Indiana Rural Health Association
BethAnn Perkins, RN
Health Consulting Strategies, Inc.
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Annual vs. Ongoing
Snap shot for planning vs. Benchmarking for
improvement
Meeting the minimum program requirements
vs. Striving for Excellence!
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Benchmarking against National Standards
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Why Measure
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Meaningful Use Quality Measures
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National Quality Forum Measures
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Unified Data Sets (UDS)
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HRSA/CMS Workgroup
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Establishing a baseline for quality
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Benchmarking for Improvement
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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
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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
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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
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Measure
Indicator
Performance
Measure
Dashboard
Standard
Quality Measure
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Relevance.
 Does the indicator relate to a condition that occurs frequently or
have a great impact on the patients at your facility?
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Measurability.
 Can the indicator realistically and efficiently be measured given
the facility’s finite resources?
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Accuracy.
 Is the indicator based on accepted guidelines or developed
through formal group-decision making methods?
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Improvability.
 Can the performance rate associated with the indicator
realistically be improved given the limitations of your clinical
services and patient population?
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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
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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.
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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
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Two Categories of Measures for Reporting
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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
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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.
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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.
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Clinical Quality Measures –Core Set
NQF Measure Number & PQRI
Implementation Number
Clinical Quality Measure Title
NQF 0013
Hypertension: Blood Pressure
Measurement
NQF 0028
Preventive Care and Screening
Measure Pair: a) Tobacco Use
Assessment, b) Tobacco Cessation
Intervention
NQF 0421
PQRI 128
Adult Weight Screening and Followup
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Clinical Quality Measures –Alternate Core Set
NQF Measure Number & PQRI
Implementation Number
Clinical Quality Measure Title
NQF 0024
Weight Assessment and Counseling
for Children and Adolescents
NQF0041
PQRI 110
Preventive Care and Screening:
Influenza Immunization for Patients50
Years Old or Older
NQF 0038
Childhood Immunization Status
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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
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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
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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
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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
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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
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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
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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%)
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Required for HRSA Funded Health Centers
and National Health Service Corp Sites
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Health Disparities
Clinical Performance Measure
Diabetes
Percentage diabetic patients whose
HbA1c levels are less than 7 percent, less
than 8 percent, less than or equal to 9
percent, or greater than 9 percent
Cardiovascular Disease
Hypertension: Percentage of adult
patients with diagnosed hypertension
whose most recent blood pressure was
less than 140/90
BMI
Percentage of patients age 18 years or
older who had their Body Mass Index
(BMI) calculated at the last visit or within
the last six months and, if they were
overweight or underweight, had a followup plan documented
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Health Disparities
Clinical Performance Measure
Prenatal Care
Percentage of pregnant women
beginning prenatal care in the first
trimester
Immunizations
Percentage of children with 2nd birthday
during the measurement year with
appropriate immunizations
Cervical Cancer
Percentage of women 21-64 years of age
who received one or more tests to screen
for cervical cancer
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Health Disparities
Clinical Performance Measure
Childhood Obesity
Percentage of patients age 2 to 17 years who
had a visit during the current year and who
had Body Mass Index (BMI) Percentile
documentation, counseling for nutrition, and
counseling for physical activity during the
measurement year
Tobacco Use
Percentage of patients age 18 years and
older who were queried about tobacco use
one or more times within 24 months
Percentage of patients age 18 years and
older who are users of tobacco an who
received (charted) advice to quit smoking or
tobacco use
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Health Disparities
Low Birth Weight
Clinical Performance Measure
Percentage of births less than 2,500
grams to health center patients
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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)
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Two Year Old Immunizations
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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)
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Two Year Old Immunizations
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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
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No exclusions
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Two Year Old Immunizations
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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
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Documentation can be obtained from statewide or other registries
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Two Year Old Immunizations
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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
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Two Year Old Immunizations
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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
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Health Disparities
Diabetes
Clinical Performance Measure
Percent of adult patients, 18-75 years of
age with diabetes (type 1 or type 2) who
had hemoglobin A1c less than 8.0%
Percent of adult patients, 18-75 years of
age with diabetes (type 1 or type 2) who
had blood pressure less than 140/90
mmHg
Percent of adult patients, 18- 75 years of
age with diabetes (type 1 or type 2) who
had LDL less than 100 mg/dL
Percentage of patients aged 18 years and
older with diabetes (type 1 or type 2) 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.
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Health Disparities
Cardiovascular
Clinical Performance Measure
Percentage of adult patients, 18-85 years
of age, who had a diagnosis of
hypertension and whose blood pressure
was adequately controlled during the
measurement year
Percent of adult patients with coronary
artery disease who had LDL less than 100
mg/dL
Percentage of patients aged 18 years and
older with cardiovascular disease 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.
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Health Disparities
Tobacco Use
Clinical Performance Measure
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.
Percentage of patients aged 18 years and
older identified as tobacco users within the
past 24 months who received cessation
intervention.
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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
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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
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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
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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).
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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
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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
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Pediatrics
Adult
Geriatric
Women
Behavioral
Patient Satisfaction
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Get information, tip sheets and more at CMS’
official website for the EHR incentive programs:
◦ http://www.cms.gov/QualityMeasures/03_ElectronicSpecifi
cations.asp
◦ http://bphc.hrsa.gov/policiesregulations/performancemeas
ures/updatedfy2012measures.pdf
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BethAnn Perkins, RN
Health Consulting Strategies, Inc.
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