Figure 4.1 provides an overview of our mapping of existing measures to HOPS and ED encounter data. Encounters were grouped into three categories in our analyses: visits, drugs/biologicals, and services/procedures. For each category, we considered the types of activities that typically occur during the encounters. We then used this assessment to determine which measures are relevant to each type of encounter for the mapping exercise. We performed this measures mapping exercise to determine the clinical conditions and services for which measures currently exist and those for which there is a deficit.
When we examined reasons for visits, we found that appropriate measures and services would include additional E&M services (i.e., visits), such as referral to other doctors and specialists; medications appropriate to findings from the examination; or a request for an appropriate service/procedure, such as colonoscopy or referral to a dermatologist to remove a pigmented mole. For example, existing measures specify that an overweight patient should have this issue addressed annually, and geriatric patients should be screened annually for cognitive and functional impairment. Measures exist to assess whether patients presenting with community-acquired pneumonia receive empiric antibiotic therapy, a situation where a visit prompts prescription of a medication. Visits may also result in referral for a service/procedure such as colonoscopy, mammography, or a laboratory test (such as creatinine for patients receiving cisplatin).
Figure 4.1. Mapping of Reasons for Visits to Existing Clinical Measures
Some encounters occur wherein patients only receive drugs or biologicals, such as interferon for Hepatitis C or Trastuzumab administration for HER2/Neu positive patients. There are some existing measures that address the appropriate use of medications and biologics, and these may be appropriate to care delivered in the outpatient hospital setting. A careful review of existing measures against the care provided in the outpatient hospital setting would be a key next step, to see if the measures are applicable and how their specifications may need to be adapted to be operationalized using hospital outpatient data sources. Given the large number and type of drugs and biologicals used, it is likely that there are substantial measure gaps related to the appropriate use of drugs and biologicals in treating Medicare beneficiaries.
Finally, with respect to the services/procedures we examined, we found two points of interest: (1) the appropriateness of ordering of the service/procedure, such as a measure specifying the clinical situations under which a patient in the ED should undergo an MRI; and (2) the quality of the provision of the service/procedure by the performing specialist, such as a measure addressing the documentation of pre-surgical axial length in cataract patients, or a measure assessing the communication of colonoscopy results to the primary care physician.