Feasibility of Evaluating the CHIPRA Care Quality Measures in Electronic Health Record Data

Gold et. al.1 address important issues on the difficulty in data collection for quality assessment programs. However, these programs have significant validity problems regarding the data measures used for assessment of physicians' care delivery.

Setting denominators for quality measures to any visit for any reason in the last year: * A teenage girl seen for a cold would need to be asked about sexual activity and screened for sexually transmitted diseases at that visit, or the care will be deemed inadequate. Vaccinations complete by specific dates: * The endpoint of the intervals are not consistent with recommended immunization schedules. Vaccinations delivered at appropriately scheduled well visits that occur 2 weeks after the recommended visit date will be considered inappropriate care. The second Hepatitis A vaccine is appropriately given at up to 18 months after the first, yet if not administered by age 23 months and 29 days, it would be scored as inappropriate. * There are no exclusion of children whose families refuse vaccination. * There is no recognition that parents may not bring immunization records when care is transferred. * Insurance companies do not yet pay for HPV vaccination for boys. Definition of sexually active: * Use of prescriptions for oral contraceptives or obtaining a pregnancy test does not imply sexual activity. These medications are often used for indications other than fertility control and pregnancy tests are necessary for many complaints, regardless of sexual history. Using ICD-9 or CPT-4 claims data to assess services provided: * Obesity care is often not paid for by insurance companies. Codes related to obesity are not likely to be billed and not likely to reflect the care provided. Assigning an activity or treatment for assessment that is not paid for by insurance companies: * It is unreasonable to evaluate care of a condition such as obesity that is not paid for. Holding primary care doctors accountable for behaviors of others over which they have no control: * Timing of a first prenatal visit. * Failure of a patient to bring immunization records. * Hospital, ED, or psychiatric hospital follow up when the primary care doctor was not notified that patient was seen in another facility. * Inappropriate use of antibiotics in an Emergency Department or urgent care facility. * ED or urgent care usage when the office is open and appointments are available. Multiple programs, each with different rules: * Children's Health Insurance Program Reauthorization Act (CHIPRA) * Patient Centered Medical Home (PCMH) * National Committee for Quality Assurance (NCQA) * Meaningful Use (MU) * Individual mandates regarding pay-for-performance from multiple insurance companies that are often based on cost instead of quality.

Critical to appropriate assessment of physician quality of care is the ability to collect measures that actually assesses quality. There are serious issues with the validity of currently existing quality assessment programs.

1 Gold R, Angier H, Mangione-Smith R, Gallia C, McIntire PJ, Cowburn S, Tillotson C, DeVoe JE. Feasibility of Evaluating the CHIPRA Care Quality Measures in Electronic Health Record Data. Pediatrics 2012 130:139 -149; doi:10.1542/peds.2011-3705

Conflict of Interest:

None declared