The Culture of Health Care

2. The Culture of Health Care Quality Measurement and Improvement Lecture b This material (Comp 2 Unit 7) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

3. Quality Measurement and ImprovementLearning Objectives • Define health care quality and the major types of quality measures: structural, process, and outcome measures (Lecture a). • Describe the current state of health care quality in the United States (Lecture a). • Discuss quality measures used in various health care settings in the US, including those required for the HITECH meaningful use program (Lecture b). • Describe the role of information technology in measuring and improving health care quality (Lecture c). • Describe the results of current health care quality efforts in the US (Lecture c).

4. Sampling of Current Quality Programs and Measures • Many sets and acronyms, and they change constantly • Still “early” in the science of quality improvement (Berwick, 2008) • “Science” defined in an IOM report (2006) • Many measurements in use (Damberg, 2011) but still need improvement (Pronovost, 2011) • Many measures have been developed, reflecting various perspectives • AHRQ maintains clearinghouse: www.qualitymeasures.ahrq.gov • Growing consensus that standard sets are needed for each perspective • We view them from following perspectives: • Health plans • Outpatient • Inpatient • Quality measures in HITECH meaningful use program

5. Quality Reporting for Health Plans • Called out because of historic role • Health Plan Employer Data and Information Set (HEDIS) by NCQA provides 60 measures that evaluate health plans, particularly health maintenance organizations • NCQA annual reports calculate lives saved based on outcomes from adherence

6. HEDIS Categories and Example Measures • Effectiveness of care • Childhood and adult immunizations • Use of beta blockers after myocardial infarction • Screening for various types of cancer • Comprehensive diabetes care • Access to/availability of care • Access to preventive health services • Availability of primary care providers • Initiation of prenatal care • Satisfaction with care • Member satisfaction surveys • Use of service • Rate trends

7. Reporting for Outpatient Setting • In United States, major efforts led by Centers for Medicare and Medicaid Services (CMS: http://www.cms.hhs.gov) in Medicare program • Physician Quality Reporting System (PQRS, formerly PQRI: http://www.cms.hhs.gov/pqri) • – Initially reimbursed extra 1% for reporting on large number of measures • – Also offered 0.5% for maintaining certification • – Penalties for failing to meet objectives began in 2015 • Electronic Prescribing (eRx) Incentive Program (http://www.cms.gov/ERxIncentive) • Reimbursed extra 1% for using eRx (through 2013) • Began penalizing in 2012 for non-use of eRx

8. Example PQRS Measures • Hemoglobin a1c, poor control in diabetes mellitus • Percentage of patients aged 18 to 75 years with diabetes mellitus whose most recent hemoglobin A1c test was greater than 9.0% • Thoracic surgery: Recording of clinical stage for lung cancer and esophageal cancer resection • Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical TNM staging prior to surgery • Weight assessment and counseling for children and adolescents • Percentage of children 2 to 18 years of age whose weight is classified on basis of BMI percentile for age and gender

9. Reporting for Inpatient Setting • Hospital Quality Alliance (HQA) www.hospitalqualityalliance.org • Collaboration among CMS, The Joint Commission, and others to create a starter set of quality measures for various conditions • In Hospital Compare Project, hospitals voluntarily provide quality information that can be accessed via www.hospitalcompare.hhs.gov • Consists of two programs based on reporting to CMS: • Inpatient Quality Reporting (IQR)—for HQA data; nonparticipation = 2% Medicare reimbursement reduction • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS)—reporting of patient satisfaction at hospitals

10. HQA Categories and Examples • Myocardial infarction • Aspirin at arrival and discharge • Inpatient mortality • Heart failure • Discharge instructions • Evaluation of left ventricular systolic function • Pneumonia • Time to blood cultures and antibiotics • Pneumococcal and influenza vaccinations • Surgical infection prevention • Prophylactic antibiotics • Prophylaxis for deep venous thrombosis • Children’s asthma care • Reliever medication while hospitalized • Home Management Plan of Care Document

11. Other Inpatient Quality Initiatives • National Surgical Quality Improvement Program (NSQIP: http://www.acsnsqip.org) • Effort of American College of Surgeons to measure, risk-adjust, and improve quality of surgical care • University Health System Consortium (UHC: http://www.uhc.edu) • Quality measurements to benchmark academic medical centers • Measured by green and red dots (½ a dot to 2 dots)

12. Clinical Quality Measures and HITECH • One goal: Improving quality, safety, and efficiency • Meaningful use achieved over multiple stages and years • Quality requirements are closely aligned with other CMS quality reporting programs • There is ongoing discussion regarding implementing new measures or discontinuing meaningful use

13. 2016 and Onward Clinical Quality Measures Eligible professionals (physicians): Report on 10 objectives • Example—Objective 1: Protect patient health information • Measure: Conduct or review a security risk analysis Eligible hospitals and critical access hospitals: Report on 9 objectives • Example—Objective 2: Clinical decision support • Measure 1: Implement five clinical decision support interventions related to high-priority health conditions • Measure 2: Enable and implement functionality for drug-drug and drug-allergy interaction checks for entire reporting period

14. Clinical Quality Measures for Meaningful Use Eligible professionals (physicians) • 2016 list of CQM measures located at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EPWhatYouNeedtoKnowfor2016.pdf Eligible hospitals and critical access hospitals • 2016 list of CQM measures located at https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EHWhatYouNeedtoKnowfor2016.pdf

15. CQM: Eligible Professional (Physician) Example Measure: Appropriate testing for children with pharyngitis (sore throat) CMS eMeasure Identification: CMS146v1 NQF #: 0002 NQS’s Priority Domain: Efficient Use of Healthcare Resources Measure Steward: National Committee for Quality Assurance Description: Percentage of children 2–18 years who were diagnosed with pharyngitis, ordered an antibiotic, and received a group A streptococcus (strep) test for episode

16. CQM: Eligible Professional (Physician) Example Continued Measure: Appropriate testing for children with pharyngitis (sore throat) Numerator statement: Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis Denominator statement: Children aged 2–18 years who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or 3 days after the visit

17. CQM: Eligible Hospital Example Measure: Stroke 2, ischemic stroke—discharge on antithrombotic therapy (drug to prevent blood clots) CMS eMeasure: 104 NQF#: 0435 Version#: 2 Measure Steward: The Joint Commission NQS Priority: Clinical process/effectiveness Description: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge.

18. CQM: Eligible Hospital ExampleContinued Measure: Stroke 2, ischemic stroke—discharge on antithrombotic therapy Numerator: Number of stroke patients prescribed antithrombotic therapy at hospitals Denominator: Number of ischemic stroke patients

19. Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) • Two components: • The Merit-Based Incentive Payment System (MIPS) • Combines programs into a single system • The Alternative Payment Models (APMs): • New models for provider reimbursement such as accountable care organizations and patient-centered medical homes • Applies to Medicaid patients • 2020 targeted timeframe

20. Quality Measurement and ImprovementSummary – Lecture b • Many different health care quality measures are used in a variety of settings from health plans to inpatient to outpatient • Health plans most commonly assess quality using the HEDIS measures of NCQA • Outpatient settings most often use PQRS measures • Inpatient settings have a variety of measures, but HQA measures are most commonly used • One of the core meaningful use criteria for eligible professionals and hospitals is a series of quality measures

21. Quality Measurement and ImprovementReferences – Lecture b References 2011 Physician quality reporting system (physician quality reporting) measures list. Retrieved from http://s3.gi.org/nataffairs/thisweek/2011PQRSPhysQualRptMeasuresList.pdf Berwick, D. (2008). The science of improvement. JAMA, 299, 1182–1184. Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363, 501–504. Centers for Medicare & Medicaid Services. (2015). 2014 clinical quality measures. Retrieved from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/2014_ clinicalqualitymeasures.html Centers for Medicare & Medicaid Services. (2015). Clinical quality measures basics. Retrieved from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/clinicalqualitymeasures.html Centers for Medicare & Medicaid Services. (2016). Electronic health records (EHR) incentive programs (HITECH meaningful use). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html Centers for Medicare & Medicaid Services. (2016). The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs)—MACRA: Delivery system reform, Medicare payment reform. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

22. Quality Measurement and ImprovementReferences – Lecture b Continued Centers for Medicare & Medicaid Services. (n.d.). Path to value. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf. Centers for Medicare & Medicaid Services. (n.d.). MACRA implementation timeline. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.pdf Centers for Medicare & Medicaid Services. (n.d.). EHR incentive programs for eligible hospitals and critical access hospitals: What you need to know for 2016 tipsheet. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ Downloads/2016_EHWhatYouNeedtoKnowfor2016.pdf Centers for Medicare & Medicaid Services (n.d.). EHR incentive programs for eligible professionals: What you need to know for 2016 tipsheet. https://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/Downloads/2016_EPWhatYouNeedtoKnowfor2016.pdf Damberg, C., Sorbero, M. E., Lovejoy, S. L., et al. (2011). An evaluation of the use of performance measures in healthcare. Santa Monica, CA: RAND Corp. Retrieved from http://www.rand.org/pubs/technical_reports/TR1148.html Government Accountability Office. (2011). CMS should address inconsistencies in its two incentive programs that encourage the use of health information technology. Washington, DC: Government Accountability Office. Retrieved from http://www.gao.gov/new.items/d11159.pdf

23. Quality Measurement and ImprovementReferences – Lecture b Continued 2 Healthcare Information and Management Systems Society (HIMSS). (2015) Reporting on clinical quality measures using certified EHR technology by eligible professionals 2015–2017. Retrieved from http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/ MU%20Stage%203%20FR%202015%202017%20Fact%20Sheet%20for%20EPs.pdf Institute of Medicine. (2006). Performance measurement: Accelerating improvement. Washington, DC: National Academies Press. Pronovost, P., & Lilford, R. (2011). A road map for improving the performance of performance measures. Health Affairs, 30, 569–573.

24. The Culture of Health CareQuality Measurement and ImprovementLecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.