The Hidden Hurdle in Reaching Meaningful Use

1. 600 East Superior Street, Suite 404 I Duluth, MN 55802 I Ph. 800.997.6685 or 218.727.9390 I www.ruralcenter.org The Hidden Hurdle in Reaching Meaningful Use What you need to know about quality reporting requirements Joe Wivoda CIO & HIT Consultant National Rural Health Resource Center Duluth, MN

2. About The Center The National Rural Health Resource Center is a nonprofit organization dedicated to sustaining and improving health care in rural communities. As the nation’s leading technical assistance and knowledge center in rural health, The Center focuses on five core areas: • Performance Improvement • Health Information Technology • Recruitment & Retention • Community Health Assessments • Networking

3. About Me I have worked in IT for 20 years, HIT for 15 years in various roles, including consultant, CIO, developer, and project manager • HIT Consultant for MN/ND Regional Extension Center • Rural HIT Network Technical Assistance • TASC HIT Consultant • Worked with HIT Vendor to achieve certification and improve service delivery

4. About Me – Non healthcare-related • Physicist: B.S. and M.S. • Musician: Bass, Upright Bass, and Guitar • PhD Student: Business Administration (innovation process) • Ham Radio: N0AU • Astronomy • Rural dweller: Hibbing, MN • Various other hobbies

5. Agenda • Brief overview of Meaningful Use • Quality requirements within Meaningful Use • Why are they difficult? • Things to be aware of (tips and tricks) • MBQIP and relation to MU quality reporting • MU Stage 2 • What to expect • How to prepare

6. Meaningful Use – Stage 1 • 24 objectives and measures for eligible hospitals (EH) • 14 are required (“core”), up to 5 of the remaining 10 may be differed to Stage 2 (“menu”) • 9 require yes / no attestation; 15 require data submission • In 2012, clinical quality metrics will be reported electronically • To meet certain objectives/measures, 80% of patients seen during the reporting period must have records in the certified EHR technology

7. Core Criteria (page 1 of 3) (n/d EHR): Numerator divided by denominator of all unique patients seen during the measurement period whose records are maintained in a certified EHR (n/d all): Numerator divided by denominator of all unique patients seen during the measurement period CPOE and ePrescribe excluded if < 100 scripts written

8. Core Criteria (page 2 of 3) (n/d EHR): Numerator divided by denominator of all unique patients seen during the measurement period whose records are maintained in a certified EHR Exclusion if pts ht, wt, & BP have no relevance to scope of practice

9. Core Criteria (page 3 of 3) (n/d EHR): Numerator divided by denominator of all unique patients seen during the measurement period whose records are maintained in a certified EHR Clinical information must be sent between different legal entities with distinct certified EHR technology or other system that can accept the information and not between organizations that share certified EHR technology “Diagnostic test results “ are all data needed to diagnose and treat disease, such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, and pulmonary function tests.

10. Quality Reporting: Just one of the requirements right? (n/d EHR): Numerator divided by denominator of all unique patients seen during the measurement period whose records are maintained in a certified EHR Exclusion if pts ht, wt, & BP have no relevance to scope of practice

11. HIT Concept Diagram

12. Quality and HIT How can HIT and an EHR improve quality? • Standardized protocols based on evidence-based best practices • Problem lists • Reminders • Improved communication • Reduced duplication • Clinical Decision Support • Engaged Patients (Personal Health Records, Patient charting)

13. Quality of Diabetes Care: Patients Treated by Physicians using EHR vs. Paper Medical Records Standard Protocols Reminders % of Patients Receiving Care A significantly higher proportion of patients being treated by physicians with EHRs received care that aligns with accepted treatment standards * Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.001

14. Why are the quality measures hard? NQF 0371 Venous Thromboembolism prophlaxis within 24 hoursDescription: This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. Measure Developer: The Joint Commission http://onc-chpl.force.com/ehrcert/EHRCriterionList#clinical.inpatient

15. The details… Where are these documented? Is that where the vendor EXPECTS them? • Numerator: • Patients who received VTE prophylaxis or have documentation why noVTE prophylaxis was given:? the day of or the day after hospital admission? the day of or the day after surgery end date for surgeries that start the day of or the day afterhospital admission • Denominator: • All patientsInclusions: Not applicable • Exclusion: • Patients:? Patients less than 18 years of age? Patients who have a length of stay (LOS) < two days and > 120 days? Patients with Comfort Measures Only documented? Patients enrolled in clinical trials? Patients who are direct admits to intensive care unit (ICU), or transferred to ICU theday of or the day after hospital admission with ICU LOS = one day? Patients with ICD-9-CM Principal Diagnosis Code of Mental Disorders or Stroke asdefined in Appendix A, Table 7.01, 8.1 or 8.2? Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics or VTE asdefined in Appendix A, Table 7.02, 7.03 or 7.04? Patients with ICD-9-CM Principal Procedure Code of Surgical Care ImprovementProject (SCIP) VTE selected surgeries as defined in Appendix A, Tables 5.17, 5.19,5.20, 5.21, 5.22, 5.23, 5.24 Source: NQF 0371 from National Quality Forum – http://www.qualityforum.org

16. Talk to your vendor! It’s important to understand how your EHR vendor has implemented the quality measures, based on their certification testing • Where does the critical information for the report need to be entered, and by whom? • How do you run the reports? • Understand the quality measures and ask your vendor specific questions about values in the numerator, denominator, as well as exclusions • http://qualityforum.org • Understand what is required before implementation!

17. MBQIP MBQIP will likely be Custom Reports • Learn your system (particularly the “data dictionary” and report writing software) • There may be easier alternatives • Web-based tools specifically for your system • Report packages – but be careful… • Talk to your neighbors! • Work together with similar facilities that have the same software. You may be able to pool resources • Talk to your vendor and share specs with them – they may be REQUIRED to provide the reports by contract!

18. MBQIP Measures Phase 1 (2011 – 2012): • Pneumonia: Hospital Compare CMS Core Measure (participate in all sub-measures); AND • Congestive Heart Failure: Hospital Compare CMS Core Measure (participate in all sub-measures) Phase 2 (September 2012): • Outpatient 1-7: Hospital Compare CMS Measure (all sub-measures that apply); AND • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Phase 3 (September 2013): • Pharmacist CPOE/Verification of Medication Orders Within 24 Hours; AND • Outpatient Emergency Department Transfer Communication

19. Phase 1 Measures: The Details Pneumonia: CMS Hospital Compare Core Measure (participate in all sub-measures); • PN-2: Pneumococcal Vaccination • PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received • in Hospital • PN-4: Adult Smoking Cessation Advice/Counseling • PN-5c: Initial Antibiotic Received Within 6 Hours of Hospital Arrival • PN-62: Initial Antibiotic Selection for CAP in Immunocompetent Patient • PN-7: Influenza Vaccination Congestive Heart Failure: CMS Hospital Compare Core Measure (participate in all sub-measures) • HF-1: Discharge Instructions • HF-2: Evaluation of LVS Function • HF-3: ACEI or ARB for LVSD • HF-4: Adult Smoking Cessation Advice/Counseling

20. Meaningful Use – Stage 2 Timing: Not sure! Speculation is not until 2014… • Electronic report transmittal (not merely attesting that reports are available, just like in 2012) • Higher thresholds for things like smoking status, CPOE participation, etc • Menu items become core • More reports, potentially hundreds more, likely about 80 • Greater focus on EHR as a driver of quality • Vendors will need to recertify • Lessons learned from Stage 1 are causing a re-think of a a number of the measures…

21. Useful Websites National Quality Forum: http://www.qualityforum.org Hospital Compare Data Specifications (Search for Specifications Manual) http://www.qualitynet.org ONC-CHPL: http://onc-chpl.force.com ONC’s Health IT Site http://Healthit.gov National Rural Health Resource Center http://www.ruralcenter.org

22. Joe Wivoda CIO & HIT Consultant National Rural Health Resource Center 600 East Superior Street, Suite 404 Duluth, MN 55802 (218) 262-9100 jwivoda@ruralcenter.org