LAN: An Introduction and Addressing of Issues With Quality Reporting

1. LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012

2. Presenters • Paul Kleeberg, MD, FAAFP, FHIMSS Clinical Director REACH – Regional Extension Assistance Center for HIT • Phil Deering Regional Coordinator REACH – Regional Extension Assistance Center for HIT • Connie Geyer RN, BSN Quality Improvement Specialist North Dakota Healthcare Review Inc. • Jerri Hiniker, RN, BSN, CPHER Program Manager Stratis Health

3. Agenda • Overview of the Learning and Action Network (LAN) • Overview of Quality Reporting for Meaningful Use • Introduction to Using Quality Reporting

4. Overview of a learning and action network (LAN) Connie Geyer and Jerri Hiniker

5. What is the Learning and Action Network (LAN)? • Partnership of REACH and the Minnesota and North Dakota Quality Improvement Organizations (QIOs) • Part of the QIO program’s ongoing prevention work

6. QIO Prevention Project • Focus: Improve health for populations and communities • Timeframe: August 1, 2011 – July 31, 2014 • Goal: • Provide a collaborative environment for the clinics/providers that are working with the Regional Extension Center (REC) and have achieved Milestone 2 (as part of Meaningful Use) to focus on optimization of their electronic health record (EHR) to improve population health

7. Learning and Action Networks • Mechanisms for fostering large scale improvement • Encourage rapid cycle improvements regardless of change methodology used • Consciously manage knowledge as a valuable resource • Provide opportunities for communities to harness knowledge, skills, and abilities of their peers • Function to support activities at the local level with ultimate goal of spread of the knowledge gained across the country • Promote sustainability and spread

8. Strategies • Review of educational needs of clinics and their providers • Provide regular opportunities for collaboration and sharing of best practices via: • Conference calls • Webinars • Face-to-face meetings • Online • Provide technical assistance as appropriatein collaboration with REC

9. Overview of Quality Reporting for Meaningful Use Phil Deering

10. CQMs – The Basics • Each EP needs to report on 3 clinical quality measures (CQMs) from a set of “Core” or “Alternate Core” quality measures. • Each EP needs to report on three additional CQMs from a list of 38 “Additional” quality measures. • Numerators, denominators, and exceptions must be those generated by certified electronic health record technology. • Link to CQM table: http://go.cms.gov/cqm_TBL

11. What if Core CQMs Don’t Apply • MU requires reporting on three Core or Alternate Core CQMs. • Report on all Core that apply (denominator ≠ 0). • Go to Alternate Core to find additional (denominator ≠ 0) that do apply if three Core don’t apply. • Finally, report 0 denominators to get three Core/Alternate Core. • Attest to 0 denominators for all if you don’t have 3 that apply • Example of Pediatrician who sees no teens • No Core apply – all for adults • Alt 2 and 3 apply – attest to numerator, denominator, and exclusions from EHR • Attest to 0 denominators for 3 Core and 1 Alt Core

12. Reporting Additional CQMs • For most, possible to find 3 that do apply • If less than 3 apply, attest that none of the others apply. • If your certified EHR technology only gives 3 Additional measures, and none apply, then you need to report 0 denominators for all of them. “The EP is not responsible for determining the status of CQMs that their certified EHR technology is not capable of calculating” Goal is to report six non-zeros or attest to the fact that you have only 0 denominators

13. What if the CQMs Are Wrong? • Many providers are confronted with certified technology that introduces CQM logic or implied workflow that is difficult or unreasonable to implement. • You do not need to attest to the “accuracy” of any of the CQMs, just the numerator and denominator generated by the certified EHR technology. • There is no threshold for low percentages. • Put another way: Don’t change your workflow to accommodate awkward CQM technology.

14. Will We Report CQMs Electronically in 2012? • Original rule stated: “CQMs by attestation in 2011, electronically in 2012”. • New guidance has emerged: • In 2012, there will be two options for CQM reporting: • Attestation • Electronic Reporting Pilots • EPs – through PQRS • Participation in the pilot is voluntary and enables EPs, eligible hospitals, and CAHs to satisfy the Medicare EHR Incentive Program requirements for reporting CQMs for the 2012 payment year. EPs, eligible hospitals, and CAHs that choose not to participate in the pilot will be able to continue to use an attestation methodology for reporting CQMs for payment year 2012.

15. Can I Report Non-certified Measures? • This is the corollary to the guidance that you don’t have to report CQMs that your EHR is not capable of providing • If your certified EHR can produce CQMs that aren’t certified by an ONC-ATCB, you can report those measures CMS FAQ ID #10649 Yes, the EP can submit results for CQMs in the additional set (Table 6 of the final rule) calculated by certified EHR technology, even if those CQMs were not individually tested and certified by an ONC-ATCB.

16. What Does Stage 2 Hold • We are committed to aligning quality measurement and reporting among our programs (for example: IQR, PQRS, CHIPRA, ACO programs). • More measures to be reported – 12 or 11 + 1 • Many new measures proposed • 81 by a rough count • Dentistry, radiology, dementia, optometry, mental health • No required percentages in Stage 2 • Guidance to align CDS rules with CQMs • Implement CDS to improve CQM

17. Introduction to using quality reporting Paul Kleeberg, MD

18. If you don’t measure it, how can you improve it? • All providers believe they provide above average care • How can you create change without creating a need for change? • Providers are inherently competitive and data driven • “My patients are different…” “That data is inaccurate!” But still improvements magically happen

19. Tracks all the quality measures of interest to them for their hypertensive patients comparing the organization, 3 clinics and one provider to the state statistics

20. Tracks the use of depression screens (completed PHQ-9 forms) over time for three separate quarters Notice most show gradual improvement over time demonstrating improvement in follow-up screening of depressed patients

21. Patient specific report allows provider to identify patients who are in need of labs or a follow-up appointment

22. Utilize Your Meaningful Use Report • Use to track progress and troubleshoot gaps in a clinic workflow or documentation • Track areas of clinical interest to you • Use them to identify patients falling through the cracks

23. How to Proceed: • Run the numbers a few times yourself to see if they make sense • Run and show data for the clinic as a whole, for all individuals – keeping the individual names anonymous but allowing providers to identify themselves • Finally make all providers data public within the clinic There may be denial, but there will be improvement

24. Discussion Questions

25. What quality reports do you currently submit from your practice? • Do you use any of these reports for care improvement and if so, which ones? • What issues have you encountered as a result of having to submit reports to multiple entities? • How would you like to see this Learning and Action Network assist you in improving quality

26. Questions?

27. Contact Information: Connie Geyer RN, BSN ND Healthcare Review Inc. CGeyer@ndqio.sdps.org Phone: 701-857-9723 Jerri Hiniker, BSN, RN, CPEHR Stratis Health jhiniker@stratishealth.org Phone: 952-853-8540  

28. Thank You!Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.