Quality Measures for Meaningful Use and Beyond

1. Quality Measures for Meaningful Use and Beyond Melissa Swanfeldt, Associate Vice President, MEDITECH Anita Karcz, MD, Chief Medical Officer, Institute for Health Metrics

2. Stage 1 Clinical Quality Measures for Meaningful Use • Quality Measure Trends Beyond MU • What we know about Stage 2 CQMs

3. Eligible Hospital Reporting for Meaningful Use 15 e-Measures • Stroke • VTE • ED Throughput

4. Challenges • Value sets use vocabularies not used widely in EHRs (SNOMED CT, RxNorm) • e-Measure specifications contain multiple errors and inconsistencies • HITSP Specification TN906 has over 500 data elements in the 15 measures • Data capture must be in discrete fields • Impact on workflow for clinicians

5. Best Practice Guidance for Data Capture • Nomenclature Mapping • LOINC • SNOMED CT and ICD-9 for problems • RxNorm • Exclusions • Contraindications • Clinical trials ARRA Quality Reporting Page

6. IHM Daily Reports

7. IHM Individual Patient Data Drilldowns

8. IHM Meaningful Use Trending

9. Stage 1 CQM’s for Eligible Professionals 44 Ambulatory Clinical Quality Measures • 3 Core/3 Alternate Core • 3 Additional Measures • Use of MPM Clinical Reporting Tool for Stage 1 • Performance and Outcomes are not measured

10. Quality Reporting Landscape Beyond Meaningful Use • CMS Proposed Measures for 2012 • National Quality Forum (e-Measures) • Dual Environment (abstracted/ e-measures) • Value-Based Purchasing • Accountable Care

12. Dual Environment Challenges Quality Measurement Governance Data Collection Issues Performance Rate Validation Public Reporting Issues Change Management Clinician Education

13. Value Based Purchasing In a statement that launched the CMS VBP program, HHS Secretary Kathleen Sebelius said, “Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us. Under this initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy."

15. VBP Current Two Domains

16. VBP Payment Reductions Starting in FY2013, a reduction of diagnosis-related group (DRG) payments will fund hospital payments under the VBP program. Reductions on the base DRG for each year: FY2013 - 1 percent FY2014 - 1.25 percent FY2015 - 1.5 percent FY2016 - 1.75 percent FY2017 - 2 percent

17. Baseline Performance Period Hospitals will be scored on their performance on clinical measures and HCAHPS from July 1, 2011 through March 31, 2012 Hospitals will be evaluated by: Achievement-compared to all hospitals’ baseline performance Improvement-current individual hospital performance compared to baseline performance Quality measure ROI - see reference section of these slides for AHA information

18. Performance Percentages

19. Illustration: VBP Scoring for a Measure Note: Less than achievement threshold= 0 achievement points; greater than/equal benchmark = 10 points; other = 1 to 9 points based on formula 19

20. Note : Threshold score is the minimum achievement threshold required Threshold score is the minimum achievement threshold required to be awarded any achievement points for a measure…median of all hospital scores. Benchmark score is the mean of the top 10% of all hospital scores; maximum points awarded if meet/exceed

21. (1)All performance standards will be reset before each FY; (2) Measure “dimensions” differ slightly from Hospital Compare; (3)HCAHPS score based on “top-box” responses

22. VBP-The Third Domain CMS is adopting its proposal to add a third quality domain, the patient outcomes domain, to the FY 2014 VBP Program. CMS did not propose or adopt a weight for the patient outcomes domain, but will do so in future rule-making.

23. FY 2014 proposed outcome domain Mortality Measures AMI 30-day mortality HF 30-day mortality PN 30-day mortality AHRQ PSI and IQI Composite Measures Complication/patient safety for selected indicators (composite) Mortality for selected medical conditions (composite) HAC Measures Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma: (includes fracture, dislocation, intracranial injury, crushing injury, burn, electric shock) Vascular Catheter-Associated Infections Catheter-Associated Urinary Tract Infection (UTI) Manifestations of Poor Glycemic Control

25. VBP - The Fourth Domain Using the recently released FY 2012 IPPS proposed rule as a vehicle, CMS has proposed to add a fourth domain, the efficiency domain, to the FY 2014 VBP Program. This domain would use claims data to develop a Medicare spending per beneficiary measure. The measure would be scored using the same methodology adopted for the process of care and patient experience of care domains. CMS did not propose a weight for the efficiency domain but will do so in future rule-making.

26. Getting Ready for VBP Collect and analyze indicators and your scores Execute solutions to improve performance • Improve clinical processes to maximize VBP scores • Implement infrastructure to improve quality: • develop strategy and governance • align incentives • inspire change Implement IT to support quality Coordinate with Meaningful Use efforts Continuous improvement

27. Making it happen Interdisciplinary working group with responsibility and resources IT, quality, nursing, ED, registration, physicians Include the front line, not just management Involve and educate the front line Feedback-early and often Communicate!

28. IHM’s Approach to VBP Concurrent review of care delivered to patients while they are still in the hospital Improve efficiency for quality and case management staff No extra burden on IT No technology barriers for clinical users

29. Quality Alert Twice Daily Reports on Patients Still in House

30. IHM Quality Alert Daily Reports Dashboard Data dashboards highlight what is done and what needs to be done

31. IHM Quality Alert Daily ReportsClick to more case detail

32. Techniques CHF-preliminary discharge instructions given on admission that include written instructions addressing activity level, diet, discharge medications, follow-up appointment, weight monitoring and what to do if symptoms worsen. Starting point for patient education process. Smoking cessation-Nurse unable to close admission profile on the EMR without addressing the  advice/counseling questions if patient smokes or has smoked in the past 12 months CHF-electronic discharge flowsheets for physicians to complete with prompts to remind the physician of medications that need to be ordered or an area for documentation of contraindications Above from case studies on IHI website

33. Techniques A multidisciplinary team that identifies and corrects problems, standing orders and reminder systems Proactive identification of patients, prompts to provide appropriate care, ED standing orders, ongoing assessment, reporting, and peer review, financial incentives for unit managers Reports identifying eligible patients, documentation of core measure-related care, real-time review of patient care, investigation of variances, ongoing sharing of performance data, sharing and spreading of best practices Above from case studies on AHRQ site

34. What are Accountable Care Organizations? • Groups of providers, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. • The purpose of ACOs will be to foster change in patient care so as to accelerate progress toward a three-part aim: better care for individuals, better health for populations, and slower growth in costs through improvements in care.

35. Key Concepts • Accountability for Patient’s Overall Care (Fee-for-Service) • Financial Incentives to Coordinate Care and Reduce Costs • Emphasis on Disease Management and Population Health • Patient-Centered Care • Reporting Capabilities for Evaluating Quality and Cost Measures • Patient Engagement

36. Quality Performance Standard is Established • The final rule also relaxed the transition to pay for performance  • The first year will be pay for reporting, but the second and third years will combine pay for reporting and pay for performance

37. Quality Reporting for ACO’s • In order to receive shared savings, ACO must meet quality standards and reduce costs • The Quality Assessment methodology proposed by CMS is designed to determine whether an ACO has achieved these two goals • Focus is on providing better care to individuals and better health for populations • 33 Quality Measures fall into 4 domains • Patient Experience of Care (7) • Care Coordination and Patient Safety (6) • Preventive Health (8) • At-Risk Populations (12) • Diabetes • Hypertension • Ischemic vascular disease • Heart failure • Coronary artery disease

38. Quality Reporting for ACO’s (cont.) • CMS relaxed proposal to require 50 percent of an ACO’s participating physicians to be meaningful users and the hope is to promote provider participation. CMS believes that the use of EHR is a valued part of the Quality Measure Process • CMS tried to use measures that were already being used under other programs to reduce the administrative burden of quality reporting • Most of the proposed measures can be derived from existing CMS programs and resources such as: • CMS Value-Based Purchasing Initiatives • Physician Quality Reporting System (“PQRS”) • eRx Incentive Program • HITECH/MU • CDC National Health Care Safety Network

39. What we know about Stage 2 CQM’s • 113 NQF Endorsed Measures • 39 Hospital Measures • 83 Eligible Professional Measures • Practice • Radiology • Oncology

40. MEDITECH Prepares for Stage 2 Quality Reports • Specification Review • Best Practice workflows • Focus Groups • Nomenclature Mapping Tools