Quality Measures for
Meaningful Use and Beyond
Melissa Swanfeldt,
Associate Vice President, MEDITECH
Anita Karcz, MD,
Chief Medical Officer, Institute for Health Metrics
• Stage 1 Clinical Quality Measures for Meaningful Use
• Quality Measure Trends Beyond MU
• What we know about Stage 2 CQMs
Eligible Hospital Reporting for Meaningful Use
15 e-Measures
• Stroke
• VTE
• ED Throughput
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
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
IHM Daily Reports
IHM Individual Patient Data Drilldowns
IHM Meaningful Use Trending
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
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
Dual Environment Challenges
Quality Measurement Governance
Data Collection Issues
Performance Rate Validation
Public Reporting Issues
Change Management
Clinician Education
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."
VBP Current Two Domains
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
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
Performance Percentages
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
1
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
(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
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.
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
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.
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
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!
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
Quality
Alert
Twice Daily
Reports
on Patients
Still in
House
IHM Quality Alert Daily Reports Dashboard
Data dashboards highlight what is done and what needs to
be done
IHM Quality Alert Daily Reports
Click to more case detail
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
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
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.
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
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
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
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
What we know about Stage 2 CQM’s
•
113 NQF Endorsed Measures
• 39 Hospital Measures
• 83 Eligible Professional Measures
• Practice
• Radiology
• Oncology
MEDITECH Prepares for Stage 2
Quality Reports
•
Specification Review
• Best Practice workflows
• Focus Groups
• Nomenclature Mapping Tools