The document proposes refining an existing Uniform Data System (UDS) measure related to adult weight screening and follow up to make it more useful for quality improvement. The current measure is seen as too complex, not actionable, and resource-intensive. The proposed changes would specify new BMI measure(s) and ancillary reports to enhance actionability and feasibility. A pilot study would develop and assess the new measures and reports, evaluate their utility, feasibility, and reliability, and assess any difference in care quality metrics between providers receiving different report types. The goal is to create measures that can help target areas for improvement at the patient, provider, and practice levels.

1. 1
SAFTINet)R/QI)Committee)Scope)Document:)Refining)the)UDS)
Adult)Weight)Screening)and)Follow)Up)Measure)to)be)More)
Actionable) ) ) ) ) ) ) ) )
Table&of&Contents&
Project(Goal( 2!
Background( 2!
Problem(Statement( 2!
Conceptual(Framework(for(Evaluating(Validity(and(Utility(of(Clinical(Quality(Performance(Measures( 3!
Methods( 3!
Current(Measure( 4!
Reported(Elements(for(Current(UDS(Adult(Weight(Screening(and(Follow(Up(Measure((UDS(Table(6B,(Section(F,(Row(13)( 4!
Data(Elements(Needed(to(Create(the(UDS(Report(As(Currently(Reported( 4!
Table!1:!Data!Elements!Required!for!Defining!the!Relevant!Population! 4!
Table!2:!Data!Elements!Required!for!Defining!and!Computing!Current!UDS!BMI!Measures!Using!Electronic!Data! 5!
Limitations(of(the(Current(Measure( 6!
Proposed(Improved(UDS(Adult(Weight(Screening(and(Follow(Up(Measure( 7!
Rationale(for(Proposed(Changes( 7!
Table(3:(Added(Elements(to(Help(Enhance(the(Actionable(Value(of(the(UDS(Report( 7!
Clinical(Quality(Performance(Reports:(options(for(pilot(project( 8!
Care(Quality(Measures( 8!
Care(Quality(Ancillary(Reports(( 8!
Data(Quality(Ancillary(Reports( 9!
Key(to(Abbreviations( 9!

2. 2
Project&Goal&
The)goal)of)this)pilot)study)is)develop)and)assess)one)or)more)quality)of)care)measures)that)address)overweight/obesity)
screening)and)management,)and)to)develop)the)ancillary)reports,)such)as)data)quality)reports)and)patient)registries,)that)
support)dataHdriven)quality)improvement.)The)primary)assessment)outcomes)for)this)project)include)1))utility)or)
“actionability”)of)the)quality)measures)and)ancillary)reports,)and)2))feasibility,)and)3))reliability)of)measure)computation,)
including)data)quality)for)data)elements)required.)
)
Background&
The)Research)and)Quality)Improvement)Committee)of)the)Scalable)Architecture)for)Federated)Translational)Inquiries)
Network)(SAFTINet),)a)practiceHbased)research)network)of)FQHCs,)identified)care)quality)priorities)and)collaborated)to)
identify,)specify,)and)pilot)the)relevant)measure(s))and)ancillary)measures)deemed)of)greatest)value)to)SAFTINet)
member)FQHCs.)SAFTINet’s)distributed)data)network)infrastructure)is)positioned)to)support)practices)in)design,)
implementation)and)use)of)quality)reporting)tools.)Our)methods)include)the)following)steps:)
Problem&Statement&
Federally)Qualified)Health)Centers)(FQHCs))and)other)health)center)programs)defined)in)Section)330)of)the)Public)Health)
Service)Act)are)mandated)to)report)Uniform)Data)Systems)(UDS))measures)to)the)Health)Resources)and)Services)
Administration)(HRSA).)SAFTINet)partners)report)that)administrators)and)providers)at)these)health)centers)often)find)
the)UDS)measures)to)lack)value)in)assisting)them)with)quality)improvement)initiatives)and)program)evaluation,)while)
the)data)needed)to)compute)the)measures)are)burdensome)for)the)practices)to)gather.))Given)the)effort)in)reporting)the)
measures,)SAFTINet)partner)would)like)to)report)measures)that)have)value)to)their)practices)(such)as)for)quality)
improvement))and)HRSA)(such)as)for)performance)benchmarking).)SAFTINet)partners)note)the)following)specific)
problems)related)to)UDS)measures)for)BMI/Weight)Counseling:)
)
1.! The)data)elements)may)not)readily)available)in)structured)fields)in)administrative)and)clinical)databases.)Health)
centers)lack)resources)to)extract)electronic)medical)record)(EMR))data)for)reporting)even)if)properly)codified.)In)
the)event)the)require)data)elements)are)not)electronically)available,)the)current)UDS)2013)Adult)Weight)Screening)
and)Follow)Up)measures)(UDS)Table)6B,)Section)F,)Row)13))require)manual)review)of)70)charts.&
2.! The)UDS)measures)lack)value)to)practices)as)they)are)not)actionable:&

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a.! Due)to)the)complexity)of)the)composite)measures,)which)combine)age,)BMI)and)followHup)into)a)single)
binary)measure,&
b.! They)do)not)segment)the)results)at)the)level)of)practice)and)provider.&&
3.! The)UDS)measures)do)not)capture)the)essence)of)quality)of)care)for)patients)with)obesity)and)the)range)of)things)
that)can)be)done)to)manage)obesity)in)primary)care.)&
Conceptual&Framework&for&Evaluating&Validity&and&Utility&of&Clinical&Quality&Performance&Measures&
1.! Relevance)
2.! Scientific)soundness)
3.! Feasibility)
&
Methods&
)
R/QI)working)group)will)(1))specify)new)BMI)measure(s);)(2))ancillary)report)to)enhance)actionability)(3))
complementaory)DQ)report;)build)and)deploy)1,2,)and)3)
)
1.! We)engaged)practices)in)the)design)of)ancillary)reports)for)UDS)measures)related)to)obesity)management,)
including)breaking)down)composite)measures)into)their)component)parts,)and)enabling)options)for)viewing)the)
data)at)various)levels)of)granularity)(by)patient)type,)practice,)and/or)provider).))
2.! Create)the)corresponding)ancillary)care)quality/data)quality)reports)using)the)SAFTINet)infrastructure)
a.! Revised)measures)including)linking)patients)to)a)specific)practice)or)provider)
b.! Ancillary)reports)methods)e.g.,))
c.! –))Evaluate)feasibility)and)value)of)1,2,)and)3)
3.! We)will)use)data)visualization)techniques)to)aid)in)the)interpretation)of)the)data)and)enhance)actionability.)We)will)
then)randomly)assign)providers)to)receive)only)care)quality)reports)or)care)quality)+)data)quality)reports)on)a)

4. 4
monthly)basis)for)6)months;)we)will)then)assess)whether)there)was)a)difference)in)care)quality)and)data)quality)
metrics)over)time)between)the)two)groups.))
4.! We)will)use)(interviews?)Surveys?))to)assess)acceptability)and)perceived)utility)to)providers)and)administrators.)
)
)
Current&Measure&&
Reported&Elements&for&Current&UDS&Adult&Weight&Screening&and&Follow&Up&Measure&(UDS&Table&6B,&Section&F,&Row&13)&
Column!A.! Number!of!patients!18!years!of!age!or!older!during!the!measurement!year!(18th!birthday!was!on!or!before!December!31!of!reporting!year)!AND!
had!at!least!one!medical!visit!during!the!reporting!year!after!their!18th!birthday!at!the!health!center,!excluding!pregnant!women!and!the!terminally!ill!
(this!is!the!same!as!the!criteria!in!the!first!column!of!the!Population!table,!above)!
Column!B.! Number!of!charts!sampled!(i.e.,!70!charts!for!manual!chart!review)!or!EHR!total!(equal!to!Column!A,!immediately!above)!
Column!C.! Of!those!in!the!denominator!(equal!to!Column!A,!immediately!above),!the!number!of!patients!who!had!their!BMI!(not!just!height!and!weight)!
documented!during!their!most!recent!visit!OR(within!six!months!of!the!most!recent!visit!AND(if!the!most!recent!BMI!is!outside!parameters,!a!followVup!
plan!is!documented.!!Parameters!for!BMI!are!as!follows:!!
a.! were!under!age!65!AND(their!BMI!was!over!25!OR!
b.! were!age!65!or!older!AND(their!BMI!was!over!30!OR!
c.! were!under!age!65!AND(their!BMI!was!under!18.5!OR!
d.! were!age!65!or!older!AND(their!BMI!was!under!22.!
Suggested!codes!for!evidence!of!BMI!are!CPTVII:!3008F!(BMI!documented),!and!for!followVup!plan!V65.3!(dietary!surveillance!and!counseling)!
Data&Elements&Needed&to&Create&the&UDS&Report&As&Currently&Reported&&
Table&1:&Data&Elements&Required&for&Defining&the&Relevant&Population&&
UDS 2013 Definition SAFTINet Adaptation
Inclusion
18 years of age or older during the measurement year (18th birthday
was on or before December 31 of reporting year) AND
> 18 years during the measurement period (year, quarter) AND
Had at least one medical visit during the reporting year after their 18th
birthday at the health center (“In a clinical setting”)
Had > 1 medical encounter at the practice after their 18th
birthday during the
measurement period
Exclusion

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Pregnant women Women with a diagnostic code for pregnancy and/or a diagnostic/procedure code
for a delivery during the measurement period
Terminally ill patients (no definition is provided) Patients who die during the measurement period, ICD-9 codes or procedure codes
indicative of terminal illness [e.g., 799.3 (Debility, unspecified), V66.7
(Encounter for palliative care)]
Table&2:&Data&Elements&Required&for&Defining&and&Computing&Current&UDS&BMI&Measures&Using&Electronic&Data&&
Measure Description Definition SAFTINet Fields or Concepts Needed
Denominator
Inclusion of Patients Eligible
for Measure by category:
•! Under!age!65!AND(BMI!
over!25!
•! !Age!65!or!older!AND(BMI!
over!30!!
•! Under!age!65!AND(BMI!
under!18.5!!
•! Age!65!or!older!AND(BMI!
under!22.!
•! All!
•! Age!>!18!years!during!the!
measurement!year!
•! >!1!visit!during!the!
measurement!year!after!
their!18th
!birthday!
•! DOB,(date(of(end(of(reporting(period,(age(at(end(of(reporting(period(
•! Date(of(service(for(all(visits(to(practices,(DOB(
Denominator Exclusion Pregnant women during
reporting period
Diagnostic and procedure codes and associated dates Women with a diagnostic code for
pregnancy and/or a diagnostic/procedure code for a delivery during the measurement period
Denominator Exclusion Terminal illness, indication
during reporting period
Diagnostic and procedure codes and associated date; Patients who die during the
measurement period, V66.7 (Encounter for palliative care)]
Numerators
Number with BMI documented
at most recent visit or within 6
months of most recent visit for
those in the following
categories:
•! Under!age!65!AND(BMI!
BMI documentation by
categories of age and BMI
CPTVII:!3008F!=BMI!documented!or!BMI!value!is!not!null.!
Age!during!reporting!period

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Measure Description Definition SAFTINet Fields or Concepts Needed
over!25!
•! !Age!65!or!older!AND(BMI!
over!30!!
•! Under!age!65!AND(BMI!
under!18.5!!
•! Age!65!or!older!AND(BMI!
under!22.!
•! All!
BMI follow-up plan
documented for those in the
following categories:
•! Under(age(65(AND(BMI(
over(25(
•! (Age(65(or(older(AND(BMI(
over(30((
•! Under(age(65(AND(BMI(
under(18.5((
•! Age(65(or(older(AND(BMI(
under(22.(
•! All(
BMI plan documented by
categories of age and BMI BMI documented and associated date
FollowVup!plan!V65.3!(dietary!surveillance!and!counseling)
Limitations&of&the&Current&Measure&
!! Feasibility:!chart!review!of!70!charts!from!across!the!organization!is!resourceVintensive,!especially!with!elements!like!documentation!of!a!weightVrelated!
followVup!plan.!
!! Reliability:!What!constitutes!a!weightVrelated!followVup!plan!may!vary!between!chart!reviewers,!especially!as!this!item!involves!examining!free!text!for!
evidence!of!a!followVup!plan.!
!! Utility:!The!current!measure!is!not!useful!for!targeting!patientV,!providerV,!or!practiceVlevel!needs.!!It!cannot!identify…!
"! Which!providers!or!practices!provide!better!care!quality!(and/or!data!quality)!
"! Which!patients!are!out!of!compliance!and!why?!!Is!it!mostly!poor!rate!of!measurement!of!BMI!or!poor!rate!of!providing!counseling!for!high/low!BMI?!
"! Which!patients!are!just!barely!overweight!and!which!are!immensely!so!

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"! Which!patients!are!overweight!and!which!are!underweight!
!! Data!quality:!If!generated!from!the!EHR,!the!current!reports!would!have!a!lot!of!missing!data!because!providers!are!not!documenting!follow!up!plans!(some,!
because!there!is!no!dedicated!field!for!this)!and!the!EHR!may!not!be!able!to!demonstrate!whether!the!calculated!BMI!value!is!visible!to!the!provider!at!the!
time!of!visit.!!Manual!review!of!70!charts!provides!no!information!about!how!to!remedy!the!data!quality!issues.!
!
Proposed&Improved&UDS&Adult&Weight&Screening&and&Follow&Up&Measure&
Rationale&for&Proposed&Changes&
!! Feasibility:!The!new!measure!would!permit!derivation!from!each!organization’s!existing!administrative!and!EHR!data!sources.!
!! Data!Quality!and!Reliability:!Reports!generated!by!the!new!measure!parameters!would!provide!feedback!to!organizations,!practices!and!providers!regarding!
practiceV!and!providerVlevel!completion!rate!in!documentation!of!BMI!and!of!a!followVup!plan.!The!organizations,!practices!and!providers!could!then!target!
areas!for!improvement!in!reporting!reliability.!
!! Utility:!The!new!measure!would!help!provide!feedback!on!patientV,!providerV,!or!practiceVlevel!care!quality.!!It!can!help!identify!!
"! Which!providers!and!practices!provide!better!care!quality!(or!data!quality—the!practices!would!need!to!work!on!distinguishing!issues!with!quality!of!care!
from!issues!related!to!data!quality)!
"! Which!patients!are!out!of!compliance!and!why?!!!
#! Is!it!mostly!poor!rate!of!measurement!of!BMI!or!poor!rate!of!providing!counseling!for!high/low!BMI?!!
#! Which!patient!groups!based!on!the!UDS!parameters!(four!groups!defined!by!age!and!BMI!noted!above!under!instructions!for!Column!C!for!the!
current!measure!
#! Which!patients!are!higher!priority!for!rectifying!a!missed!followVup!opportunity!based!on!parameters!determined!by!evidence!or!by!practice!
preference—e.g.,!target!patients!who!have!BMI!over!35!as!highest!priority!for!providing!followVup!!
"! Which!patients!are!overweight!and!which!are!underweight!
Proposed Measures (adults >=18, not pregnant)
1. % of those with BMI >=30, % missing BMI, n, subgroup 18-64, >=65
2. % of patient with BMI =30 or greater, and no diagnosis of obesity
3. % of patient with BMI =30 or greater, and nutrition referral or group obesity encounter or ….
Proposed Measures BMI<18 – as above
Table)3:)Added)Elements)to)Help)Enhance)the)Actionable)Value)of)the)UDS)Report&
Additional Element Rationale for Added Value
Sex Can help check to make sure there are no males excluded for pregnancy

8. 8
Additional Element Rationale for Added Value
Indicator for BMI parameter
category
Can help practices better understand which of the four BMI parameter categories experience poorer
compliance with follow-up measure
Indicator for BMI in- or out-of-
parameters
Can help practices determine which patients were compliant with UDS measure because of BMI in-
range and which because of follow-up documentation
Type of follow-up documented If this degree of detail exists, patients who had exercise- or diet-related follow-up documented might
help practices figure out which follow-up category needs improvement in either care quality or data
quality
Height, weight Can help determine whether BMIs are missing because of an EHR calculation issue or because height
is missing (or weight); can verify cause of unrealistic BMI values
Practice Practice associated with the most frequent visits in the measurement period. This can help partners link
measure performance to specific practices
Provider identifier Provider associated with the most frequent visits in the measurement period. This can help partners
link measure performance to specific providers
Patient identifier Practices can identify patients in need of either a BMI measurement or a follow-up action for an out-
of-range BMI
Missing values For each element in Tables 2 and 3, report the proportion missing. This can help identify data quality
gaps that are impacting the measure of care quality
&
Clinical&Quality&Performance&Reports:&options&for&pilot&project&&
Care&Quality&Measures&
The new measure is care quality
Care&Quality&Ancillary&Reports&&
[Bethany—can you put in what you had outlined/drawn in our session after the last R/QI meeting?]
Some ideas for types of ancillary reports:
!! Report!summary!value!as!required!by!UDS!

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!! Report!akin!to!the!DI!reports,!allowing!partners!to!compare!at!the!practice!level,!varying!parameters!such!as!those!in!Table!2!
!! Report!akin!to!the!DI!reports!with!providerVlevel!metrics,!with!only!the!partner’s!data!available!to!that!partner,!including!variables!from!Tables!2!and!3!
!! Registry!of!all!patients!in!Column!A,!including!variables!from!Tables!2!and!3!
!! “Slice!&!Dice”!care!quality!
!! Broken!down!into!component!parts!!!
!
Data&Quality&Ancillary&Reports&
!
1.! By!Practice!(this!is!really!not!done!at!provider!level),!for!those!>18!years!of!age!at!end!date!of!measurement!period,!with!one!visit!during!measurement!
period!
a.! Gender=males!with!pregnancy!code,!#/%!
b.! Ht!–!DQ!range!check,!acceptable!range!0V90!inches:!missing!and!out!of!range,!#/%!{if!eventually!more!granular!<60,!60V71,!72V!78,!79V84,!>85!}!
c.! Ht!value!where!units!are!not!inches,!#/%!
d.! Wt!–!DQ!range!check,!acceptable!range!0V500!pounds,!missing!and!out!of!range,!#/%,!!{<100,!101!V150,!151V200,!201V250,!251V300,!>300!}!
e.! Wt!value!where!units!are!not!pounds,!#/%!
f.! BMI!range!check,!acceptable!range!0V40,!missing!and!out!of!range,!#/%!
g.! !Age!–!DQ!range!check!
2.! By!Organization,!Practice,!Provider!for!those!>18!years!of!age!at!end!date!of!measurement!period!
a.! #/%!missing!BMI!documentation!
Key&to&Abbreviations&
•! BMI Body Mass Index
•! EHR Electronic Health Record
•! MU Meaningful use
•! PCMH Patient centered medical home
•! PCP Primary care provider
•! UDS Uniform Data System
!
!

10. 10
Remaining!work!to!be!done:!
1.! Conceptual!framework!for!evaluating!the!validity!and!utility!of!clinical!quality!performance!measures.!Does!one!exist,!or!should!we!create!one?!
a.! Are!these!measures!ever!evaluated?!How!are!they!established!and!evaluated?!!
b.! What!concerns!do!partners!have!about!existing!measures?!!
i.! Not!actionable!
ii.! Time!consuming,!a!lot!of!effort!to!create!(if!not!in!EHR,!must!do!chart!audit)!
c.! What!should!be!the!goals!for!the!health!care!system!in!developing!and!evaluating!the!validity!and!utility!of!clinical!quality!perf!measures?!
2.! Define!“actionable”!
a.! What!makes!a!measure!more/less!actionable?!
i.! What!makes!BMI/weight!counseling!more/less!actionable,!specifically?!
ii.! How!generalizable!to!other!UDS,!meaningful!use!measures?!!
iii.! Questions!to!ask:!Is!the!information!true?!Is!the!information!useful?!Is!it!relevant!to!the!way!I!practice,!e.g.!adult!weight!screening.!
Does!it!inform!a!particular!action!that!would!improve!care,!general!quality!of!care?!!
b.! What!kinds!of!actions!would!they!take?!How!would!we!detect!action/followVup?!
c.! What!features!of!a!measure!or!a!report!would!affect!actionability?!
i.! Granularity!
ii.! Data!quality!assurance!(validity,!reliability)!
iii.! “slice!and!dice”!unit!of!analysis!
3.! Define!scope!of!the!work!for!SAFTINet!pilot!
a.! How!to!prioritize?!
b.! What!research!questions!will!we!answer?!
!