National Committee on Vital & Health Statistics

August 31, 1998

The Honorable Donna E. Shalala
Secretary of Health and Human Services
200 Independence Avenue SW
Washington, D.C. 20201

The Honorable Alexis M. Herman
Secretary
Department of Labor
200 Constitution Avenue, NW
Washington, D.C. 20210

Dear Secretary Shalala and Secretary Herman:

The National Committee on Vital and Health Statistics (NCVHS) has reviewed the final report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans, and would like to congratulate the Commission on this excellent report. The Commission’s thorough examination of the key factors impacting the quality of health care in the United States and their thoughtful recommendations are highly commendable.

The NCVHS was kept abreast of the activities and directions of the Commission during the course of their deliberations, and we were pleased that several NCVHS members were able to provide expert testimony to assist the Commission and/or its Subcommittees. Our previous comments on the Commission’s Consumer Bill of Rights address several issues that are raised again by this report. We refer you to our letter of March 10, 1998 for further details on such points as standardization of quality measures, comprehensiveness of quality measurement sets, cost-effectiveness of data collection and reporting strategies, the importance of cultural competence of providers to a consumer empowerment strategy and the need for comprehensive confidentiality legislation. We are highly supportive of the Commission’s recommendations regarding:

• Strengthening the evidence basis for health practices (while noting our previous communication regarding the need for flexibility in defining what constitutes an acceptable evidence base for particular populations and services);
• Strengthening and coordinating quality measurement, reporting and oversight functions within and across the various sectors of the health care industry;
• Stimulating quality improvement within health care organizations and professions;
• Promoting accountability for performance throughout the health care industry at the community level; and
• Empowering consumers to make informed choices about their health plans, providers and treatments.

The NCVHS was particularly encouraged to see the significant attention devoted to the issue of “Investing in Information Systems” in chapter fourteen of the Commission’s report. The NCVHS found the Commission’s recommendations in this area to be highly supportive of our own recent activities to help advance the administrative simplification provisions of HIPAA. Notable examples of NCVHS efforts, which complement and further the objectives of the Commission include:

• Efforts to establish national standards for the structure, content, definition and coding of electronic administrative and financial transactions and for uniform identifiers for payers, providers, employers and individuals that will:
  • Enhance capabilities for measuring and reporting on quality of care by improving timeliness, reducing data entry errors, enhancing consistency of data and enabling linkage of data across settings and time intervals; and
  • Reduce barriers to access to care by improving the timeliness of referral and authorization and benefit eligibility determinations, while simultaneously creating a tracking mechanism for such determinations;
• Efforts to develop national standards for computer-based patient records that will:
  • Enhance opportunities for participation in regional or national health networks that enable data sharing among caregivers;
  • Create opportunities for expanding the scope of quality measurement and reporting, while lowering the costs associated with those activities; and
  • Improve quality of care by ensuring the availability of needed medical information and enhancing decision-making; and
• Defining principles for protecting the confidentiality and security of individually identifiable health care information.

We are pleased to be able to contribute to furthering some of the aims identified by the Commission through these efforts, and while we applaud the Commission’s focus on investment in information systems, the NCVHS would like to encourage a broadening of this concept to information technologies, thus including telemedicine as a tool for improving access to needed care.

In reviewing the Commission’s recommendations related to measuring and improving quality of care, it was clear that many of those recommendations rest upon the successful resolution of key data and information issues with which the NCVHS continues to grapple. The Commission did an excellent job of articulating what needs to be done to further their stated purpose, and the NCVHS now has an opportunity to articulate how some of the data dependent objectives might best be supported. For example, we strongly agree that measuring and reporting on care for vulnerable populations is an important objective, but the ability to achieve that objective rests in great part on the ability to identify relevant population subgroups through existing data channels, an area where the NCVHS has and continues to play an important role. Likewise, the NCVHS has been a proponent for the development of appropriate data and tools for measuring the quality of care provided in post-acute settings, where vulnerable populations are heavily represented. Other areas related to addressing gaps in existing data would include evaluating and recommending sources of information for tracking errors in health care delivery and sources of consumer satisfaction information that might complement standardized member or patient surveys, such as information on complaints or grievances or reasons for disenrollment from a health plan.

Indeed, the NCVHS was struck by the number of opportunities we now have to contribute toward realizing the many recommendations of the Commission for enhancing quality measurement and improvement capabilities that depend upon a strong health data and information infrastructure. NCVHS activities around defining data and information needs, evaluating existing data initiatives, recommending data development strategies, enhancing data quality, and facilitation data sharing among public and private entities, as well as addressing associated needs to assure the protection of health information of individuals, will all support the Commission’s recommendations to expand efforts to measure and improve quality in the health care industry.

In formulating the NCVHS work plans for the coming year, there are a number of key areas in which we are proposing to further those ends, within the scope of our own charter. The following areas are worthy of particular mention:

• Evaluating the adequacy of existing data on which to base quality measurement priorities and recommending improvements to current data collection and/or reporting initiatives;
• Improving data quality through facilitating the adoption of the CPR and monitoring adoption of administrative simplification standards;
• Facilitating data linkage through the adoption of national identifiers;
• Identifying important data content gaps with respect to quality measurement and offering recommendations for resolving them in future releases of claims, enrollment, pharmacy or other administrative transaction standards or in the CPR;
• Recommending data content, formats and functionality of CPRs to support quality measurement and improvement; and
• Reducing the measurement burden on providers by recommending the adoption of standard data collection formats for clinical and administrative quality data necessary to report quality measures.

Over the longer term, we also will be addressing issues related to the following areas that were identified by the Commission as needing attention:

• Ensuring the appropriate use of health services, which involves population-based data on adequacy of services delivery with regard to both services needed over time (e.g., continuing primary care; long-term care) as well as services for time-limited purposes (e.g., emergency care, specialty consultations);
• Expanding research on new treatments and evidence of effectiveness, which will require clinical data to be collected in a standard way so as to permit analyses of relationships between the process and outcomes of services. Information from ongoing clinical data, if well collected and maintained, can complement the knowledge gleaned from more conventional research designs and have the added benefit of generalizability if collected from representative samples of the population;
• Reducing the underlying causes of illness, injury, and disability, which will require that data be linkable to information on non-clinical characteristics that contribute to determining health status.

These data needs provide formidable challenges to privacy and therefore must be accompanied by strong confidentiality and security enforcement.

We are currently planning a national conference on Data Needs for the Twenty-First Century. Many of these data issues will receive a hearing at that workshop, in the context of a wider agenda to further the National Health Information Infrastructure.

We look forward to assisting the Department in its efforts to implement many of the recommendations of the Commission.

Cordially,

Don E. Detmer, M.D.
Chair

cc:
John Eisenberg, M.D.
Margaret Hamburg, M.D.