2011 Clinical
Measures
Enhancements
For Reporting
February 15, 2012
Objectives for Today’s Presentation
 Today’s presentation is designed to help grantees
understand:
• What the new measures are and why they are being
added
• How to complete and submit Clinical Measures data
on Tables 6B and 7 of the 2011 UDS
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Background and Overview of
the Clinical Measures
Background and Overview
2011 UDS Clinical Measures
 The 2011 Clinical Measures enhancements were vetted in the
same way as earlier measures
• Published initially as PAL 2010-12 on 8/30
• http://bphc.hrsa.gov/policiesregulations/policies/pdfs/pal
201012.pdf
• Subsequently announced in Federal Register
• Comments and recommendations solicited from health
centers, PCAs, PCOs, and the general public
• Comments were reviewed and package was approved by
OMB January 3, 2011
• Introduced in the 2010-11 UDS Training
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Background and Overview
2011 UDS Clinical Measures
 Four Clinical Measures in three clinical areas have been
added to the measures which will be used in grant
applications and in the UDS
• Weight assessment and counseling for children and
adolescents
• Adult weight screening and follow-up
• Tobacco use assessment and cessation counseling pair
• Asthma – Pharmacological treatment
 Two existing measures are being modified
• Vaccines for children are updated to current standards
• Hemoglobin A1C goals for diabetics are expanded
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Background and Overview
Today
 Data to document performance on these four new measures
are being collected during CY-2011
 No new data over and above that needed for rigorous charting
should be necessary
• Electronic Health Records (EHRs) may be used
• Chart reviews may still be used as appropriate
• Use of CPT Category II codes may simplify process
 No new clinical activities should be necessary to report the
Clinical Measures
 Data will be submitted in the 2011 UDS
6
Clinical Measures
and the HRSA Data Strategy
Clinical Direction
Focus on Quality
 New clinical measures will allow BPHC and health
centers to demonstrate the quality of patient care using
an enhanced set of measures which are part of the CMS
“Meaningful Use” data set
• New measures focus on preventive health care
• Most have AMA CPT-II codes
• All qualify under the Meaningful Use rules
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Clinical Direction
Focus on Comparability
 New clinical measures are being adopted by a wide
range of non-330 organizations
• Permits BPHC to demonstrate the quality and value
of care provided at health centers
• Permits health centers to obtain comparable
information in their states and the nation
• BPHC will continue to provide reports which permit
health centers to identify appropriate individual
targets for quality improvement
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Clinical Direction
Focus on Integration
 BPHC will integrate these new clinical measures into the
SAC and BPR grant applications
• First year will permit its use as baseline data
• In the future, baseline data can be edited
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Clinical Direction
Focus on Meaningful Use
 2011 Clinical Measures reporting further prepares
grantees to meet CMS’s “Meaningful Use”
implementation requirements
 The additional Measures promote and support
implementation of EHR data collection and reporting
procedures by health centers
 Measures are recognized by the National Quality Forum
(NQF)
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Quality of Care Measures
Overview
Quality of Care Measures - 1
 The new measures will be included on Table 6B as
quality of care measures, consistent with the manner in
which BPHC has been reviewing Primary Prevention
measures in the past.
 These measures are all “process” measures:
• If patients receive timely routine and preventive care,
then we can expect improved health status
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Overview
Quality of Care Measures - 2
 Weight assessment and counseling for children and adolescents
• IF clinicians ensure that patients’ Body Mass Index Percentile
is recorded, and patients (and parents) are counseled on
nutrition and physical activity regardless of the patient’s
weight THEN the likelihood of obesity and its sequela will be
reduced
 Adult Weight screening and follow up
• IF clinicians routinely calculate and record the BMI for adult
patients, identify patients with weight problems and develop a
follow up plan for overweight and underweight patients, THEN
the likelihood of the debilitating sequela of serious weight
problems can be reduced
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Overview
Quality of Care Measures - 3
 Tobacco use assessment
• IF patients are routinely queried about their tobacco use
(including smokeless tobacco) THEN providers will be able
to intervene more quickly and effectively and reduce the
incidence of cancer, asthma, emphysema, and other
tobacco related illnesses
 Tobacco use intervention
• IF tobacco users are provided with an effective mix of
counseling and pharmacologic intervention THEN tobacco
users will be more likely to quit smoking and will therefore
have a lower incidence of cancer, asthma, emphysema,
and other tobacco related illnesses
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Overview
Quality of Care Measures - 4
 Pharmacological treatment of asthmatics
• IF patients identified with persistent asthma are provided
with appropriate pharmacological intervention THEN they
will be less likely to have asthma attacks, they will require
fewer emergency room visits and be less likely to develop
complications related to asthma including death
 Childhood immunizations
• IF children receive their vaccinations in a timely fashion
THEN they will be less likely to contract vaccine
preventable diseases or to suffer from the sequela of these
diseases
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Child and Adolescent Weight
Assessment and Counseling
(NQF 0024)
Child and Adolescent Weight
Measure
 Percent of patients in universe with weight assessment and
counseling documented
• Requires documentation of 3 separate elements; all must be
documented during the measurement year:
• Documentation of BMI percentile (not BMI or weight + height.
Actual percentile must be recorded.)
• Documentation that patient (or patient’s parent as
appropriate) has been counseled on nutrition documentation
that patient (or patient’s parent as appropriate) has been
counseled on physical activity
• Measure calculation:
Line12 Column c (patients with compliance documented)
Line12 Column b (patients in universe or sample)
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Child and Adolescent Weight
Universe and Exclusions
 All children and adolescents who were between 2 and 17
years during the measurement year (i.e., born between
1/1/1994 and 12/31/2009) and
• Had at least one medical visit during the
measurement year
• In an environment which had equipment present to
measure weight and height
• Were first ever seen prior to their 17th birthday
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Child and Adolescent Weight
Documentation of Compliance
 BMI Percentile is noted in chart or EHR
• Well child templates should display BMI percentile, not
just BMI or height and weight.
• BMI growth charts may also document
 Counseling on nutrition and activity should be in charts and
EHRs
• May be narrative form or check box
• Must be specific, i.e., not “counseled pt.”
• Anticipatory guidance to parent is counted when
documented in child’s record
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Child and Adolescent Weight
Completing the UDS: Line 12
 Column a: Number of children and adolescent medical
patients aged 2 to 17 who were seen during the measurement
year.
 Column b: Will be 70 unless a comprehensive EHR is
present, in which case column b will be equal to column a.
 Column c: Number (of those reported in column b) who have
a recorded BMI percentile and recorded counseling on
nutrition and recorded counseling on physical activity
Children and adolescents aged 2 – 17
with a BMI percentile AND counseling
on nutrition and physical activity
documented for the current year
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Child and Adolescent Weight
Data on Overweight/Obese Children
 National Data
16%
 Health Center Patient Survey
21%
 Healthy People 2020 Goal
14%
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Adult Weight Assessment and
Required Followup
(NQF 0421)
Adult Weight and Follow-up
Measure
 Percent of patients in universe with a calculated BMI recorded and
with appropriate followup if indicated.
• Requires possible documentation of 2 separate elements both of
which must be documented in the past six months or during the
current visit:
1. Documentation of BMI (not weight and height – actual
calculated BMI must be recorded.)
2. If patient is overweight (BMI = 25 or over for patients under
65, 30 or over for patients over 65) or if patient is
underweight (BMI < 18.5) Documentation of a followup
plan by provider or by a referral provider
3. Measure calculation:
Line13 Column c (patients with compliance documented)
Line13 Column b (patients in universe or sample)
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Adult Weight and Follow-up
Universe and Exclusions
 All adults who were age 18 or older during the
measurement year (i.e., born before 12/31/1993) and
• Had at least one medical visit during the
measurement year
• In an environment which had equipment present to
measure weight and height
• Were ever seen after their 18th birthday
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Adult Weight and Follow-up
Documentation of Compliance
 BMI is noted in chart or EHR
• Nursing templates (or encounter forms) would
normally show BMI
• Templates usually show height and weight; BMI
may need to be calculated and recorded
separately
• AND (if patient is overweight or under-weight) follow
up weight management plan is documented
• May be with provider
• May be by referral
(successful completion not required)
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Adult Weight and Follow-up
Completing the UDS: Line 13
 Column a: Number of adult medical patients aged 18 and over
seen during the measurement year.
• Will be roughly same as adjusted 18+ year olds on Table 3a
 Column b: Will be 70 unless a comprehensive EHR is present, in
which case column b will be equal to column a
 Column c: Number (of those reported in column b) who have a
recorded BMI and recorded followup plan if patient is overweight
or underweight.
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Adult Weight and Follow-up
Data on Overweight/Obese Adults
 National Data
68%
 Health Center Patient Survey
75%
 Healthy People 2020 Goal
61%
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Tobacco Use Assessment
(NQF 0028a)
Tobacco Use Assessment
Measure
 Percent of patients in universe queried about tobacco use in
the measurement year or the prior year.
• Requires documentation that provider or support staff
asked patient if they used tobacco and the patient’s
response.
 Measurement calculation:
Line14 Column c (patients with compliance documented)
Line14 Column b (patients in universe or sample)
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Tobacco Use Assessment
Universe and Exclusions
 All adults who were age 18 or older during the
measurement year (i.e., born before 12/31/1993) and
• Had at least one medical visit during the
measurement year
• Had at least two medical visits ever
• Were ever seen after their 18th birthday
 No exclusions
(Note that because of the two visit rule, universe is
different than Adult weight)
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Tobacco Use Assessment
Documentation of Compliance
 Tobacco use (not “smoking”) is noted in chart or EHR.
• Documentation that provider or support staff asked
patient if they used tobacco and the patient’s
response.
• CPT Category II Codes can be used to record:
– 1000F = Patient was queried about use
– 1034F = smoker
– 1035F = smokeless tobacco user
– 1036F = non-tobacco user
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Tobacco Use Assessment
Completing the UDS: Line 14
 Column a: Number of adult medical patients aged 18 and over
seen during the measurement year.
• Will be roughly same as adjusted 18+ year olds on Table 3a
 Column b: Will be 70 unless a comprehensive EHR is present, in
which case column b will be equal to column a
 Column c: Number (of those reported in column b) for whom
documentation demonstrates that patient was queried about
tobacco use
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Tobacco Cessation Intervention
(NQF 0028b)
Tobacco Cessation Intervention
Measure
 Percent of universe of known tobacco users who received tobacco
use intervention during the measurement year or the prior year
• Requires documentation that provider (or appropriate support
staff):
• Provided tobacco cessation counseling
and/or
• Provided pharmacological intervention – i.e., a prescription
was written or a drug dispensed
• Measure calculation:
Line15 Column c (patients with compliance documented
Line15 Column b (patients in universe or sample)
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Tobacco Cessation Intervention
Universe and Exclusions
 All adults who were age 18 or older during the
measurement year (i.e., born before 12/31/1993) who
were known to be tobacco users and
• Who had at least one medical visit during the
measurement year
• Who had been seen at least twice ever
• Who were ever seen after their 18th birthday
 No exclusions
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Tobacco Cessation Intervention
Documentation of Compliance
 Chart note or EMR coded to demonstrate counseling or
pharmacological intervention
• Documentation that provider or appropriate staff provided
cessation counseling
and/or
• Documentation of prescription written or drug dispensed
(may include OTC medications)
• CPT Category II Codes can be used to record:
– 4000F = Patient was counseled to quit tobacco use
– 4001F = Pharmacologic therapy: Prescription was
written or drug dispensed
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Tobacco Cessation Intervention
Completing the UDS: Line 15
 Column a: Number of adult medical patients aged 18 and over
identified as current tobacco users
• Will have no relation to 18+ year olds on Table 3a
 Column b: Will be 70 unless a comprehensive EHR is present, in
which case column b will be equal to column a
 Column c: Number (of those reported in column b) for whom
documentation demonstrates that tobacco cessation counseling
or pharmacologic intervention occurred (last 24 months
presumed but not required)
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Asthma: Pharmacologic Therapy
(NQF 0047)
Asthma
Measure
 Percent of patients aged 5 – 40 with mild, moderate, or
severe persistent asthma who were prescribed preferred or
acceptable alternative pharmacologic therapy
• Requires documentation that medication was prescribed or
dispensed
 Measurement calculation:
Line16 Column c (patients with compliance documented)
Line16 Column b (patients in universe or sample)
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Asthma
Universe and Exclusions
 All patients aged 5 to 40 during the measurement year
(i.e., born between 1/1/1971 and 12/31/2006) who:
• Were currently diagnosed with (mild, moderate, or
severe) persistent asthma
• CPT Category II Codes can be used to record:
1038F = persistent asthma (not 1039F –
intermittent asthma)
• Had at least one medical visit during the
measurement year
• Had at least two medical visits ever
 No exclusions
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Asthma
Documentation of Compliance
 Copy of prescription or note that prescription was given
during the current year
• For inhaled corticosteroids
• For acceptable alternative pharmacologic therapy:
– Leukotriene modifiers
– Cromolyn sodium
– Nedocromil sodium
– Sustained release methylxanthines
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Asthma
Completing the UDS: Line 16
 Column a: Number of patients aged 5 to 40 with persistent
asthma seen during the measurement year
• Will be similar to patients seen with primary diagnosis on
Table 6a. No age limits on table 6a.
 Column b: Will be 70 unless a comprehensive EHR tracks this
condition, in which case column b will be equal to column a
 Column c: Number (of those reported in column b) for whom
documentation demonstrates that appropriate pharmacotherapy
was provided
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Modification of
Two Year Old Immunizations
(NQF 0038)
Two Year Old Immunizations
Measure
 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
Universe and Exclusions
 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
 No exclusions
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Two Year Old Immunizations
Documentation of Compliance
 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
 Documentation can be obtained from state-wide or other
registries
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Two Year Old Immunizations
Documentation of Compliance
 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
Completing the UDS: Line 16
 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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Quality of Care Measure
Table 7 – Diabetes
(NQF 0575)
Reporting Diabetic Care
Quality of Care Measure
 One quality of care measure will
be reported differently for 2011:
• In 2010 patients with HbA1c
between 7 and 9 were in one
category
• In 2011, there will be two
categories:
– Greater or equal to 7%
and less than 8%
– Greater or equal to 8%
and less than or equal to
9%
 Everything else is unchanged
2010
2011
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Technical Assistance
 UDS web page: http://www.hrsa.gov/datastatistics/health-center-data/index.html
• TA call replays
• Online training modules
• Data analysis tools
• Data download functionality
 Measures specifications:
https://www.cms.gov/QualityMeasures/03_ElectronicSpe
cifications.asp
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Technical Assistance
 For all UDS content questions, contact the UDS Help Desk at:
• Phone: 1-866-UDS-HELP (866-837-4357)
• E-mail: udshelp330@bphcdata.net
 BPHC Help Line
• For all UDS electronic reporting questions, contact the BPHC
Help Line at:
– Phone: 1-877-974-BPHC
– E-mail: bphchelpline@hrsa.gov
 HRSA Call Center
• For all technical/system issues, contact the HRSA Call Center at:
– Phone: 877-464-4772
– E-mail: CallCenter@hrsa.gov
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