Performance Measures – Taking Quality to the Next Step

1. Performance Measures – Taking Quality to the Next Step Indiana Rural Health Association BethAnn Perkins, RN Health Consulting Strategies, Inc.

2. RHC Program Evaluation & QAPI • Annual vs. Ongoing • Snap shot for planning vs. Benchmarking for improvement • Meeting the minimum program requirements vs. Striving for Excellence!

3. Kicking it up a Knotch Benchmarking against National Standards

4. Topics Covered • Why Measure • Meaningful Use Quality Measures • National Quality Forum Measures • Unified Data Sets (UDS) • HRSA/CMS Workgroup • Establishing a baseline for quality • Benchmarking for Improvement

5. Why Measure? • Separates what you think is happening from what is really happening • Establishes a baseline: It’s ok to start out with low scores! • Helps to avoid putting ineffective solutions in place • To monitor improvements and prevent slippage • Indicates whether changes lead to improvements • Allows for comparing performance across sites

6. Data for Quality Improvement: • Goal is to improve care: not discover new knowledge • Testing is observable: not blinded • “Just enough” data: not 100% and not maximal power • Changing hypothesis as learning takes place • Purpose not to formally evaluate

7. Performance Improvement • Choose measure • Establish baseline • Choose aim to guide improvement • Make system changes to improve performance • Monitor performance over time • Analyze and act on your data

8. Say what? • Measure • Indicator • Performance Measure • Dashboard • Standard Quality Measure

9. What is a good measure? • Relevance. • Does the indicator relate to a condition that occurs frequently or have a great impact on the patients at your facility? • Measurability. • Can the indicator realistically and efficiently be measured given the facility’s finite resources? • Accuracy. • Is the indicator based on accepted guidelines or developed through formal group-decision making methods? • Improvability. • Can the performance rate associated with the indicator realistically be improved given the limitations of your clinical services and patient population?

10. Some Measurement Assumptions for QI • The purpose of measurement is for learning not judgment • All measures have limitations, but the limitations do not negate their value • Measures are one voice of the system. Hearing the voice of the system gives us information about the system. • Measures tell a story; goals give a reference point

11. Types of Measures • Process – Evaluates the rate of a clinics use of specific evidence based processes of care, e.g. frequency that the clinic orders HbA1C on its Diabetic patient • Outcome – Evaluates the results of an activity, plan, process, or program and their comparison with the intended or projected results, e.g. Does the fact that I have ordered the HbA1C at the frequency recommended lower the patient’s blood sugar? • Balancing – Evaluates if changes designed to improve one part of the system causing new problems in other parts of the system, e.g. Implementing Open Access Scheduling to reduce your “No Show”, is it effecting your scheduled patients or your provider workload.

12. Requirements for Meaningful Use Meaningful Use is using certified EHR technology to: • Improve quality, safety, efficiency, and reduce health disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health

13. Under Meaningful Use: Two Categories of Measures for Reporting • 1) Health IT objectives, which include a “core set” and a “menu set,” that focus on an Eligible Provider’s use of certain EHR functions (e.g., entering medication orders using Computerized Physician Order Entry – CPOE) • 2) Clinical Quality Measures (CQMs), which focus on processes, experience, and/or outcomes of patient care, observation, or treatment

14. Clinical Quality Measures • Stage 1 – Clinical Quality Measures Criteria • Clinical quality measures adopted for the Medicare EHR incentive program would also apply to the EPs in the Medicaid EHR incentive program. • CMS limits the clinical quality measures to those for which electronic specifications are available as of the date of publishing the final rule. • EPs are required to submit information using certified EHR technology on 3 core or alternate core clinical quality measures and 3 additional clinical quality measures.

15. Clinical Quality Measures • Eligible professionals must report from the table of 44 clinical quality measures which includes, 3 Core, 3 Alternate Core, and 38 additional CQMs. • Core CQMs - EPs must report on 3 required core CQMs, and if the denominator of 1 or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures. • EPs also must also select 3 additional CQMs from a set of 38 CQMs (excluding the core/alternate core measures). It is acceptable to have a '0' denominator provided the EP does not have an applicable population. • In sum, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures. A maximum of 9 measures would be reported if the EP needed to attest to the 3 required core, the three alternate core, and the 3 additional measures.

16. Requirements for Clinical Quality Measures for MU • Clinical Quality Measures –Core Set

17. Requirements for Clinical Quality Measures • Clinical Quality Measures –Alternate Core Set

18. Additional CQMs • Asthma Assessment • Appropriate Testing for Children with Pharyngitis • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment • Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) • Hypertension: Blood Pressure Measurement • Prenatal Care: Anti-D Immune Globulin • Controlling High Blood Pressure

19. Additional CQMs – cont. • Weight Assessment and Counseling for Children and Adolescents • Smoking and Tobacco Use Cessation, Medical assistance • Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment • Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention • Breast Cancer Screening

20. Additional CQMs – cont. • Cervical Cancer Screening • Chlamydia Screening for Women • Colorectal Cancer Screening • Use of Appropriate Medication for Asthma • Childhood Immunization Status • Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old • Pneumonia Vaccination Status for Older Adults • Asthma Pharmacologic Therapy • Low Back Pain: Use of Imaging Studies

21. Clinical Quality Measures – cont. • Diabetes: Eye Exam • Diabetes: Foot Exam • Diabetes: HbA1c Poor Control • Diabetes: Blood Pressure Management • Diabetes: Urine Screening • Diabetes: LDL Management & Control • Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patient with CAD • Ischemic Vascular Disease (IVD): use of Aspirin or other Antithrombotic

22. Clinical Quality Measures – cont. • Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior MI • Ischemic Vascular Disease (IVD): Blood Pressure Management • Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol • Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control • Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation • Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) • Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

23. Clinical Quality Measures – cont. • Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) • Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy • Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care • Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment

24. Additional CQMs – cont. • Oncology Colon Cancer: Chemotherapy for Stage II Colon Cancer Patients • Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer • Prostate Cancer: Avoidance of Overuse of Bone Scan for staging Low Risk Prostate Cancer Patients • Adult Weight Screening and Follow-Up • Diabetes: HbA1c Control (<8%)

25. Uniform Data System UDS Required for HRSA Funded Health Centers and National Health Service Corp Sites

26. UDS Measures

27. UDS Measures – cont.

28. UDS Measures – cont.

29. UDS Measures – cont.

30. Measure Definitions Eligibility (all patients potentially eligible for the targeted care or service) Numerator (# of patients who have had recommended test or achieved a target level ) Denominator (# of patients who are eligible to receive care of a particular type less those who we exclude)

31. Two Year Old Immunizations(NQF 0038)

32. Two Year Old Immunizations Measure • Percent of children who turned two during the measurement year who were fully immunized on their second birthday • All listed vaccines should have been given by 19 months – 24 months builds in a 6 month grace period • Vaccinations may be given by health center or others as long as it is documented • Measurement calculation: Line10 Column c (patients with compliance documented) Line10 Column b (patients in universe or sample)

33. Two Year Old Immunizations Universe and Exclusions • All patients who turned two during the measurement year (i.e., born between 1/1/2009 and 12/31/2009) who: • Had at least one medical visit during the measurement year • Was first ever seen before their second birthday • No exclusions

34. Two Year Old Immunizations Documentation of Compliance • Documentation of required vaccines or for any vaccine: • Shows evidence of having had the disease or • Shows evidence of allergy to a vaccine or its components • Documentation can be obtained from state-wide or other registries

35. Two Year Old Immunizations Documentation of Compliance • Fully compliant means compliant for each of 14 diseases spelled out in the guidance: • 4 DTP/DTaP • 3 IPV • 1 MMR • 3 Hib • 3 HepB • 1VZV (Varicella) • 4 Pneumococcal conjugate • 2 HepA • 2 or 3 RV (Rotavirus) • 2 Flu

36. Two Year Old Immunizations Completing the UDS: • Column a: Number of two year old medical patients seen in measurement year • Will be similar to patients reported on table 3A • Column b: Will be 70 unless a comprehensive EHR tracks immunizations, in which case column b will be equal to column a • Column c: Number (of those reported in column b) who had each and every vaccine or, for any they did not have, had allergy or disease documented

37. HRSA Small Quality Grant - Meaures

38. HRSA Small Quality Grant - Measures

39. HRSA Small Quality Grant - Measures

40. Measure Example Eligibility: Patients 18 - 75 years of age with type 1 or type 2 diabetes seen in the clinic within the last 2 years Numerator: # of patients from the denominator whose most recent HbA1c is less than 8.0%. The A1c result must be completed within the last 12 months Denominator: Eligible patients EXCLUDING patients with polycystic ovaries, steroid induced diabetes and gestational diabetes

41. Eligible Patients: Patients 18 - 75 years of age with type 1 or type 2 diabetes seen in the clinic within the last 2 years Denominator: Eligible patients less exclusions Numerator: Patients with a HbA1c value < 8.0% and last test < 1 year ago

42. Focusing Forward • Idea of measurement is to understand how our care systems are working • Objective of the program is to close the gap between current care and the care we want to provide • Measures are an important tool for our improvement journey

43. HRSA/CMS and Quality • Fall 2012 a RHC Workgroup was convened to consider standardizing quality measures in the RHC. • Consider Quality requirement from 11 stakeholders – 69 Measures Total. • Identified those measures that correlated with RHC services – 46 Measures. • Considered the frequency by which each measure occurred as a requirement for the stakeholder group (MU had to be a part of any measure considered).

44. Top Measures Affecting RHCs • Controlling High B/P • IVD: Use of Asprin or another Antithrombotic • IVD: Complete Lipid Profile and LDL Control <100 • Hear Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Agniotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction

45. Top Measures Affecting RHCs • Comprehensive Diabetes Care: HbA1c control (<8%) • Diabetes Eye exam • Use of Appropriate medication for people with asthma • Measure pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention • Childhood Immunization Status • Pneumonia vaccination status for older adults

46. Pillars of Population • Pediatrics • Adult • Geriatric • Women • Behavioral • Patient Satisfaction

47. Resources • Get information, tip sheets and more at CMS’ official website for the EHR incentive programs: • http://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp • http://bphc.hrsa.gov/policiesregulations/performancemeasures/updatedfy2012measures.pdf

48. Thank You!! BethAnn Perkins, RN Health Consulting Strategies, Inc.