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Quality Reporting in the era of Health Information Technology
David A Nelsen, Jr, MD, MSAssociate ProfessorAssociate Chief Medical Officer for
Clinical Informatics
Quality Reporting in the era of Health Information Technology
Quality Reporting & Meaningful UseQuality Reporting & Quality ImprovementExperiences with QR & QILooking to the Future
Quality Reporting & Meaningful Use
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.
Core Clinical Quality MeasuresMeasure Recommended Measure Title Recommended Measure Description
0013 AMAHypertension: Blood
Pressure Measurement
Percentage of patient visits for patients aged
18 years and older with a diagnosis of
hypertension who have been seen for at least 2
office visits, with blood pressure (BP) recorded.
0028a AMAPreventive Care and
Screening Measure Pair: a. Tobacco Use Assessment
Percentage of patients aged 18 years or older
who have been seen for at least 2 office visits,
who were queried about tobacco use one or
more times within 24 months.
0028b AMA
Preventive Care and
Screening Measure Pair: b. Tobacco Cessation
Intervention
Percentage of patients aged 18 years and older
identified as tobacco users within the past 24
months who received cessation intervention.
0421 QIPAdult Weight Screening and
Follow‐Up
Percentage of patients aged 18 years and older
with a calculated BMI in the past six months or
during the current visit documented in the
medical record AND if the most recent BMI is
outside parameters, a follow‐up plan is
documented.
Additional Clinical Quality IndicatorsMeasure Recommended Measure Title
0001 Asthma Assessment
0002Appropriate Testing for Children with
Pharyngitis
0004Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment
0012Prenatal Care: Screening for Human
Immunodeficiency Virus (HIV)
0014 Prenatal Care: Anti‐D Immune Globulin
0018 Controlling High Blood Pressure
0024Weight Assessment and Counseling for Children
and Adolescents
0027Smoking and Tobacco Use Cessation, Medical
assistance
0031 Breast Cancer Screening
0032 Cervical Cancer Screening
0033 Chlamydia Screening for Women
0034 Colorectal Cancer Screening
0036 Use of Appropriate Medications for Asthma
0036 Use of Appropriate Medications for Asthma
0038 Childhood immunization Status
0041Preventive Care and Screening: Influenza Immunization for
Patients ≥
50 Years Old
0043 Pneumonia Vaccination Status for Older Adults
0047 Asthma Pharmacologic Therapy
0052 Low Back Pain: Use of Imaging Studies
0055 Diabetes: Eye Exam
0056 Diabetes: Foot Exam
0059 Diabetes: HbA1c Poor Control
0061 Diabetes: Blood Pressure Management
0062 Diabetes: Urine Screening
0064 Diabetes: LDL Management & Control
0067Coronary Artery Disease (CAD): Oral Antiplatelet Therapy
Prescribed for Patients with CAD
0068Ischemic Vascular Disease (IVD): Use of Aspirin or another
Antithrombotic
0070Coronary Artery Disease (CAD): Beta‐Blocker Therapy for
CAD Patients with Prior Myocardial Infarction (MI)
Additional Clinical Quality Indicators
0070Coronary Artery Disease (CAD): Beta‐Blocker Therapy
for CAD Patients with Prior Myocardial Infarction
(MI)
0073Ischemic Vascular Disease (IVD): Blood Pressure
Management
0074Coronary Artery Disease (CAD): Drug Therapy for
Lowering LDL‐Cholesterol
0075Ischemic Vascular Disease (IVD): Complete Lipid Panel
and LDL Control
0081
Heart Failure (HF) : Angiotensin‐Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
0083Heart Failure (HF): Beta‐Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD)
0084Heart Failure (HF) : Warfarin Therapy Patients with
Atrial Fibrillation
0086Primary Open Angle Glaucoma (POAG): Optic Nerve
Evaluation
0088Diabetic Retinopathy: Documentation of Presence or
Absence of Macular Edema & Level of Severity of
Retinopathy
0089Diabetic Retinopathy: Communication with the
Physician Managing Ongoing Diabetes Care
0105Anti‐depressant medication management: (a) Effective
Acute Phase Treatment, (b)Effective Continuation Phase
Treatment
0385Oncology Colon Cancer: Chemotherapy for Stage III
Colon Cancer Patients
0387Oncology Breast Cancer: Hormonal Therapy for Stage
IC‐IIIC Estrogen Receptor/Progesterone Receptor
(ER/PR) Positive Breast Cancer
0389Prostate Cancer: Avoidance of Overuse of Bone Scan
for Staging Low Risk Prostate Cancer Patients
0575 Diabetes: HbA1c Control (<8%)
Quality Reporting & Meaningful Use
We have adopted the suggested approach for 2011 and 2012 that limits the required information on clinical quality measures results to that which can be automatically calculated by the certified EHR technology. As to non-certified EHR technology, the HITECH Act incentive program specifically requires the meaningful use of certified EHR technology.
Quality Reporting & Meaningful Use
We agree with the desirability of considering the three transmission methodologies listed in the proposed rule. The submission through a portal is the only mechanism that is feasible and practical for 2012 electronic clinical quality measure submission. We plan to test HIE/HIO and registry submission for future possible implementation through HITECH.
Quality Reporting & Certification
Quality Reporting-the reality
Hypertension: Blood Pressure MeasurementPercentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded.
Quality Reporting-the reality
Required Elements to Report 0013 (hypertension: BP measurement)
NPI of providerPatient date of birthDate(s) of office visit(s) with NPIDate of report (sliding window)Problem list contains 401.*Systolic BP observation on DOSDiastolic BP observation on DOSExclusions?
Quality Improvement in the era of Health Information Technology
David A Nelsen, Jr, MD, MSAssociate ProfessorAssociate Chief Medical Officer for
Clinical Informatics
Quality Improvement
Acronym Soup
TRIZ
改善
Quality Improvement
“Customer” FocusedLeadershipInvolvement of relevant personsProcess drivenSystems approach to ManagementContinuous ImprovementData drivenReciprocally beneficial relationships
Quality Improvement
“Retrospective” ModalitiesQuality AssuranceRisk ManagementRoot Cause AnalysisFMEA
Quality Improvement
“Real-Time” QIClinical Decision Support (CDS)
Knowledge BaseInference “engine”Interface/Display
“Basic” CDSPreventive remindersDisease management guidelines
Quality Improvement
“Intermediate” CDSDrug-Drug interactionsDrug-Allergy
“Advanced” CDSDrug-Lab resultDrug-ProblemProblem-Lab resultProblem-Observation
Meaningful Use
Stage 1-”...implementing clinical decision support tools to facilitate disease and medication management...”Stage 2-”... build upon Stage 1 by both altering the expectations of the functionalities in Stage 1 and likely adding new functionalities...”Stage 3-”... focus on promoting improvements in quality, safety and efficiency leading to improved health outcomes, focusing on decision support for national high priority conditions...”
CMS & Pay for Performance
Medicare Care Management Performance (MCMP)Physician’s Quality Reporting Initiative (PQRI) E-Prescribing Incentive Program
Quality Reporting [ ]C
Medicare Care Management Performance (MCMP)
Demonstration project (7/2007-6/2010)Promote adoption of HIT in small & medium size MD officesImprove care for patientsBonus payments for Doctors who meet or exceed CMS standards
MCMP
Medicare and Medicaid Prescription Drug, Improvement, and Modernization act of 2003In coordination with Doctor’s Office Quality Information Technology (DOQ-IT) in AR, CA, MA & UTImplementation locally by QIO
MCMP
DOQ-IT participation required for MCMPVoluntary
No play, no payTied to NPIElectronic Results SubmissionSubmit ALL requested data
Submit to audits as required
Nuts & Bolts
Initial phase “Pay for Reporting”Quality data for 2006 as baselinePayment based on # of beneficiaries, not performance.
Subsequent years reported 3-4 mos after year closed out to allow claims to be processedSome data from claimsOther clinical measures (bonus for EMR)
Table 1: Clinical Quality Measures in the MCMP Demonstration
Diabetes Heart Failure Coronary Artery Disease Preventive Care
(measured on population with specified chronic diseases)
DM-1 HbA1c Management
HF-1 Left Ventricular Function Assessment
CAD-1 Antiplatelet Therapy PC-1Blood Pressure Measurement
DM-2 HbA1c Control
HF-2 Left Ventricular Ejection Fraction Testing
CAD-2 Drug Therapy for Lowering LDL Cholesterol
PC-5 Breast Cancer Screening
DM-3 Blood Pressure Mgmnt
HF-3 Weight Measurement CAD-3 Beta Blocker Therapy – Prior MI
PC-6 Colorectal Cancer Screening
DM-4 Lipid Measurement
HF-5 Patient Education CAD-5 Lipid Profile PC-7 Influenza Vaccination
DM-5 LDL Cholesterol Level
HF-6 Beta Blocker Therapy CAD-6 LDL Cholesterol Level
PC-8 Pneumonia Vaccination
DM-6 Urine Protein Testing
HF-7 ACE Inhibitor/ARB Therapy
CAD-7 ACE Inhibitor/ARB Therapy
DM-7 Eye Exam HF-8 Warfarin Therapy for Patients with AF
DM-8 Foot Exam##
Original DOQ-ITHeart Failure (HF-cont’d)
Weight Measurement ACE Inhibitor Therapy Warfarin Therapy for Patients with Atrial Fibrillation Blood Pressure Screening ##
Hypertension (HTN)Blood Pressure Screening ##Blood Pressure Control ##Plan of Care documented ##
Preventive Care (PC) Blood Pressure Measurement Colorectal Cancer Screening Tobacco Use ##LDL Cholesterol Level Tobacco Cessation ##Lipid Measurement ##Influenza Vaccination Breast Cancer Screening Pneumonia Vaccination
Coronary Artery Disease (CAD)Antiplatelet Therapy Lipid Profile Drug Therapy for Lowering LDL Cholesterol LDL Cholesterol Level Beta-Blocker Therapy—with prior MI ACE Inhibitor Therapy Blood Pressure Measurement ##
Diabetes Mellitus (DM)HbA1c Management Lipid Measurement HbA1c Management control ##LDL Cholesterol Level Blood Pressure Management Urine Protein Testing Eye Exam Foot Exam
Heart Failure (HF)Left Ventricular Function (LVF) Assessment Patient Education Left Ventricular Function (LVF) Testing Beta-Blocker Therapy
PQRI Measures
2007: 74 measures2008: 134 measures
0
50
100
150
200
250
300
2007 2008 2009 2010 2011 2012
2009: 186 measures2010: 216 measures
?
PQRI typical measure
Measure #1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
DENOMINATOR: Patients aged 18-75 years with the diagnosis of diabetes Denominator Coding: An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify denominator patients.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04
AND one of theseCPT E/M service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
PQRI typical measure
Measure #1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
NUMERATOR: Patients with most recent hemoglobin A1c level > 9.0% Numerator Instructions: This is a poor control measure. A lower rate indicates better performance (e.g., low rates of poor control indicate better care)
Numerator Coding: Most Recent Hemoglobin A1c Performed:
CPT II 3046F: Most recent hemoglobin A1c level > 9.0% ORCPT II 3044F: Most recent hemoglobin A1c level < 7.0% ORCPT II 3045F: Most recent hemoglobin A1c level 7.0% to 9.0% ORHemoglobin A1c not Performed, Reason Not Specified
UAMS MCMP Experience
2 Primary Care ClinicsFamily Medicine-Faculty & resident PhysiciansSenior Health-Faculty, Fellows, APN clinicians
EMR since 1998Strong physician leadershipPDSA QI Model
UAMS requirements to accomplish MCMP
Point of Care tools in the EMRReal-time documentation of non-flowsheet items
Diabetic foot examOutside labs
Real-time analysis of deficiencies“services due” protocolsComplex guidelines
Item completion aids
EMR Examples
EMR Examples
EMR Examples
UAMS requirements to accomplish MCMP
Reporting Tools'drill down' at the enterprise, clinical practice, provider type (resident, faculty, APN), and individual patient level. Ongoing summaries of all MCMP performance parameters. Reports to??
Chair, medical directors, dean, individual?
Performance Reporting
FM Faculty Performance Using HEDIS-like Measures compared to NCQA 2004 database
84
48
66 68
57
72
59
42
86
57
72 72
60
72
81
50
91
48.8 52
86.6
73.5 80
.9
49
66.8
93.5
64.9
58.5
89.1
74
0
52.6
64.6
75.9
45 46.7
76
54.1 64
.7
0
61.4
0102030405060708090
100
ldl chol/DM eye/DM renal/DM hgba1c mammo pap CRC htn control
FMC faculty 04-05 FMC faculty qtr 1 2006 NCQA Com insurance 2004 NCQA Medicare 2004 NCQA Medicaid 2004
Performance Reporting
MCMP Results- UAMS Family Medicine
Year 1 $5000Year 2 ~$27000Year 3 ~$32000Year 4
The Future of Quality Reporting & Quality Improvement
Hospital & Outpatient Quality Measurement and ReportingFORMAL Quality Improvement will be essential and desirableTightly defined numerators and denominators = Apples to ApplesElectronic Medical Records/HIT It’s the Workflow, (stupid)
