Hospital Quality Data: HHS Should Specify Steps and Time Frame for Using Information Technology to Collect and Submit Data: GAO-07-320.

Hospitals submit data in electronic form on a series of quality measures to the Centers for Medicare & Medicaid Services (CMS) and receive scores on their performance. Increasingly, the clinical information from which hospitals derive the quality data for CMS is stored in information technology (IT) systems. GAO was asked to examine (1) hospital processes to collect and submit quality data, (2) the extent to which IT facilitates hospitals' collection and submission of quality data, and (3) whether CMS has taken steps to promote the use of IT systems to facilitate the collection and submission of hospital quality data. GAO addressed these issues by conducting case studies of eight hospitals with varying levels of IT development and interviewing relevant officials at CMS and the Department of Health and Human Services (HHS). The eight case study hospitals used six steps to collect and submit quality data: (1) identify the patients, (2) locate information in their medical records, (3) determine appropriate values for the data elements, (4) transmit the quality data to CMS, (5) ensure that the quality data have been accepted by CMS, and (6) supply copies of selected medical records to CMS to validate the data. Several factors account for the complexity of abstracting all relevant information in a patient's medical record, including the content and organization of the medical record, the scope of information and the clinical judgment required for the data elements, and frequent changes by CMS in its data specifications. Due in part to these complexities, most of the case study hospitals relied on clinical staff to abstract the quality data. Increases in the number of quality measures required by CMS led to increased demands on clinical staff resources. Offsetting the demands placed on clinical staff were the benefits that case study hospitals reported finding in the quality data, such as providing feedback to clinicians and reports to hospital administrators. GAO's case studies showed that existing IT systems can help hospitals gather some quality data but are far from enabling hospitals to automate the abstraction process. IT systems helped hospital staff to abstract information from patients' medical records, in particular by improving accessibility to and legibility of the medical record. The limitations reported by officials in the case study hospitals included having a mix of paper and electronic records, which required staff to check multiple places to get the needed information; the prevalence of data recorded as unstructured narrative or text, which made locating the information time-consuming because it was not in a prescribed place in the record; and the inability of some IT systems to access related data stored in another IT system in the same hospital, which required staff to access each IT system separately to obtain related pieces of information. Hospital officials expected the scope and functionality of their IT systems... [ABSTRACT FROM AUTHOR]