Advancing Chief Complaint-Based Quality Measurement FINAL REPORT JUNE 24, 2019 This report is funded by the Department of Health and Human Services under contract HHSM-500- 2017-00060I for Task Order 75FCMC18F0005. CONTENTS EXECUTIVE SUMMARY 2 BACKGROUND 3 PURPOSE 5 METHODOLOGY AND APPROACH 6 CHIEF COMPLAINT MEASUREMENT FRAMEWORK 7 CURRENT LANDSCAPE OF CHIEF COMPLAINT STANDARDIZATION 12 ADDRESSING MEASUREMENT GAPS IN FUTURE DEVELOPMENT 16 CHIEF COMPLAINT-BASED eCQMS 19 RECOMMENDATIONS 23 NEXT STEPS 25 REFERENCES 26 APPENDIX A: Committee Members and NQF Staff 28 APPENDIX B: Definitions 30 APPENDIX C: Scan of Measures and Measure Concepts 31 APPENDIX D: Classification System Scan 32 APPENDIX E: Details of Environmental Scan Findings 33 APPENDIX F: Key Informant Interviewees 35 APPENDIX G: Sample Key Informant Interview Guide 36 2 NATIONAL QUALITY FORUM EXECUTIVE SUMMARY Emergency departments (EDs) play a central role in the delivery of acute, unscheduled care in the U.S. with nearly 145 million visits and more than one-quarter of all acute care visits.1 EDs are also the healthcare setting on the front lines of detecting disease outbreaks and linking with public health entities who monitor threats to public health. The ED’s unique role in the healthcare system enables healthcare delivery for all populations—spanning age groups, acuity, health, and socioeconomic status. Chief complaint data have historically been These approaches span the public and private collected to guide healthcare providers’ diagnostic sectors, vary in their capabilities, and are use-case- decision making and care planning in EDs and specific (e.g., syndromic surveillance, research, other settings like urgent care, primary care, and quality measurement). However, there is still no retail health settings. Chief complaints represent current guidance or consensus on how to navigate patient-reported symptoms collected at the these approaches, understand their strengths and start of a visit that describe what prompted the weaknesses, and select the best approaches and patient to seek care. Chief complaints—or other tools for a specific use case. ways of representing them such as presenting This project aimed to develop a strategic roadmap problems, clinical syndromes, or reason for visit— for advancing chief complaint data standardization are important because the chief complaint often and chief complaint-based quality measure guides diagnostic decision making and care. It is development and implementation, as well as also a vital data element collected by regional and exploring other use cases for standardized chief state public health systems to monitor for disease complaints. This project also sought to describe outbreaks. opportunities for harmonizing approaches to Chief complaint data have various uses that collecting and aggregating chief complaint data facilitate patient-centered care, decision support, across acute care and public health use cases. disease surveillance, and quality measurement. The roadmap was built on the findings of an However, the lack of standardization of chief environmental scan and key informant interviews, complaints creates challenges for use cases that which were conducted to gain an understanding require aggregation of similar patients for quality of the current landscape of chief complaint-based measures or detecting disease outbreaks. Efforts quality measurement and current approaches to resolve the challenges with standardization for standardizing chief complaint data. Based on of chief complaints have been discussed for these findings, the National Quality Forum (NQF) more than two decades. However, recent guided a multistakeholder Committee in the advancements in information technology (IT) and development of a measurement framework and informatics may present solutions to several of the recommendations to advance the implementation barriers—areas that have limited standardization. of chief complaint standardization, measure Researchers and informaticists have developed development, and implementation. several approaches and tools that can standardize chief complaints including classification systems, nomenclatures, ontologies, and IT-based tools. Advancing Chief Complaint-Based Quality Measurement 3 BACKGROUND Emergency departments (EDs) play a central role In addition to the lack of standardization upon in the delivery of acute, unscheduled care in the entry of chief complaint data, there is no accepted U.S. with nearly 145 million visits and more than standard nomenclature for classifying chief one-quarter of all acute care visits.11 EDs serve complaints for secondary uses like syndromic as a 24/7 resource for treating critical illnesses, surveillance or quality measurement. Other uses such as acute myocardial infarction, stroke, severe for chief complaint data include ED operations and trauma, and sepsis. In addition, EDs have several management (i.e., staffing, resource assessment), other functions including diagnosing acute research, and education. conditions—specifically evaluating undifferentiated Chief complaint data have historically been symptoms such as chest or abdominal pain and collected as a primary data point to guide distinguishing benign versus serious diagnoses2 healthcare providers’ diagnostic decision making that require immediate treatment. EDs often and care plan. When patients arrive in the ED, the function as a safety net for patients facing barriers chief complaint and other initial findings such as to healthcare access and when other services are the physical exam, vital signs, and other patient- not available or affordable. Nearly 60 percent of specific risk factors (e.g., medical history, age, care provided in the ED is conducted outside of gender) are often used to formulate a work-up regular business hours (8 am to 5 pm).3 EDs are plan as the clinical team seeks to determine an also a primary resource during disasters—both appropriate course of treatment and eventual natural and manmade. It is the healthcare setting diagnosis. Therefore, chief complaint data are on the front lines of detecting disease outbreaks critical in understanding whether the approaches and linking with public health entities who monitor taken are efficient and appropriate when threats to public health. The ED’s unique role in comparing across hospitals and other entities. the healthcare system enables healthcare delivery for all populations—spanning age groups, acuity, Chief complaint data have various uses that health, and socioeconomic status. facilitate patient-centered care, disease surveillance, and quality measurement. However, Chief complaints represent patient-reported the lack of standardization of these data has symptoms collected at the start of an ED visit limited its utility and makes aggregation of chief that describe what prompted the patient to seek complaints for specific use cases a complex care. Chief complaints—also commonly referred undertaking. Discussions about efforts to resolve to as presenting problems, clinical syndromes, or the challenges with standardization for quality reasons for visit—are important because the chief measurement have gone on for more than two complaint often guides diagnostic decision making decades. However, advancements in information and care. It is also a vital data element collected technology (IT) and informatics may present by regional and state public health systems to some solutions to several of the barriers that monitor for disease outbreaks. Providers typically have limited broad use of chief complaint data. record these data in a free text field in the Specifically, the high prevalence of electronic electronic health record (EHR) or paper chart, health records in EDs and other acute healthcare usually in the patient’s own words. In some cases, settings presents an opportunity to facilitate an EHR may feature a corresponding structured measurement by the adoption of systematic field in which a clinician can select one or more electronic capture of standardized chief complaint terms that align with the patient’s chief complaints. data. Standardizing chief complaints also 4 NATIONAL QUALITY FORUM presents a set of challenges with integrating new (ICD-CM), which facilitates the specification of technology or programming new capabilities into reliable quality measures. The lack of a similar existing systems, which can be expensive and approach to systematic standardization of chief complex. To address this need, researchers and complaint data has led to a persistent gap in ED informaticists have developed several approaches performance measurement. (i.e., classification systems, nomenclatures, Measuring quality in the ED using a diagnosis ontologies, and IT solutions) that span the public determined after evaluation does not address and private sectors and vary in their utility based the variability in practice required to establish on the use case (e.g., syndromic surveillance, the diagnosis from a chief complaint. Solely research, quality measurement). However, there using diagnosis limits utility when the goal is to is still no current guidance or consensus on how link similar patients to measure concepts such to navigate these approaches, understand their as resource utilization, shared decision making, strengths and weaknesses, and select the best and missed diagnoses. It is also clear that using approaches for a specific use case. final diagnosis is limited because of the poor correlation between final diagnosis and chief Quality Measurement complaint