Doctors Office Quality-Information Technology DOQ-IT Initiative: and Paying for Performance

1. Doctors’ Office Quality-Information Technology (DOQ-IT Initiative): andPaying for Performance Oklahoma Foundation for Medical Quality (405) 840-2891 Does anyone here in the audience think that health care is a little bit behind, and that computer technology will help? OFMQ also thinks that too. Today we will be talking about a project that is aimed at helping with this issue. I’d like to thank Teresa Bolden for having me here. I appreciate all of you who have come here to learn about billing & coding issues and to learn how Medicare is moving forward with regard to Information Technology or “I.T” for short. Since Teresa wants us to stay on time and I have a lot to cover, we will take questions at the end, and I can be available for a little while afterwards. (may not know all the answers all your questions, but I know who to contact, if necessary.)Does anyone here in the audience think that health care is a little bit behind, and that computer technology will help? OFMQ also thinks that too. Today we will be talking about a project that is aimed at helping with this issue. I’d like to thank Teresa Bolden for having me here. I appreciate all of you who have come here to learn about billing & coding issues and to learn how Medicare is moving forward with regard to Information Technology or “I.T” for short. Since Teresa wants us to stay on time and I have a lot to cover, we will take questions at the end, and I can be available for a little while afterwards. (may not know all the answers all your questions, but I know who to contact, if necessary.)

2. Oklahoma Foundation for Medical Quality Oklahoma Foundation for Medical Quality (OFMQ) Formerly known as the peer review organization (PRO) Now, called the “QIO”, or quality improvement organization Holds the contract with (CMS) the Centers for Medicare & Medicaid Services to provide quality improve- ment and patient advocacy for Medicare beneficiaries in Oklahoma I know that some of you know who we are, but some of you may not so … We were formerly known as a peer review organization (PRO), but Now we’re called a “QIO”, or quality improvement organization. The QIO concept better reflects what we’re really about now. Every state in the union has a QIO, we are the one in OK. We hold the contract with (CMS) the Centers for Medicare & Medicaid Services to provide quality improvement and patient advocacy for Medicare beneficiaries in Oklahoma. I know that some of you know who we are, but some of you may not so … We were formerly known as a peer review organization (PRO), but Now we’re called a “QIO”, or quality improvement organization. The QIO concept better reflects what we’re really about now. Every state in the union has a QIO, we are the one in OK. We hold the contract with (CMS) the Centers for Medicare & Medicaid Services to provide quality improvement and patient advocacy for Medicare beneficiaries in Oklahoma.

3. Oklahoma Foundation for Medical Quality Quality Improvement Organization (QIO): Primary Mission: To monitor and measurably improve the quality of health care delivered to Medicare beneficiaries Primary Focus: On systems of care, rather than the care delivered to one patient at a time Our Primary Mission is to monitor and measurably improve the quality of health care delivered to Medicare beneficiaries. Our Primary Focus is on systems of care, rather than focusing on the care delivered to only one patient at a time. We know that changing systems translates into better care. Our Primary Mission is to monitor and measurably improve the quality of health care delivered to Medicare beneficiaries. Our Primary Focus is on systems of care, rather than focusing on the care delivered to only one patient at a time. We know that changing systems translates into better care.

4. Oklahoma Foundation for Medical Quality A “New” National Vision for Health Care - Safety, Quality and Efficiency: Nearly 40 years ago, the vision for electronic health record (EHR) systems was born In 1991 the IOM’s report increased interest in computer-based patient records In 2001 the IOM said information technology (IT) must support clinical processes Today, we are in “The Year of the EHR” I want to talk w/you today about A “New” National Vision for Health Care - Safety, Quality and Efficiency. This is a new national vision. But truthfully its not all that new. Nearly 40 years ago, the vision for electronic health record (EHR) systems was born. 40 years was a long time ago! In 1991 the IOM’s report increased interest in computer-based patient records In 2001 the IOM said information technology (IT) must support clinical processes Today, 2005, we’re in what’s being called “The Year of the EHR” I want to talk w/you today about A “New” National Vision for Health Care - Safety, Quality and Efficiency. This is a new national vision. But truthfully its not all that new. Nearly 40 years ago, the vision for electronic health record (EHR) systems was born. 40 years was a long time ago! In 1991 the IOM’s report increased interest in computer-based patient records In 2001 the IOM said information technology (IT) must support clinical processes Today, 2005, we’re in what’s being called “The Year of the EHR”

5. Oklahoma Foundation for Medical Quality Almost every other sector in our economy is using IT to work smarter and better. Healthcare is a little behind, and we know we need to move forward. There are a lot of converging technologies helping us to move there. This slide shows just some of the results of in IT-enabled health care system.Almost every other sector in our economy is using IT to work smarter and better. Healthcare is a little behind, and we know we need to move forward. There are a lot of converging technologies helping us to move there. This slide shows just some of the results of in IT-enabled health care system.

6. Oklahoma Foundation for Medical Quality What Does the New Health Care Environment Look Like? Cost conscious Customer driven Web connected Information rich Best practices known by all Patients will become informed purchasers Safety, quality and accountability expected What Does the New Health Care Environment Look Like? It is … Cost conscious (due to efficiencies gained, such as no more chart chasing, or appropriate coding, or elimination of transcription) Customer driven (patients will demand that their physicians have access to the latest information at their fingertips) Web connected (enabling connectivity, increasing access to information) Information rich (currently, we’re not using information as we should) Best practices known by all (not just by a few) Patients will become informed purchasers (we’re talking about dramatic changes in healthcare structure. For example, President Bush’s healthcare savings account puts the onus on the consumer to be sure they get the best healthcare they can receive.) Safety, quality and accountability will be expected What Does the New Health Care Environment Look Like? It is … Cost conscious (due to efficiencies gained, such as no more chart chasing, or appropriate coding, or elimination of transcription) Customer driven (patients will demand that their physicians have access to the latest information at their fingertips) Web connected (enabling connectivity, increasing access to information) Information rich (currently, we’re not using information as we should) Best practices known by all (not just by a few) Patients will become informed purchasers (we’re talking about dramatic changes in healthcare structure. For example, President Bush’s healthcare savings account puts the onus on the consumer to be sure they get the best healthcare they can receive.) Safety, quality and accountability will be expected

7. Oklahoma Foundation for Medical Quality CMS, DHHS, and Federal Action: Start special pilot project : DOQ-IT Collaboration with VA on Vista EHR Medicare Modernization Act: IT demos Appointment of David Brailer, MD, National Healthcare IT Coordinator National Health Information Infrastructure The federal government is very much involved in this effort, and there are several special projects ongoing in this regard: CMS began a special pilot project called DOQ-IT (Doctor’s Office Quality – Information Technology) just over a year ago in 4 states, and now has pushed it out on a national level. That’s the project we’re here to discuss today, and will go into on later slides. There is collaboration with VA on Vista EHR, the VA’s EMR system that is being engineered for non-VA practices at a nominal cost. The Medicare Modernization Act calls for IT demonstration projects, including ePrescribing Appointment of David Brailer, MD, as National Healthcare IT Coordinator (fondly known as the “Information Czar”) And the creation of the National Health Information Infrastructure, David Brailer’s initiative. The federal government is very much involved in this effort, and there are several special projects ongoing in this regard: CMS began a special pilot project called DOQ-IT (Doctor’s Office Quality – Information Technology) just over a year ago in 4 states, and now has pushed it out on a national level. That’s the project we’re here to discuss today, and will go into on later slides. There is collaboration with VA on Vista EHR, the VA’s EMR system that is being engineered for non-VA practices at a nominal cost. The Medicare Modernization Act calls for IT demonstration projects, including ePrescribing Appointment of David Brailer, MD, as National Healthcare IT Coordinator (fondly known as the “Information Czar”) And the creation of the National Health Information Infrastructure, David Brailer’s initiative.

8. Oklahoma Foundation for Medical Quality National Health Information Infrastructure (NHII): An initiative to improve the effectiveness, efficiency, safety and quality of health and health care in the U.S. Lead by David J. Brailer, M.D. Executive Order calling for widespread adoption of interoperable EHRs within 10 years. The NHII is an initiative to create a comprehensive knowledge based network of interoperable systems of clinical, public health, and personal health information that would improve decision-making by making health information available when and where it is needed. It is geared at improving the effectiveness, efficiency, safety and quality of health and health care in the US. It encompasses the set of technologies, standards, applications, systems, values and laws that support all facets of individual health, health care and public health. This is a voluntary organization aimed at coordinating IT efforts across many agencies. It is NOT a centralized database of medical records or a government regulation. This initiative came as a result of President Bush calling for widespread adoption of interoperable EHRs within 10 years. Interoperability means interconnecting all these computers so they can all talk to each other. In order to have interoperability we must first have connectivity. The NHII is an initiative to create a comprehensive knowledge based network of interoperable systems of clinical, public health, and personal health information that would improve decision-making by making health information available when and where it is needed. It is geared at improving the effectiveness, efficiency, safety and quality of health and health care in the US. It encompasses the set of technologies, standards, applications, systems, values and laws that support all facets of individual health, health care and public health. This is a voluntary organization aimed at coordinating IT efforts across many agencies. It is NOT a centralized database of medical records or a government regulation. This initiative came as a result of President Bush calling for widespread adoption of interoperable EHRs within 10 years. Interoperability means interconnecting all these computers so they can all talk to each other. In order to have interoperability we must first have connectivity.

9. Oklahoma Foundation for Medical Quality NHII: Consumer-centric and Information-rich Health Care : Medical information follows the consumer Information tools enhance medical decision making Clinicians have appropriate access to a patient’s treatment history, medical records, medication, lab results, etc… What we’re looking at is a Consumer-centric and Information-rich Health Care system in which .. Medical information follows the consumer wherever the consumer goes. Eventually we hope to have portals of consumer information so that whatever provider they go to, or whatever healthcare facility they go to, the patient’s medical history, medication list, etc., goes with them. In this Consumer-centric and Information-rich Health Care system, information tools will enhance medical decision making. Best practices will be embedded into these systems so that doctors can treat according to these guidelines. This will result in fewer errors, fewer unnecessary treatments or wasteful care and fewer variations in care. Have you ever seen doctors seeing patients without a chart? This new infrastructure is designed to avoid this kind of thing. What we’re looking at is a Consumer-centric and Information-rich Health Care system in which .. Medical information follows the consumer wherever the consumer goes. Eventually we hope to have portals of consumer information so that whatever provider they go to, or whatever healthcare facility they go to, the patient’s medical history, medication list, etc., goes with them. In this Consumer-centric and Information-rich Health Care system, information tools will enhance medical decision making. Best practices will be embedded into these systems so that doctors can treat according to these guidelines. This will result in fewer errors, fewer unnecessary treatments or wasteful care and fewer variations in care. Have you ever seen doctors seeing patients without a chart? This new infrastructure is designed to avoid this kind of thing.

10. Oklahoma Foundation for Medical Quality Mission of the National DOQ-IT Project: Improve physician office care management of chronic illness and preventive services using workflow redesign, evidence-based guidelines, best practices, and data reporting through the use of electronic health record (EHR) systems The mission of the National DOQ-IT Project is to improve physician office care management of chronic illness and preventive services using workflow redesign, evidence-based guidelines, best practices, and data reporting through the use of electronic health record (EHR) systems. The mission of the National DOQ-IT Project is to improve physician office care management of chronic illness and preventive services using workflow redesign, evidence-based guidelines, best practices, and data reporting through the use of electronic health record (EHR) systems.

11. Oklahoma Foundation for Medical Quality DOQ-IT Project Focuses on Improved Outcomes in Five Areas: Coronary Artery Disease Diabetes Mellitus Heart Failure Hypertension Preventive Care (including mammography, adult immunizations, colorectal cancer screening) We are focusing on Improved Outcomes in Five Areas: Coronary Artery Disease Diabetes Mellitus Heart Failure Hypertension Preventive Care (including mammography, adult immunizations, colorectal cancer screening) These are common problems in the Medicare population. We are focusing on Improved Outcomes in Five Areas: Coronary Artery Disease Diabetes Mellitus Heart Failure Hypertension Preventive Care (including mammography, adult immunizations, colorectal cancer screening) These are common problems in the Medicare population.

12. Oklahoma Foundation for Medical Quality Clinical Quality Measures: DOQ-IT measures, jointly developed with AMA’s Physicians’ Consortium on Performance Improvement, and harmonized with NCQA Derived from evidence based medicine Emphasize the ability of the system to output data to a clinical data warehouse Built on HL7 and other standards Are clearly defined in specifications (see www.doqit.org). The OQ-IT measures were jointly developed with the AMA’s and the National Committee on Quality Assurance They were derived from evidence based medicine … And emphasize the ability of the system to output data to a clinical data warehouse They are built on HL7 and other standards and are clearly defined in specifications. You can visit the DOQIT web site to download these specifications at www.doqit.org. The OQ-IT measures were jointly developed with the AMA’s and the National Committee on Quality Assurance They were derived from evidence based medicine … And emphasize the ability of the system to output data to a clinical data warehouse They are built on HL7 and other standards and are clearly defined in specifications. You can visit the DOQIT web site to download these specifications at www.doqit.org.

13. Oklahoma Foundation for Medical Quality Key DOQ-IT Project Partners: American Academy of Family Physicians (AAFP) American Medical Association (AMA) American College of Physicians (ACP) Pacific Business Group on Health (PBGH) The DOQ-IT project is not being performed in a vacuum. There are several national organizations that have endorsed this initiative such as: American Academy of Family Physicians (AAFP) American Medical Association (AMA) American College of Physicians (ACP) Pacific Business Group on Health (PBGH) The DOQ-IT project is not being performed in a vacuum. There are several national organizations that have endorsed this initiative such as: American Academy of Family Physicians (AAFP) American Medical Association (AMA) American College of Physicians (ACP) Pacific Business Group on Health (PBGH)

14. Oklahoma Foundation for Medical Quality EMR Supports Quality: Provides a platform for office redesign Rx writing and transmission Medication interactions and allergy checking Built-in guidelines and protocols Decision support tools Online resources The DOQ-IT project emphasizes that IT or EMR technology supports quality by: Providing a platform for office redesign: creating more efficiencies in the physician office setting Automating prescription writing and transmission: How much time have you seen wasted in physician offices around the issue of prescription writing and refills? With an EMR this entire process is streamlined, and can, in most cases, be transferred electronically from the EMR to the pharmacy. Automating medication interactions and allergy checking, thus enhancing patient safety Providing Built-in guidelines and protocols embedded within the system itself. For example, for a patient with Kidney disease related to diabetes, in a couple of clicks the doctor can find out what the national guidelines are in order to provide the best care for this patient. An EMR can provide decision support tools and Online, readily available resourcesThe DOQ-IT project emphasizes that IT or EMR technology supports quality by: Providing a platform for office redesign: creating more efficiencies in the physician office setting Automating prescription writing and transmission: How much time have you seen wasted in physician offices around the issue of prescription writing and refills? With an EMR this entire process is streamlined, and can, in most cases, be transferred electronically from the EMR to the pharmacy. Automating medication interactions and allergy checking, thus enhancing patient safety Providing Built-in guidelines and protocols embedded within the system itself. For example, for a patient with Kidney disease related to diabetes, in a couple of clicks the doctor can find out what the national guidelines are in order to provide the best care for this patient. An EMR can provide decision support tools and Online, readily available resources

15. Oklahoma Foundation for Medical Quality OFMQ’s DOQ-IT Project Goals: Encourage either adoption of full EHR, or systems of e-prescribing, e-laboratory results management, and e-care reminders/registries Recruit physician practices in both urban and rural settings in Okla. Provide ongoing assistance Undertake local/regional initiatives Analyze data to identify strategies and opportunities for quality improvement Our project goals include adoption of some sort of IT such as a full EHR, or systems of e-prescribing, e-laboratory results management, or electronic registries. We will identify and recruit physician practices throughout the state … And then provide ongoing assistance to practitioners in the areas of administrative and care process improvement via the utilization of IT in improving quality/safety, efficiency, and cost in managing patients, including patients with chronic diseases. We will undertake local initiatives, including activities with partners, to promote the adoption and use of IT. And, as the data on the Quality Improvement Measures become available, we will receive, review, and analyze this data with regard to practitioner performance and identify opportunities for improvement.Our project goals include adoption of some sort of IT such as a full EHR, or systems of e-prescribing, e-laboratory results management, or electronic registries. We will identify and recruit physician practices throughout the state … And then provide ongoing assistance to practitioners in the areas of administrative and care process improvement via the utilization of IT in improving quality/safety, efficiency, and cost in managing patients, including patients with chronic diseases. We will undertake local initiatives, including activities with partners, to promote the adoption and use of IT. And, as the data on the Quality Improvement Measures become available, we will receive, review, and analyze this data with regard to practitioner performance and identify opportunities for improvement.

16. Oklahoma Foundation for Medical Quality OFMQ Role: Analyze and support practice readiness evaluation Assist practice in identifying IT solutions to meet their needs Support vendor selection Provide workflow design recommendations Our Roles will include: Analyzing and supporting practice readiness evaluation for where a practice is on the EMR adoption continuum, and if they are already using an EMR now, identifying how they can get the best use out of that system to gain additional efficiencies. We will also assist practices in identifying IT solutions to meet their needs We will support the vendor selection process. There are hundreds of vendors out there. We can assist a practice by finding out what they need and matching those needs with vendors capabilities. And, we will provide workflow design recommendations. We can look at a practice with fresh set of eyes. Sometimes an outside set of eyes can see things you can’t, because you tend to see things the same way. Our Roles will include: Analyzing and supporting practice readiness evaluation for where a practice is on the EMR adoption continuum, and if they are already using an EMR now, identifying how they can get the best use out of that system to gain additional efficiencies. We will also assist practices in identifying IT solutions to meet their needs We will support the vendor selection process. There are hundreds of vendors out there. We can assist a practice by finding out what they need and matching those needs with vendors capabilities. And, we will provide workflow design recommendations. We can look at a practice with fresh set of eyes. Sometimes an outside set of eyes can see things you can’t, because you tend to see things the same way.

17. Oklahoma Foundation for Medical Quality OFMQ Role (cont’d): Facilitate data submission and standard reporting Work with practices to review population based outcomes Assist in identifying quality improvement interventions Assist with staff training on electronic systems’ capabilities We will also … Facilitate data submission and standard reporting Work with practices to review population based outcomes. This is nearly impossible with paper charts. For those of you who don’t have an EMR, think of what you would have to go through to find, for example, all patients with congestive heart failure who are not on beta blockers? With an EMR, this information is readily available in a few clicks. We can also assist in identifying quality improvement interventions, as well as Assist with staff training on electronic systems’ capabilities We will also … Facilitate data submission and standard reporting Work with practices to review population based outcomes. This is nearly impossible with paper charts. For those of you who don’t have an EMR, think of what you would have to go through to find, for example, all patients with congestive heart failure who are not on beta blockers? With an EMR, this information is readily available in a few clicks. We can also assist in identifying quality improvement interventions, as well as Assist with staff training on electronic systems’ capabilities

18. Oklahoma Foundation for Medical Quality Barriers to EHR Adoption, particularly in Small Practices: Lack of financial capital for IT investment Lack of alignment of financial incentives for data collection and quality performance Confusion and uncertainty about vendor products and IT industry Implementation is resource intensive Successful implementation requires physician leadership and culture change One of the things we are trying to address as we encourage physicians to adopt IT, are the barriers to adoption. These barriers are particularly a problem in smaller practices where resources are stretched quite thin . Some of these are: Lack of financial capital for IT investment Lack of alignment of financial incentives for data collection and quality performance. Right now doctors who do a poor job get paid just like doctors who do better, and there are payers currently looking at incentives to encourage those who do better. Confusion and uncertainty about vendor products and IT industry. There are many new players in the field, and it’s tricky to think about who will be around 2 years, 5 years, or even 10 years from now. Implementation is resource intensive. Physicians are already maxed out now with resources, and to implement an EMR takes time, energy, and effort to move over that learning curve. We know it’s a very resource-intensive time. Most who have made the transition are very happy they have done so. Successful implementation requires physician leadership and culture change One of the things we are trying to address as we encourage physicians to adopt IT, are the barriers to adoption. These barriers are particularly a problem in smaller practices where resources are stretched quite thin . Some of these are: Lack of financial capital for IT investment Lack of alignment of financial incentives for data collection and quality performance. Right now doctors who do a poor job get paid just like doctors who do better, and there are payers currently looking at incentives to encourage those who do better. Confusion and uncertainty about vendor products and IT industry. There are many new players in the field, and it’s tricky to think about who will be around 2 years, 5 years, or even 10 years from now. Implementation is resource intensive. Physicians are already maxed out now with resources, and to implement an EMR takes time, energy, and effort to move over that learning curve. We know it’s a very resource-intensive time. Most who have made the transition are very happy they have done so. Successful implementation requires physician leadership and culture change

19. Oklahoma Foundation for Medical Quality Physician Resistance: And these are some of the things that physicians are telling us about this change: I can’t possibly afford this This will slow me down It may work for others, but my practice is different Why aren’t the payors providing monetary incentives?And these are some of the things that physicians are telling us about this change: I can’t possibly afford this This will slow me down It may work for others, but my practice is different Why aren’t the payors providing monetary incentives?

20. Oklahoma Foundation for Medical Quality Classes of Benefitsfor EHR Adoption: What we find when we move to an EHR are three kinds of benefits: The actual hard-dollar benefits, such as can be gained by improved coding and claims, and savings secondary to not paying for transcription and data handling costs. Then there are the stretch dollar benefits such as increased office efficiencies and efficiencies gained from not having to chase charts around. Finally, there are the soft benefits such as increased staff satisfaction and improved care. Of course, don’t ask staff in the first couple of weeks of EHR adoption. But once they are used to it and operating smoothly, people are much happier, and feel like they are spending more time doing important things such as patient care and less time on wasteful inefficiencies.What we find when we move to an EHR are three kinds of benefits: The actual hard-dollar benefits, such as can be gained by improved coding and claims, and savings secondary to not paying for transcription and data handling costs. Then there are the stretch dollar benefits such as increased office efficiencies and efficiencies gained from not having to chase charts around. Finally, there are the soft benefits such as increased staff satisfaction and improved care. Of course, don’t ask staff in the first couple of weeks of EHR adoption. But once they are used to it and operating smoothly, people are much happier, and feel like they are spending more time doing important things such as patient care and less time on wasteful inefficiencies.

21. Oklahoma Foundation for Medical Quality Incremental vs. Big Bang:Pro’s and Con’s Reduces “shock” to staff and physicians Spreads out costs of software and implementation over longer period Project less likely to ‘blow up’ Total training, implementation costs may be higher ROI is not achieved as quickly Risk getting ‘stuck’ at midpoint Shortens painful “parallel paper/EMR” operation period Achieves ROI more quickly Less likely to get “stuck” partway to the goal Higher risk of ‘blow up’ Significant productivity hit at go-live and some time afterward Staff or physicians unable to cope with change may rebel Of course, there is no one way to go live on an EHR system, but generally speaking, larger practices do better with the incremental approach, and smaller practices are more easily able to take the big bang approach.Of course, there is no one way to go live on an EHR system, but generally speaking, larger practices do better with the incremental approach, and smaller practices are more easily able to take the big bang approach.

22. Oklahoma Foundation for Medical Quality DOQ-IT Project Compensation/Incentives: Participating practices do not receive financial compensation The Centers for Medicare & Medicaid Services (CMS) is looking at incentives for physician offices with EHRs: Rapid payment Increase of payment Pay for Performance At this time, there is no formal compensation, or pay-for-performance plan on a national scale. However, CMS as well as other payors, are currently looking at this in various pilots being run throughout the country. Eventually, we feel that we will get there nationally. So, those practices who are already well along on the adoption curve will be ahead of the game.At this time, there is no formal compensation, or pay-for-performance plan on a national scale. However, CMS as well as other payors, are currently looking at this in various pilots being run throughout the country. Eventually, we feel that we will get there nationally. So, those practices who are already well along on the adoption curve will be ahead of the game.

23. Oklahoma Foundation for Medical Quality A Critical Deadlock: So, this is how things are right now. Payors can’t offer incentives just yet. Providers are slower to purchase EHRs because they are so expensive, and Vendors feel they can’t bring down prices until more are being sold.So, this is how things are right now. Payors can’t offer incentives just yet. Providers are slower to purchase EHRs because they are so expensive, and Vendors feel they can’t bring down prices until more are being sold.

24. Oklahoma Foundation for Medical Quality Creating a Positive Spiral: But this is where we want to move … Payers seeing a benefit from provider adoption Providers readily adopting because of reduced risk and increased incentives And vendors providing affordable products because of growing market demandBut this is where we want to move … Payers seeing a benefit from provider adoption Providers readily adopting because of reduced risk and increased incentives And vendors providing affordable products because of growing market demand

25. Oklahoma Foundation for Medical Quality Conclusions: The “New Model of Care” and electronic medical records will be essential to participate in the 21st Century health care system. Practice economics, quality, safety, efficiency and the need for accountability will drive the change Those who are unable or unwilling to make the change will not be viewed as providing up-to-date medical care. What can we conclude? The “New Model of Care” and electronic medical records will be essential to participate in the 21st Century health care system. Practice economics, quality, safety, efficiency and the need for accountability will drive the change Those who are unable or unwilling to make the change will not be viewed as providing up-to-date medical care. Some will be left behind, but at OFMQ our goal is to insure that this does not happen. Our official project will begin in the late summer of this year. We will look forward to working closely with you and your practices as we more forward in this project.What can we conclude? The “New Model of Care” and electronic medical records will be essential to participate in the 21st Century health care system. Practice economics, quality, safety, efficiency and the need for accountability will drive the change Those who are unable or unwilling to make the change will not be viewed as providing up-to-date medical care. Some will be left behind, but at OFMQ our goal is to insure that this does not happen. Our official project will begin in the late summer of this year. We will look forward to working closely with you and your practices as we more forward in this project.

26. Oklahoma Foundation for Medical Quality References: “The Decade of Health Information Technology: Delivering Consumer-centric & Information-rich Health Care” http://aspe.hhs.gov/sp/nhii/ Achieving Electronic Connectivity in Healthcare: A Preliminary Roadmap from the Nation's Public and Private-Sector Healthcare Leaders http://www.connectingforhealth.org/resources/general resources.html Doctors' Office Quality - Information Technology (DOQ-IT) http://www.doqit.org/doqit/jsp/index.jsp Office of the National Health Information Technology Coordinator (ONCHIT) http://www.hhs.gov/healthit/ www.ofmq.com

27. Oklahoma Foundation for Medical Quality P4PPaying for Performance P4PPaying for Performance Oklahoma Foundation for Medical Quality (405) 840-2891

28. Oklahoma Foundation for Medical Quality IOM

29. Oklahoma Foundation for Medical Quality Methods to Raise Quality

30. Oklahoma Foundation for Medical Quality Purchasers are now exploring linking payment to performance as another way to improve quality. Currently, purchasers pay the same for units of service (hospital stay, physician visit) regardless of quality of care provided

31. Oklahoma Foundation for Medical Quality P4P Setting Performance expectations Measuring Performance Rewarding Results (financial and other incentives)

32. Oklahoma Foundation for Medical Quality Setting Performance Expectations Collaborative Process – Purchasers, Providers, Consumers Indicator Measures – Unambiguous, understandable, valid, reliable, timely, efficient to collect, risk-adjusted, wide applicability

33. Oklahoma Foundation for Medical Quality Quality Measures Structural - Process - Outcomes

34. Oklahoma Foundation for Medical Quality Quality of care can be measured in different ways…

35. Oklahoma Foundation for Medical Quality …and rated based on a variety of targets.

36. Oklahoma Foundation for Medical Quality Issues in the Selection of Quality Measures Outcome measures (i.e. mortality) require risk adjustment Disease-specific(B.B. post M.I.) doesn’t necessarily reflect overall quality Volume as a proxy (leapfrog) but quality variation Statistical issues with small providers/low volume programs Separating hospital performance and medical staff performance Subjective standards (communication/satisfaction) not easily measured

37. Oklahoma Foundation for Medical Quality Non-Financial Awards High rating on publicly disclosed report card (healthgrades.com) Elimination of referral or prior authorization requirements for providers Confidential profiling – (GAP- Guidelines Applied in Practice) Michigan study on AMI with performance compared to benchmark Selective Contracting – Choice Plus – Buyers Health Care Action Group selectively contracts with providers based on performance

38. Oklahoma Foundation for Medical Quality Financial Rewards/Incentives Bonus Payments Awards for Improvement Projects Fee Schedules Based on Performance “At-Risk” Contracting Cost Differentials for Consumers

39. Oklahoma Foundation for Medical Quality Bonus Payments Provider meeting predetermined standards receive higher payments Examples: CMS/Premier Hospitals (278 participating) PacifiCare Quality Incentive Program BCBS of Hawaii – QSP program

40. Oklahoma Foundation for Medical Quality An Example of Bonus Payments: PacifiCare Quality Incentive Program Percentage Change in Service Rates from 2Q 2002 to 2Q 2003

41. Oklahoma Foundation for Medical Quality An Example of Bonus Payments: BCBS of Hawaii Quality and Service Recognition Program Change in Total Points by Hospital (100 Points Possible) 2001-2002

42. Oklahoma Foundation for Medical Quality Awards for Improvement Projects Buyers Health Care Action Group (BHCAG), Minnesota financial awards for systems with improvement projects Empire BCBS increasing hospital payments for implementing patient safety measures

43. Oklahoma Foundation for Medical Quality Fee Schedule Based on Performance Central Florida Health Care Coalition (CFHCC) grouping physicians – Platinum, Gold, Silver based on national standards Payment above, at, or below Medicare schedule

44. Oklahoma Foundation for Medical Quality “At-Risk” Contracting Portion of reimbursement increases contingent upon performance Anthem BCBS an example

45. Oklahoma Foundation for Medical Quality An Example of “At-Risk” Contracting: Anthem Midwest Hospital Quality Program 2002 Hospital Quality Program Scorecard Section Hospital Quality Improvement Plan & Program Joint Commission Grid Score ED/Asthma/Pneumonia Cardiac Care Joint Replacement Care Obstetrical care Cancer Care Acute MI/Congestive Heart Failure Patient Safety Total

46. Oklahoma Foundation for Medical Quality 2002 Hospital Quality Program Scorecard

47. Oklahoma Foundation for Medical Quality Cost Differentials for Consumers Aetna and Blue Shield of California “Tiered” networks, with lower co-payments or deductibles when “higher-quality” providers are used. “Choice” Providers / ”Affiliate” Providers

48. Oklahoma Foundation for Medical Quality Reporting Rewarding Voluntary Involuntary

49. Oklahoma Foundation for Medical Quality Reporting Requirements Hospitals 2004 2006 10 Indicators 23 Indicators

50. Oklahoma Foundation for Medical Quality Reporting “Requirements” Physicians 2004 2006 Diabetes, Mammography CAD 7 Adult Immunizations Diabetes 8 5 Indicators CHF 8 HTN 3 Preventive 9 35 Indicators

51. Oklahoma Foundation for Medical Quality DOQ-IT Measures Overview

52. Oklahoma Foundation for Medical Quality Heart Failure (HF) Left ventricular function (LVF) assessment Patient education Left ventricular function (LVF) testing Beta-blocker therapy Weight measurement ACE inhibitor therapy Blood pressure screening Warfarin therapy for patients with atrial fibrillation Hypertension (HTN) Blood pressure screening Blood pressure control Plan of care Preventive Care (PC) Blood pressure measurement Pneumonia vaccination Tobacco use Colorectal cancer screening Lipid measurement Tobacco cessation Influenza vaccination LDL cholesterol level Breast cancer screening DOQ-IT Measures Overview (Cont’d)

53. Oklahoma Foundation for Medical Quality Reporting Voluntary Incentives Involuntary Reporting Penalties Reporting

54. Oklahoma Foundation for Medical Quality Bonus Payments Performance Based Fee Schedule Awards “At-Risk” Contracting Consumer Differentials

55. Oklahoma Foundation for Medical Quality Sample P4P Programs Aetna Anthem Blue Cross Blue Shield of Midwest (OH, IN, KY) Anthem Blue Cross Blue Shield of VA (formerly Trigon) Blue Cross Blue Shield of IL Blue Cross Blue Shield of MA Blue Cross Blue Shield of MN Blue Cross Blue Shield of MI Blue Cross Blue Shield of MO Blue Cross Blue Shield of Rochester (Excellus) and Rochester IPA (NY) Blue Cross of CA Blue Shield of CA Bridges of Excellence Buyers Health Care Action Group Centers for Medicare and Medicaid Services (CMS) and Premier Inc. Cigna (CA)

56. Oklahoma Foundation for Medical Quality AMA’s 5 Ps 4 P4P Ensure quality of Care Fosters the patient-physician relationship Voluntary participation Accurate data and fair reporting Fair and equitable incentives

57. Oklahoma Foundation for Medical Quality The light at the end of the tunnel may be… the train coming. But the train represents Physician reporting and the caboose is Pay for Performance. In the 21st Century, none of us can afford to miss the train.

58. Oklahoma Foundation for Medical Quality All Aboard!!