Expanding Quality Metrics to Include Telehealth

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In 2017, the National Quality Forum (NQF) developed a framework that provides a guide to the development of measures that assess and evaluate telehealth in the areas of access to care, cost, effectiveness, and the overall patient/provider experience.

Join Jason Goldwater, MA, MPA, PMP, Senior Director, The CedarBridge Group, LLC, as he leads a discussion on how the framework was created, the way the framework can be effectively utilized, and the next steps in developing robust quality measures to provide unparalleled insight into the effect of telehealth on patient outcomes of care.

This event was recorded on February 15, 2018. It will require approximately one hour of your time.


Follow-up Participant Questions:

Q: We should not look at chronic conditions and behavioral health as separate categories rather they are inextricably interconnected. For example, untreated behavioral conditions impede or prevent chronic medical condition recovery or improvement, hence significantly driving up health total care costs. Can you comment?

A: I could not agree more. Here’s the issue, however. While there has generally been a lot of enthusiasm and widespread acceptance of the framework, a couple of things that I’ve been asked is could we narrow the framework down a bit and create smaller frameworks. One that many ask about is mental and behavioral health and to do that as a separate category. So why did they ask that? There were a couple of reasons.

They were telling me that they see more of those cases than anything else, and that there are more, particularly on children and adolescents. They’re seeing more untreated mental health conditions in which telehealth provides a significant advantage. There are a lot of vendors that are out there that provide these types of services and there are also some restrictions upon the types of reimbursement that is delivered through these services even though they are being provided almost disproportionately to others in certain rural and urban communities. As a result, they said there would be a great benefit to having a guide to measure concepts around mental and behavioral health that really understood the impact of telehealth, specifically in this area not just in the areas that we mentioned.

For example, there’s been a lot of research written about the effect of cognitive behavioral therapy on anxiety. If you’re providing that through telehealth, what are the benefits that accrue from that? What are the benefits of telehealth and reducing substance abuse? What are the benefits of telehealth of reducing some overuse of opiods that may be caused through mental and behavioral health conditions?

So, I think what I was taking away from that was that while I agree they are very much linked, and we shouldn’t necessarily look at them separately all of the time, I think in some cases, looking at them separately is fine for no other reason than it will drive greater policy change. If you know the reimbursement rules are relaxing a little bit, and mental health is one of those issues that they haven’t in. So if we’re going to get them to try and increase reimbursement and remove some of these originating site restrictions and really understand what those benefits of telehealth would be on mental and behavioral health, then we do have to separate them out. But I think that would be for a very designated purpose. I think there’s also measures we could do when they are linked together.

Q: What do you think about the future of teletherapy online behavioral health?

A: I think that’s the biggest growing field in telehealth at the moment. I think that again, not coming from me, but coming from people that are practicing. I think that’s where we can show the greatest impact of telehealth. I said this before, mental health is always an issue that those of us in health care talk about, but generally overall, we don’t talk about it until something tragic happens.

So now, mental health is on everybody’s mind because of the incredibly tragic shooting that occurred in Florida yesterday, and it brings to bear again why mental health services need to be widely accessible and why those interventions need to be done as early rather than later. Telehealth provides the way to do it. There have been numerous studies showing the impact telehealth on children and adolescents with eating disorders, depression, anxiety, suicide ideation, and so forth.

If we’re going to try to make a greater impact on mental health services, we have to be able to show that telehealth is one of best, most effective ways of doing that. We have to show understanding of what those impacts are and what those discriminators are to really change policy, and really change quality, and to change people’s minds.

Q: Are the core metrics described something that has taken hold nationally? In other words, are we working towards a nationally accepted core set of measures that fit the criteria of benefiting patients and providers?

A: Yes. We are starting to work towards that. CedarBridge is in talks to hopefully begin a project that would take that framework, leverage a number of people that were on that committee, and start to narrow down those concepts into specific core measures that could be used.

Since I’m not with NQF anymore, the sort of regulatory restraints of not being able to develop measures no longer applies to me. I would love to work with the committee and build out a set of measures, get public comment back on those, and have those cover priority areas and be able to distribute those nationally to all of these resource centers as well as practitioners so that then we could start to develop a national evidence base of what the benefits of telehealth are. I can’t get into anymore specifics at this point, but I am saying that we are working on this. When I have some news that I can share, I will share it with all of you.

Q: Do you think that outcomes measures are generally a logical progression from quality measures?

A: I do. I think the big focus on quality measures is on patient outcome. There’s three different ways of measuring quality of care. You can measure the structure, there’s a support quality effort, the process – does a provider or caregiver do X that leads to Y or an outcome. If you do X, the outcome is this. The emphasis of CMS and this was reinforced at their quality conference. They want to focus almost exclusively on outcomes. They want to examine outcomes from the patient’s perspective as well as the providers. So I think the strongest argument for telehealth in terms of understanding its utility, its benefit, an its effectiveness is to look at the particular clinical outcomes. If a provider uses a modality to interact with the patients and engages in a practice that is grounded in evidence, does it lead to a clinical outcome that would be identical to that if they saw them in person. In some cases, we’ll probably have to use some process measures because those also would be underscoring what the benefit in utility is. I think what people really want to know in the telehealth space is would the clinical outcomes be identical. There’s lots of people who say of course they would, but that’s why you measure it so I understand what would be, what wouldn’t be, and those that are falling short why and what could be done to again correct those positions.

Q: Would you comment on the recommended effect sizes for every domain. They are rather new and may require an inferential calculation.

A: I think that’s hard to know at this point in time. In your eyes, they’re very broad and you know what the weight of all of those would be. It’s sort of difficult. I think we would have a much better understanding of that when we’re able to take the concepts and start to build them into actual measures. Then we’ll have a better understanding of sort of portion and impact and again the types of data that could be collected. What that overall sample size would be and so forth. I think right now, you know it’s conceptual. It was designed to be perpetual so it’s how we actually have specific measures.

Q: Do you have a few standard set of questions that hospitals or ambulatory clinics can add to existing patients experience surveys that have been tested for how the questions are asked to get at patient experience.

A: Yes, we did some exploratory work on how the CAPS survey was the most widely used patient experience survey, satisfaction survey, and how telehealth could be incorporated into that. But then there was sort of this other discussion of should it be it’s own separate independent instrument. I’m not sure. I would want to see how we’re going to measure experience of care from a patient and provider perspective, and if we have measures that are aligning themselves with instruments like CAPS, then yes, we should be incorporating those. I don’t think there would be a lot of business.

If we find that the measures are really looking at something unique to telehealth, and we don’t find an acceptable instrument to incorporate them into, then we might have to do something different. It’s preferential to use what’s already there. Creating an instrument to get a patient experience is a trying process. It would be great if we were able to incorporate that into instruments that are already there and to be able to pull the data elements directly from them.

Q: Doing this work and this project, were there any great surprises that you discovered? You mentioned 2500 clinical measures already in place. 

A: I don’t think that there were any major surprises. From my personal perspective, I’ve know for a while that there are a glut of measures that come from identifying the ability to create measures not having a lot of parameters around priority areas and letting everyone develop. Then you choose which ones you would be developing for endorsement.

Developing measures is certainly not a bad thing. Having more than not enough is always preferable. What surprised me was what the priority areas. I figured that travel and timeliness would be one because those fit into AXA, I was surprised about how much the committee wanted to be focused on actionable information, and that came after some rather vigorous debate for a bit, but that made a lot of sense to me – that you’re not looking for the modality to immediately solve the problem, you’re looking for the modality to provide the data to understand what to do to help solve the problem.

It’s an important aspect to understand because if you’re able to really show that if you’re using a mobile device, and it’s providing information, you know the next step is to take this medication from this test or go to the doctor immediately, that’s a value that you may not have already thought of. I was a bit surprised by that.

Other than that, the passion of the people involved, incredible dedication to wanting to do this correctly and getting it right so that we can, again, be able to get a much better, broader, national perspective of telehealth wasn’t surprising. In fact, the energy level was so high that I really think that’s what led to the success of the project.