Quality data reporting generating data reports for incentive programs
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Quality Data Reporting: Generating Data Reports for Incentive Programs. Don Gettinger, BS, CPHIT, CPEHR Health Care Excel. Introductions. What we are going to cover. Overview of incentive programs and associated data measures Generating accurate data reports

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Quality Data Reporting: Generating Data Reports for Incentive Programs

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Quality data reporting generating data reports for incentive programs

Quality Data Reporting:Generating Data Reports for Incentive Programs

Don Gettinger, BS, CPHIT, CPEHR

Health Care Excel



What we are going to cover

What we are going to cover

  • Overview of incentive programs and associated data measures

  • Generating accurate data reports

  • How to use the Model for Improvement to drive change

  • Learn what programs are available to assist you

Incentive programs

Incentive Programs

Incentive programs cont d

Incentive Programs (Cont’d)

Ehr incentive program

EHR Incentive Program

  • The Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs

    • Receive up to $63,750 incentive per provider over five to six years

    • Must use a certified EHR

    • Must meet 20 of 25 objectives to receive funding

Ehr incentive program cont d

EHR Incentive Program (Cont’d)

  • Report Clinical Quality measures

    • Must report six measures

      • Three core measures that all providers must report

      • Three additional measures chosen from a list of 38

    • Requirement is met by simply reporting the numerator and denominator

Physician quality reporting system pqrs

Physician Quality Reporting System (PQRS)

  • The reporting program formerly known as Physician Quality Reporting Initiative (PQRI) and Physician Voluntary Reporting Program (PVRP)

  • Incentive payment is a percentage of Medicare-allowed charges

  • More than 200 measures to choose from

Quality data reporting generating data reports for incentive programs


  • Must successfully report at least three measures

  • Three different reporting methods

  • Incentive is met by successfully reporting data

E prescribing incentive

E-Prescribing Incentive

  • Must report that you successfully

    e-prescribed on at least 25 unique visits

  • Three different reporting methods

  • Several exemptions to prevent payment adjustment in 2012

Patient centered medical home

Patient Centered Medical Home

  • Many payers provide incentives or inclusion in preferred provider networks for achieving PCMH recognition

  • Collect and use data for population management

  • Use performance and patient experience data for continuous quality improvement

Quality health first

Quality Health First

  • Uses data in the Indiana Health Information Exchange (IHIE) to populate quality reports and clinical decision support alerts

  • Used by some local payers to provide incentives or inclusion in preferred provider networks

Clinical quality measures

Clinical Quality Measures

  • Measures drive improvement

  • Measures inform consumers

  • Measures influence payment

Clinical quality measures cont d

Clinical Quality Measures (Cont’d)

“Measurement matters. When clinicians see their numbers, they act to improve them, using their professional pride and competitiveness to find solutions.”

Randall D. Cebul, MD, Director, Better Health Greater Cleveland

Clinical quality measures cont d1

Clinical Quality Measures (Cont’d)

Measure Number: NQF 0031, PQRI 111

Title: Preventive Care and Screening: Screening Mammography

Description: Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months

Getting accurate data

Getting Accurate Data

Ihi model for improvement

IHI Model for Improvement

What is the IHI Model for Improvement?

  • Model identifies four elements of successful process improvement

  • An approach for organizing and carrying out plans for improvement

Getting accurate data cont d

Getting Accurate Data (Cont’d)

Getting accurate data cont d1

Getting Accurate Data (Cont’d)

Top 10 things to do if

Top 10 things to do if…

You don’t care about your data

10. Keep your documentation processes the same as they have been

9.Assume that a scanned document will be pulled into quality reports

8. Don’t require injections and tests be documented in discrete fields

Top 10 list cont d

Top 10 list (Cont’d)

7. Don’t educate staff about why the quality measures are important to patient care

6. Don’t let your patients know you are working on these measures

5. Choose which quality measures to track without engaging providers in decisions

Top 10 list cont d1

Top 10 list (Cont’d)

4.Only discuss preventive care with a patient during an annual physical

  • Wait to look at your data for the first time when it is time to report

  • Accept “I’m too busy” as a valid excuse

    1. Don’t ask for help



Regional Extension Centers (RECs)

  • Provide training and support services to assist doctors and other providers in adopting EHRs

  • Offer information and guidance to help with EHR implementation

  • Give technical assistance as needed

Indiana recs

Indiana RECs

Indiana recs1

Indiana RECs

Indiana Health Information Technology Extension Center (I-HITEC)






Health Information Exchange

A Health Information Exchange (HIE) is an electronic movement of health-related information among organizations utilizing nationally recognized standards and policies.

Indiana hies

Indiana HIEs

Indiana Health

Information Exchange


Michiana Health Information Network








Quality Improvement Organizations (QIOs)

Focusing on Eight Quality Measures

  • CRC Screening

  • Mammography

  • Flu Immunization

  • Pneumonia

  • Immunization

  • Aspirin Therapy

  • LDL Control

  • BP Control

  • Smoking Screening

  • and Counseling

Qio learning and action network

QIO Learning and Action Network

Providers, practice managers, State and National Health stakeholders and the QIO.

  • Improve specific Clinical Quality Measures

  • Promote Meaningful Use (MU)

  • Support Health Information Exchange (HIE)

  • Encourage participation in PQRS

  • Address disparities in care.

Qio learning and action network cont d

QIO Learning and Action Network (Cont’d)

  • Webinars and teleconferences

  • Educational resources on current HIT subjects

  • Opportunities to network with and learn from peers

  • Tools and interventions for quality improvement

Indiana qio

Indiana QIO

Health Care Excel


(812) 234-1499



  • We get more of what we focus on

    • Focus on problems—more problems

    • Focus on success—more success

    • Focus on what works—more of what works

    • Focus on good stories—more good stories

    • Focus on results—more results

      We can choose what we focus on!



Don Gettinger

Health Information Technologist

Population and Community Health

Health Care Excel

Telephone:  812-234-1499, ext.336

This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-IN-POPHEALTH-11-007 09/15/2011

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