Public Health IT Quality Reporting This material (Comp13_Unit9) was developed by Columbia...

Public Health IT

Quality Reporting

This material (Comp13_Unit9) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.

Quality ReportingLearning Objectives

2

1. Identify/describe important characteristics and components of useful health care quality measurement systems

2. Identify the past and present efforts to transform medical practice through pay-for-performance initiatives

3. Identify national group efforts involved in the establishment of quality standards/metrics (NCQA, NQF, etc.) based upon claims and EHR data

4. Describe how quality metrics are integrated, tracked, and used in EHRs and describe real-world implementations in eClinicalWorks, EPIC, NextGen

5. Describe the use of EHR-based quality metrics in pay-for-performance incentive projects

6. Summarize the preliminary findings/conclusions from the EHR pay-for-performance project and possible future directions

Health IT Workforce Curriculum Version 3.0/Spring 2012

Public Health IT Quality Reporting

Health Systems and Quality of Care

3Health IT Workforce Curriculum Version 3.0/Spring 2012


• How do you quantify the ‘goodness’ in health care?

• “Every system is perfectly designed to achieve exactly the results it gets.”

– Avedis Donabedian

Principles for Quality Measure Development



Reasons to Measure Quality



Health Care Quality Measurement in Use by the Health Care Industry

Table 1.1



Resources for Validated Performance Measures Types of Measures

Ambulatory Quality Alliance (AQA) •Physician and other Clinician Performance•Acute/ Chronic Care •Surgery/ Procedures

•Consumer Assessment of Health Providers Survey (CAHPS®) - Clinician and Group Survey•Cost of Care

Joint Commission on Accreditation of health care Organizations (JCAHO)

•Hospital Accreditation and Certification•Patient Safety

National Committee for Quality Assurance (NCQA)

•Health care Effectiveness Data and Information Set (HEDIS)•Health Care Organization Accreditation•Provider Recognition Programs

National Quality Forum (NQF) •Patient and Family Engagement •Population Health •Safety

•Care Coordination •Palliative and End-of-Life Care •Overuse

National Quality Measures Clearinghouse sponsored by the Agency for health care Research and Quality (AHRQ)

Resource for clinical practice guidelines for• health care providers --integrated delivery systems•health plans --purchasers

Data Sources



• How reliable are these data sources for the different types of measurement?

Using EHRs forAutomated Quality Reporting

• EHR users document patient data into EHR

• Patient data are aggregated & formatted into standardized quality measures & transmitted to NYC health department

• Some EHR users have systems that aggregate patient data into a standardized format

• Others require another entity/software program to aggregate data prior to transmitting to NYC health department

(Shih, 2010.)



Quality Measures in Data Warehouse

Example: Smoking

(Shih, 2010.)



Caveat

• Having electronic medical records doesnt mean quality reporting accurately reflects practice performance– Example: Majority of smoking status and

smoking cessation intervention not captured for automated quality measure reporting



Distribution of Documentation Smoking Status & Cessation

Intervention

Chart 1.1



Numerator Loss

Denominator Loss

“The Quality World is Flat”

• For the past 3 years, no statistically significant increase in quality measures:

• 57% Commercially insured

• 64% Medicaid insured

• 86% Medicare insured



Pay for Performance Design Considerations:Avoiding Unintended Consequences

Table 1.2



Barriers in Payment Strategies Re-alignment with Clinical Goals

Treat patients that are easily compliant

Pay more for harder to treat patients

Too many indicators and requests for patient information

Focus on with the largest impact on lives and costs

Rewards typically go to “Top Performers” only

Reward all efforts

Unclear what is being paid for Transparent and easy to understand payment methods

Reward amounts not commensurate with effort

Incentive amount must be meaningful

Pay for Performance Design Considerations: What Should a Program Pay For?

Table 1.3



Examples Pros ConsParticipation Data submission

Data reporting

Data collection

Attestation

Encourages all to participate; provides a good starting point

Does not distinguish the best from the average or low performers

Achievement of a specific goal or benchmark

80% of hypertensive patients have blood pressure measured <140/90

Clear standard for passing, drives improvement

Threshold can be too high, making achievement seem impossible for some providers or practices

Top tier Score or performance is in the top 10th percentile among peers or comparison providers

Creates competition to be the best

Rewards fewer participants and only those that have exceptional achievement

“zero defects”

meet multiple goals; patient achieves all recommended clinical guidelines

Patient with diabetes have met all goals: eye exam, foot exam, nephropathy test, LDL test &control, BP control, smoking cessation intervention, and A1c test &control

Assurance of meeting a very high standard, drives improvement

Can be discouraging to providers as achievement is difficult and potentially not feasible for a large proportion of patient population

Increa

sing D

ifficulty in

Ach

ievem

en

t

NYC Health eHearts Rewards

• Payment that rewards disease prevention and effective chronic disease management

• $6M Grant from Robin Hood Fund• Aggregated data from EHR serves as basis for

rewards and recognition• Prevention as a top priority

– Focus on an area with maximum potential for saving lives (cardiovascular health)

• Reduce disparities • Incentive amounts are meaningful

– Pay on ALL eligible patients – Higher rewards for harder to treat patients



Quality Measures for Rewards – The “ABCS”

Table 1.4



Aspirin TherapyAges 18 years or older with Ischemic Vascular Disease or ages 40 years or older with Diabetes on aspirin or another anti-thrombotic therapy

Blood Pressure Control

Patients 18-75 years of age with Hypertension, without Ischemic Vascular Disease or Diabetes who have a BP < 140/90

Patients 18-75 years of age with a diagnosis of Diabetes AND Hypertension with the most recent BP below 130 systolic and 80 diastolic

Patients 18-75 years of age with a diagnosis of Ischemic Vascular Disease AND Hypertension without Diabetes with a BP below 140 systolic and 90 diastolic

Cholesterol Control

Male patients >= 35 years of age and female patients >=45 years of age without Ischemic Vascular Disease or Diabetes who have a total cholesterol < 240 or LDL < 160 measured in the past 5 years

Patients 18-75 years of age with a diagnosis of Ischemic Vascular Disease or Diabetes and Lipoid disorder who had a LDL < 100 in the past 12 months

Smoking Cessation

Patients ages 18 years or older identified as current smokers who received cessation interventions or counseling

Health eHearts Payment Per Patient

Table 1.5



Measures( ABCS )

Medicaid orUn-Insured

Commercial,Medicare, or Other Insurance

Antithrombotic Therapy $20 $20

BP Control General Population $40 $20

BP Control High Risk Population $80 $40

Cholesterol Control Gen Pop $40 $20

Cholesterol Control High Risk $80 $40

Smoking Cessation Intervention $20 $20

Sample Provider Quality Reports From Health eHearts

(NYCDOH, 2010.)



Health eHearts Year 1 Results

• Practices with incentives showed improved quality measure scores over 1 year on 2 of the 4 measures – (Aspirin Therapy and Blood Pressure Control)

• Practices earned an average of $12,000 in 1 year

• Providers requested comparisons to citywide quality performance averages

• Providers requested additional instructions on how to identify patients that did not meet targets



Health eHearts Year 2 Results

• After receiving financial rewards in year 1, will staff and providers will be more attuned to meeting quality measures?

• A new cohort of providers was recruited--half randomized to financial incentives

• Same program design of quarterly report cards and payment schedule



Measures in Achieve Meaningful Use

Table 1.6



2011 Measures (July 2010 Final HITECH)

Maintain active medication list for more than 80% of patients that have at least one entry recorded as structured data

Maintain active medication allergy list for more than 80% of patients that have at least one entry recorded as structured data

Record smoking status for patients 13 years of age or older for more than 50% of patients 13 years of age or older that have smoking status recorded as structured data

Diabetics Hgb A1c <8%

Hypertension: Blood pressure measurement

Ischemic Vascular Disease Patients with LDL under control

Adult Weight Screening and Follow-up

Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention

Colorectal cancer screenings

Breast cancer screenings

Ischemic Vascular Disease Patients on aspirin prophylaxis

Preventive Care and Screening: Influenza Immunization for patients 50 years old or older

Pneumonia Vaccination for older adults.

Quality ReportingSummary

• Important characteristics and componets of health care quality measurement systems

• Measures to achieve meaningful use• eHearts payment systems example• “ABC” of quality measures for rewards



Quality ReportingReferences

References:

1. Brown, L., Franco, L.M., Rafeh, N. Quality assurance of health care in developing countries. Retrieved on October 1st, 2010 from http://pdf.usaid.gov/pdf_docs/Pnabq044.pdf

2. Donabedian, A. Evaluating the Quality of Medical. 1966 (reprinted in Milbank Quarterly, 2005, visit: http://www.milbank.org/quarterly/830416donabedian.pdf)

3. Retrieved on October 1st, 2010 from What is evidence based medicine? http://www.cebm.net/index.aspx?o=1914

4. Desirable Attributes of HEDIS. Retrieved on October 1st, 2010 from Desirable http://www.ncqa.org/tabid/415/Default.aspx

5. NQF Measures Evaluation Criteria. Retrieved on October 1st, 2010 from Desirable http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx

6. Lee TH. (2007). Eulogy for a Quality Measure. N Engl J Med 357:1175-1177

7. Retrieved on October 1st, 2010 from http://www.ncqa.org.

8. Retrieved on October 1st, 2010 from http://www.nqf.org.

9. Retrieved on October 1st, 2010 from http://www.aqaalliance.org.

10. Retrieved on October 1st, 2010 from http://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

11. Retrieved on October 1st, 2010 from http://www.mnmc.org.

12. Retrieved on October 1st, 2010 from http://www.iha.org.

13. Retrieved on October 1st, 2010 from http://www.mhqp.org.

14. AHRQ Resources on Pay for Performance (P4P): A Decision Guide for Purchasers, by R. Adams Dudley and Meredith B. Rosenthal. (Final Contract Report) Rockville, MD: Agency for health care Research and Quality, 2006. AHRQ Pub. No. 06-0047. Retrieved on October 1st, 2010 from http://www.ahrq.gov/qual/p4pguide.htm

15. Retrieved on October 1st, 2010 from PCIP http://www.nyc.gov/html/doh/html/pcip/pcip.shtml



http://pdf.usaid.gov/pdf_docs/Pnabq044.pdf

http://www.milbank.org/quarterly/830416donabedian.pdf

http://www.cebm.net/index.aspx?o=1914

http://www.ncqa.org/tabid/415/Default.aspx

http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx

http://www.ncqa.org/

http://www.ncqa.org/

http://www.nqf.org/

http://www.nqf.org/

http://www.aqaalliance.org/

http://www.aqaalliance.org/

Quality ReportingReferences

Charts, Tables, Figures:

1.1 Table: Shih, S. (2010). Health care quality measurement in use by the health care industry. Primary Care Information Center, New York Department of Health and Mental Hygiene.

1.1 Chart: Shih, S. (2010). Distribution of documentation smoking cessation status & cessation intervention. Primary Care Information Center, New York Department of Health and Mental Hygiene.

1.2 Table: Shih, S. (2010). Pay for performance design considerations: avoiding unintended consequences. Primary Care Information Center, New York Department of Health and Mental Hygiene.

1.3 Table: Shih, S. (2010). Pay for performance design considerations: What Should a Program Pay For? Primary Care Information Center, New York Department of Health and Mental Hygiene.

1.4 Table: Shih, S. (2010). Quality measures for rewards “The ABC’s”. Primary Care Information Center, New York Department of Health and Mental Hygiene.

1.5 Table: Retrieved on October 1st, 2010 from http://www.cms.gov/EHRIncentivePrograms/Downloads/EHR_Incentive_Program_Agency_Training_v8-20.pdf

1.6 Table: NQF Measures Evaluation Criteria. Retrieved on October 1st, 2010 from http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria

Images:

Slide 8 : Shih, S. (2010). Using EHRs for automated quality reporting. Primary Care Information Center, New York Department of Health and Mental Hygiene.

Slide 9: Shih, S. (2010). Quality measures in data warehouse. Primary Care Information Center, New York Department of Health and Mental Hygiene.

Slide 18: Shih, S. (2010). Sample provider quality reports from health eHearts. Primary Care Information Center, New York Department of Health and Mental Hygiene.



Public Health IT Quality Reporting This material (Comp13_Unit9) was developed by Columbia...

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