The American Society of Clinical Oncology recently established a new Quality Department to intensify the organization's focus on quality initiatives. Deborah Kamin, RN, PhD, Interim Senior Director of the new department, spoke with OT about its purpose and plans. Dr. Kamin also serves as Senior Director of ASCO's Cancer Policy and Clinical Affairs Department.
What prompted ASCO to create a Quality Department at this time?
Kamin: The three main programs around quality of care within the society have been guidelines, performance measurement, and health information technology. Those three things are critical to forming a rapid learning health system, which is a concept the Institute of Medicine has put forth.
We have had some very focused efforts in those three areas for quite a while, but they have grown up in independent ways in separate divisions. In addition, they haven't been connected in a way that really allows them to leverage their respective strengths in the information that they are collecting and developing. We wanted to create a more unified quality program by connecting these three areas.
Another reason is the fact that the environment that we're in right now is very focused on value and accountability; the health reform bill, of course, has a very heavy focus on quality. So it's the right time to invest even more in quality than we have in the past, and to take it to the next level.
As a professional organization for physicians who care for people with cancer, we obviously want to be in a leadership position and set the standards for how quality is defined in oncology. We think it's important to have a dedicated function to lead that kind of effort in the next decade.
Please define "rapid learning organization" as it applies to what ASCO will be doing.
Kamin: Of course, science informs our guidelines and clinical recommendations and standards. Those standards are what we use to measure performance and judge the quality of care. The tool that we have now to measure performance is the Quality Oncology Practice Initiative (QOPI.)
Theoretically, those data feed back into informing science and reshaping the questions that you ask. In essence, it becomes a virtual cycle with information and science informing guidelines, guidelines being used to benchmark performance, and then outcomes of care being fed back into the system to drive hypotheses and clinical research.
Health information technology is critical to this process because that allows the information to be exchanged easily. As we all know, the Administration has done a great deal to incentivize investment in health information technology, but we have a long way to go. That is another reason for putting a great deal of focus on quality right now. We need to work as a community to agree on some of the standards and connectivity so that we can communicate in a way that better informs our understanding of the delivery of care and its outcomes.
Let's take each component of the Quality Department separately. What will ASCO be doing differently to support the use of health care IT?
Kamin: We will continue to help our members sort through the various options that are out there and encourage their adoption of electronic health record technology.
I also think we will be looking for other ways that we can use technology to help our members. It might be setting standards, which is a huge issue all across medicine and oncology is no exception. For example, when we say "lymphoma," do we all mean the same thing? And, which staging conventions should be used?
Unless the terms we use are consistent, then the technology can't really help us because it will capture different things and report information in a way that is not consistent. So ASCO may step up its activities around simply trying to get people to agree on the standards themselves.
Thinking about the technology itself-the hardware and software and the decision-support tools - we are asking if there are ways that we can package technology for members that would make it easier for them in day-to-day practice. That is one area that we are looking at, and we are very interested in figuring out ways that we can do more to help members from that perspective.
How will ASCO's role in the development of cancer care guidelines change going forward?
Kamin: Until now, ASCO's guideline portfolio has been relatively narrow, but deep. Unless there is very strong evidence, ASCO typically does not issue a guideline. We have not done a lot of work in consensus-driven guidance[horizontal ellipsis]so we don't cover the full range of care across the routine management of cancer. However, we are going to take a hard look at how we can broaden our portfolio from its relatively narrow position that we have right now.
Moving on to performance measurement, QOPI started as a quality improvement program and last year ASCO introduced a program that allows "QOPI-certified" practices to distinguish themselves with payers. How do you see QOPI evolving in the future?
Kamin: We have now 700 practices participating in QOPI-that represents about 1,000 practice sites. Fifty-nine practices are now certified.
It is my understanding that some practices have managed to arrange higher reimbursement rates (because they have achieved QOPI certification) and that some payers are subsidizing a practice's cost of participation in QOPI. Also, certain payers have agreed to relieve the provider of administrative burdens, such as not requiring pre-authorization, if they are certified or participating in QOPI. So I think plans are recognizing QOPI in the way we hoped. We would, however, like to see much more of it, and we're working on that.
One of the most difficult things in the environment today is the multiplicity of recognition programs, pathways and so forth. There is huge pressure on the payer community to control cost, show value, and be accountable so everybody is developing their own program. As a result, providers now have scores of programs and different measures and different requirements, depending on the plan and the community they are in, to respond to. I think it's not helping quality, and will ultimately erode it. It's just too much of a burden and too confusing for people.
We would like QOPI to be the standard, but recognize that it needs some refinement. For instance, the portfolio of clinical guidance that we have available is currently not robust enough to cover all cancers. This is something the ASCO board will be discussing at a retreat. But we would like our members to say, "ASCO is the first place that I want to go. It's the standard, it's consistent, it's [recognized by] all plans, and I only have to go one place to satisfy all these different public reporting requirements and recognition programs."
Whether that means we build [this resource] ourselves, partner with people, or use some other arrangement, we would like there to be an agreed-upon single standard that oncologists can use and [that will] be credible to them. We have a lot of work to do in the community to get to this place, but that would be our goal.
How would QOPI need to change to work as the standard for measuring cancer care performance that all payers recognize?
Kamin: Right now, QOPI is a retrospective review of records, and we need to take it to the next level for it to support the rapid learning system idea. It has to capture real-time clinical decision-making, and that is more like a registry model.
We recently completed a breast cancer registry pilot to see if it was feasible for practices to provide that kind of information in real time, and we learned a lot from it. We're going to continue developing that because that is definitely where we would like QOPI to go.
The goal is to track what happens to the patient from the moment they are diagnosed, all the way through their experience. QOPI is not complete; it primarily includes medical oncology measures and it is retrospective and it is focused on ambulatory care.
The QOPI steering committee has been talking about the need for greater emphasis on [radiation therapy and surgery] measures. We have begun dialogue with those specialties to see what we can do to work together to get some measures that would reflect those different disciplines, in addition to the medical oncology measures we have now.
Many oncologists have expressed frustration with the government's Physician Quality Reporting System, which does not include oncology-specific measures. Could QOPI be used by the government as the oncology component of PQRS?
Kamin: We recently met with [Centers for Medicare & Medicaid Services Administrator] Don Berwick on this very subject. The case that we are making to CMS is that if people have confidence in what is being measured, and it is relevant to them and formulated by their own peers, the Administration will achieve its goal of getting more people involved in the culture of self-examination and quality improvement.
We are currently figuring out ways that QOPI could satisfy the government's reporting requirement.