This document is submitted by the Massachusetts Health Data Consortium (MHDC) and its Data Governance Collaborative (DGC) in response to the request for comment on the 2024 Aligned Measure Set sent to us via email.

About MHDC

Founded in 1978, MHDC, a not-for-profit corporation, convenes the Massachusetts’s health information community in advancing multi-stakeholder health data collaborations. MHDC’s members include payers, providers, industry associations, state and federal agencies, technology and services companies, and consumers. The Consortium is the oldest organization of its kind in the country.

MHDC provides a variety of services to its members including educational and networking opportunities, analytics services on both the administrative and clinical side (Spotlight), and data governance and standardization efforts for both clinical and administrative data (the Data Governance Collaborative/DGC and the New England Healthcare Exchange Network, respectively).

About DGC

The DGC is a collaboration between payer and provider organizations convened to discuss, design, and implement data sharing and interoperability among payers, providers, patients/members, and other interested parties who need health data. It is a one stop interoperability resource. The DGC primarily focuses on three areas:

1. Collaboration: Development of common understanding of and specifications for data standards, exchange mechanisms, and what it means to participate in the modern health IT ecosystem
2. Education: helping members understand their regulatory obligations, the data and exchange standards they're expected to use, and modern technology and related processes
3. Innovation: Identification and development of projects and services needed to make modern health data practices and exchange a reality

Additional Background

The Data Governance Collaborative’s very first project was creating a flat file quality measures data exchange specification exchanged via Secure FTP. Many of the payers and providers in Massachusetts are using this specification to exchange clinical and patient data needed for quality measures.

Among other components, we are currently working on plans to incorporate FHIR-based quality measures exchange into a future version of MHDC’s NEHEN exchange service (NEHEN 3.0).

General Comments

This section provides comments on the proposed measure set.

Measures in the Set

While the specific request we received was to comment on whether any additional measures should be added to the 2024 Aligned Measure Set, participants in our Data Governance Collaborative believe that perhaps the movement should be in the other direction and some of the measures currently listed for inclusion could be reconsidered and removed.

Specifically, some of the payer participants in our Data Governance Collaborative noted that some measures included in the measure set have not proven to be very useful in their pay for performance contracts with commercial plans. Indeed, they found that for many measures the number of patients who qualified for the denominator was so small as to make the measures close to meaningless. Less than 10% of the plans met criteria of 30 qualified patients in various measures proposed for inclusion in the set including but not limited to:

• Follow-up after Hospitalization for Mental Illness
• Follow-up after ED visit for Mental Illness
• Informed, Patient-Centered Hip and Knee Replacement
• Pharmacotherapy for Opioid Use Disorder

Behavioral Health Assessment (for Pregnant Women) Measure

We wondered why behavioral health assessments were only being considered/measured for patients during pregnancy. It seems like a good measure to apply to all patients, with a stratification for pregnancy status if deemed appropriate.

In addition, we wonder if it would be more appropriate to use the terminology pregnant person instead of pregnant woman – much of the industry seems to be moving to this usage to reflect the difference between biology and gender identification.

Medication Usage Specificity

In some of the measures, use of a particular medication is a noted exclusion factor for patients with a note that the assumption is the patient is taking the medication for a specific purpose/to treat a specific condition. It is often stated or implied that the exclusion is being made because of that assumed condition and not the medication itself. However, many medications are used for multiple purposes and there is no indication of how to treat patients who are taking the medication for a reason unrelated to the one discussed in the measure as the reason for the exemption.

For example, the medication memantine is listed as a dementia medication under several measures including colorectal cancer screening, eye exams for patients with diabetes, and imaging for lower back pain among others. The exclusion is specifically listed as related to dementia and the medication is listed as one of several that qualify as a dementia medication. While dementia is one common use for the medication, memantine is also commonly used to reduce the occurrence of migraines. It is unclear if patients without a dementia-related diagnosis who take memantine specifically to prevent migraines should be included or excluded in these measures.

Medication Delivery Mechanism

In some of the measures, use of a particular medication is a noted exclusion factor for patients. One example is the prolonged use of corticosteroids for the Use of Imaging Studies for Low Back Pain measure. However, for most medical purposes, the delivery mechanism makes a big difference in how the use of a corticosteroid is considered in terms of interactions, risks, potential side effects, and more. Whether the steroid is administered orally vs injected vs inhaled vs topically makes a significant difference. Most considerations of steroid use in terms of these factors disregard topical use and many also disregard inhaled uses (either orally or through the nasal passages). It seems unlikely that the exclusion was meant to include eczema patients who take very small doses of topical steroids daily or asthma patients who do the same via oral inhalation or allergy patients who do the same via nasal inhalation, but as written it does. While most inhaled steroids are not included on the list of medications that force exclusion, at least two common topical steroids are on the list (hydrocortisone and triamcinolone). As written, patients who take one or both of those medications topically who also suffer from lower back pain would be excluded from the measure which does not seem desirable.

Page Numbering

We assume this will be sorted out in a final document, but we note that the front of the measure set included a table of contents with contiguous page numbers, but many of the individual measures had their own numbering mechanism either restarting from 1 or starting with some random other number so it was not possible to use the table of contents to move directly to a specific measure. We also recommend that any table of contents include live links to the relevant measures and that there be a “back to top” link at the bottom of each measure to improve navigation of the set as a whole.