AHRQ CVEs involve 600 health care leaders and represent more than 124 million lives, or more than one-third of the U.S. population. CVEs are intended to increase transparency and accountability by providing public information about the cost and quality of health care; they benefit from peer-to-peer interaction supported by AHRQ's CVE Learning Network. CVE stakeholders drive the content of the Learning Network technical assistance, which includes the following eight areas:
- Collaborative leadership and sustainability;
- Public at-large engagement;
- Quality and efficiency measurement;
- Public reporting;
- Provider incentives;
- Consumer incentives;
- Coordinated cross-organizational, cross-stakeholder quality improvement; and
- Health information technology/health information exchange.
Community quality collaboratives: Community-based organizations of multiple stakeholders that might include health care providers, purchasers (employers, employer coalitions, Medicaid, and others), health plans, and consumer advocacy organizations that work together to improve health care at the local level. These collaboratives vary in level of sophistication and degree of organization.
Denominator: The lower part of the fraction used to calculate a rate or ratio using the total population of interest.
Diagnostic Cost Groups (DCGs): Diagnostic Cost Groups classify diagnoses from administrative data into clinical groupings to create an aggregated measure of expected resource use. The measure, called a “relative risk score,” is calculated at the individual patient level and quantifies the financial implications of the patient's total “illness burden” or morbidity.
Diagnosis-Related Groups (DRGs): Developed for Medicare as part of the Inpatient Prospective Payment System, DRGs classify hospital discharges into one of several hundred groups expected to have similar hospital resource use. DRGs are assigned by an annually updated “grouper” program based on ICD-9-CM (defined below) diagnoses, procedures, age, sex, discharge status, and presence of complications or comorbidities. In the current version, known as Medicare Severity DRGs or MS-DRGs, cases with a single diagnosis or major operating room procedure are often classified into one of three mutually exclusive severity levels: with major comorbidity or complication (CC), with CC, or without CC.
Electronic health record (EHR): In health informatics, an electronic medical record (EMR) is considered to be one of several types of EHRs, but EMR and EHR are also used interchangeably. EHRs are sometimes defined as including other systems that keep track of medical information, such as practice management software that facilitates the day-to-day operations of a medical practice. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payers, perform billing tasks, and generate reports.
Healthcare Effectiveness Data and Information Set (HEDIS): HEDIS is a set of standardized measures designed by the National Committee for Quality Assurance to evaluate the quality of health care and service provided by health plans and physicians.
Healthcare Cost and Utilization Project (HCUP): HCUP is a family of health care databases and related software tools and products developed through a Federal-State-industry partnership and sponsored by AHRQ. HCUP databases bring together the data collection efforts of State data organizations, hospital associations, private data organizations, and the Federal Government to create a national information resource of service-level health care data (HCUP involves a number of partners).
Health information exchanges (HIEs): HIEs provide the capability to move clinical information electronically between disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIEs is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIEs also provide the infrastructure for secondary use of clinical data for purposes such as public health; clinical, biomedical, and consumer health informatics research; and institution and provider quality assessment and improvement.
Health information technology (HIT): HIT provides the umbrella framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government, quality entities, and insurers. HIT in general is viewed as a promising tool for improving the overall quality, safety and efficiency of the health delivery system.
ICD-9-CM: International Classification of Diseases, Clinical Modification (ICD-9-CM) is a classification used to assign codes to diagnoses associated with hospital, laboratory, and physician office utilization in the United States. The ICD-9-CM is based on the World Health Organization's ICD-9 but provides additional morbidity detail and is annually updated. In addition, the Cooperating Parties that created ICD-9-CM added a volume with procedure codes.
Institute of Medicine (IOM): The Institute of Medicine (IOM) is a not-for-profit, nongovernmental organization chartered in 1970 as part of the National Academy of Sciences. Its purpose is to provide national advice on issues related to biomedical science, medicine, and health, and its mission is to serve as adviser to the Nation to improve health. IOM provides independent guidance and evidence-based analysis, relying on a volunteer workforce of scientists and other experts operating under a rigorous, formal peer-review system.
The Joint Commission (TJC): The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations, is a private nonprofit organization that evaluates health care facility compliance with Federal and industry standards through its accreditation process. The declared mission of this organization is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.”
Leapfrog Group: Leapfrog is an employer-based group that seeks to “trigger giant leaps forward in the safety, quality and affordability of health care.” Leapfrog surveys hospitals and scores their adherence to 13 of the 27 safe practice areas identified by the National Quality Forum. The Leapfrog survey also includes items about adherence to evidence-based processes of care for several high-risk conditions and procedures. The results are posted at www.leapfroggroup.org/ for public use.
National Health Information Network (NHIN): The U.S. Department of Health and Human Services awarded contracts to four groups of health care and health information technology organizations to develop prototypes for NHIN architecture. The contracts awarded to these four consortia are designed to move the Nation toward the President's goal of personal electronic health records by creating uniform architecture for health care information that can follow consumers throughout their lives.
Mean: In statistics, the mean is the mathematical average of a set of numbers. The mean is calculated by adding two or more scores and dividing the total by the number of scores.
Median: A median is described as the number separating the higher half of a sample from the lower half. The median of a finite list of numbers can be found by arranging all the observations from lowest value to highest value and picking the middle one. If there is an even number of observations, the median is not unique, so one often takes the mean of the two middle values.
Medstat Medical Episode Groups® (MEGs): Medstat's MEG is a commercial software package that enables health plans to analyze patient treatments, evaluate quality of care, and manage associated costs. It does so by grouping inpatient, outpatient, and pharmaceutical claims into clinically homogeneous units of analysis called “episodes.” Each episode describes a patient's complete course of care for a single illness or condition. Results are used for provider profiling, disease management, quality improvement, and cost and utilization analyses.
Numerator: The upper part of the fraction used to calculate a rate or ratio using a subset of a population of interest (e.g., those patients with a heart attack who received bypass surgery).
Pay-for-performance (P4P) programs: P4P is a strategy to improve health care delivery that relies on the use of market or purchaser power. Depending on the context, P4P refers to financial incentives that reward providers for the achievement of a range of payer objectives, including delivery efficiencies, submission of data and measures to a payer, and improved quality and patient safety.
Physician thumbprint: A term used to describe individual physician effect on quality of care. It can be expressed as a composite measure of various metrics influenced more by physicians than patients.
Quality Improvement Organization (QIO): QIOs are private organizations that implement improvements in the quality of care for their State or region and respond to quality-related complaints from Medicare beneficiaries. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, CMS identifies the core functions of the QIO Program as improving quality of care for beneficiaries and protecting the integrity of the Medicare Trust Fund. QIOs help ensure that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting. QIO responsibilities also include addressing reported violations of the Emergency Medical Treatment and Labor Act (EMTALA) and other related responsibilities as articulated in Federal law.
Regional Health Information Organizations (RHIO): RHIOs are multistakeholder organizations responsible for integrating health information exchange in the United States. RHIOs seek to affect the safety, quality, and efficiency of health care as well as access to health care through health information technology. RHIOs are a specialization of HIE.
Risk adjustment: Risk adjustment is a statistical process used to identify and adjust for variation in patient outcomes that stem from differences in patient characteristics (or risk factors) across health care organizations. Depending on the presence of risk factors at the time of health care encounters, patients may experience different outcomes regardless of the quality of care provided by the health care organization. Comparing patient outcomes across organizations without appropriate risk adjustment can be misleading. By adjusting for the risks associated with outcomes of interest, risk adjustment facilitates a more fair and accurate interorganizational comparison.
Relative Value Units (RVUs: Medicare uses a physician fee schedule to determine payments for more than 7,000 physician services. The fee for each service depends on its relative value units (RVUs), which rank on a common scale the resources used to provide each service. These resources include the physician's work, expenses of the physician's practice, and professional liability insurance. To determine the Medicare fee, a service's RVUs are multiplied by a dollar conversion factor. Estimating and updating the RVUs is a labor-intensive process because there are no readily available, up-to-date data on the resource requirements of each service.
Symmetry Episode Treatment Groups (ETGs): Symmetry Episode Treatment Groups® (ETGs®) is another example of commercial software that classifies health conditions and groups related treatment by episode of care.
Taxpayer Identification Number (TIN): A TIN is an identification number used by the Internal Revenue Service (IRS) in the administration of tax laws. It is issued either by the Social Security Administration or by the IRS. As the financial entity that receives payment on physicians' behalf, it does not necessarily correspond to a physician practice site or even a physician organization.
Unique Physician Identification Number (UPIN): The UPIN is a unique number for each physician and limited licensed practitioner who is enrolled in the Medicare program. Each UPIN can be associated with a practitioner's full name, specialty, license number, ZIP Code, and State.