FIHN PCP Pod Meeting April 6, 2017

EHR Measure Scores Reminder: Customer Service and Claim based Measure Scores pending 20.97 Eye 39.11 A1c 35.48 Eye 20.56 A1c

Abstraction concerns Many patients failed CARE-3 (ACO-39): Documentation of Current Medications in the Medical Record (49.41%) Most commonly due to lack of Route of Administration details Also many prescriptions missing dose and frequency information A similar measure replaces this for 2017 but still uses definition of a current reconciled medications list “The medication list should include all medications (prescriptions, over- the-counter, herbals, supplements, etc.) with dose, frequency, route, and reason for taking it. It is also important to verify whether the patient is actually taking the medication as prescribed or instructed, as sometimes this is not the case. “

Abstraction concerns Patients are failing PREV-9 (ACO-16): BMI Screening and follow-up (82.3%) Different parameters based on age: EHR may not alert differently for 65+ Age 65 and older BMI >= 23 and < 30 Age 18-64 BMI >= 18.5 and < 25 Many elderly patients are underweight per these parameters and are not receiving plans Others are receiving plans to eat fewer calories, low salt, low fat, etc.- this would count on a report but may be a concern for appropriateness

Abstraction concerns Patients are failing or being excluded from MH-1 (ACO-40) at very high rates: Depression Remission at 12 months (6.7%) Not the Depression Screening measure Denominator: Age 18+ with dx of major depression or dysthymia AND an initial PHQ-9 score > 9 during the encounter Numerator: Who achieved remission at 12 months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than 5 Denominator exclusions: permanent nursing home residents, , dx of bipolar, dx of personality disorder

Abstraction concerns FIHN MSSP is just above benchmark for DM Composite: Hemoglobin A1C Poor Control and Retinal Eye Exam (31.2%) 18-75 with diabetes with A1c >9%; inverse measure 18-75 with diabetes who had a retinal or dilated eye exam by an eye care professional or negative retinal exam in 12 months prior to measurement period These are composed together for the score

2017 Primary Focus on: Depression Screening (c f/u plan) Breast Cancer Screening Colorectal Cancer Screening Diabetes Composite Measure (HbA1C + Retinal Exam) Depression Remission at 12 Months

Changes to MSSP 2017 Quality Measures

Medication Reconciliation Post Discharge DESCRIPTION: The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list DEFINITION: Medication Reconciliation –Discharge medications are reconciled with the most recent medication list in the outpatient medical record. Must include evidence of medication reconciliation and the date. Any of the following evidence meets criteria: Examples on signed documentation Current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds at discharge, discontinue all discharge meds) Current medications with a notation that the discharge medications were reviewed Notation: “reconciled the current and discharge meds” A current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service Notation that no medications were prescribed or ordered upon discharge Document in EHR for quality reporting – check box for “reconciled” or “verified” Important Note: Dose, frequency, route and reason for taking must be noted to the best of the provider’s ability

ACO 44: Use of Imaging for Low Back Pain Numerator Denominator Comments EHR Documentation Patients who received an imaging study (e.g. plain x-ray, MRI, CT Scan) conducted on the episode start date or in the 28 days following. All patients 18 -50 years of age who had an outpatient or ER encounter with a principal diagnosis of low back pain during the start of the measurement period through 28 days prior to the end of the measurement period. Exclusions – patients with a low back pain diagnosis during the 180 days prior; patients with cancer; recent trauma, intravenous drug abuse, neurological impairment Exceptions - none Measure captured via claims. Measure reported as inverted measure (i.e. higher percentage indicates appropriate treatment (proportion for whom imaging studies didn’t occur)

Depression Screening with follow-up At least once in 2017- maybe during Annual Wellness Visit OR on Medicare Screening Questionnaire If PHQ-2 is positive, follow up with PHQ-9 and/or Plan May consider using z13.89 (encounter for screening of other disorder) Document Exclusions: Active dx of depression or bipolar disorder Document Exceptions: Refusals

Examples of a Follow-up Plan Additional evaluation for depression or PHQ-9 Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacologic interventions (drug therapy) Other intervention or follow-up for the diagnosis or treatment of depression

At-Risk Domain MH: Depression Remission Depression Remission – do PHQ-9 for every visit on a patient with depression or dysthymia; or schedule on a yearly basis (e.g. at the time of the MC Wellness Visit) 2017 Measure Index period 12/01/15-11/30/2016 Document Exclusions – hospice or palliative care, permanent nursing home residents, diagnosis of bipolar or personality disorder

NextGen Charting vs eClinicalWorks

NextGen

Documenting Exclusions

Exception/Exclusion documentation

Mammogram Use Medicare Screening Questionnaire Exclusions: Bilateral or two unilateral mastectomies

Colorectal Cancer Screening Use Medicare Screening Questionnaire Encourage FOBT (x3), Flex Sig, Cologuard, Virtual Colonoscopy for those who refuse Colonoscopy Document exclusions: total colectomy or colorectal cancer

NextGen

Exclusions

Diabetes Composite HbA1c (must record date, and be <9 (controlled)) Current Retinal Exam: Every year for positive retinopathy, Every 2 years for negative retinopathy

Eye Exam Referral & Fax Form

Diabetes Composite – HbA1c If send out – please order test BEFORE office visit (to discuss results of the test) Medicare allows every 6 months for IGT, every 3 months for Diabetes If pt consistently remains >9, consider Endocrine consultation

Medication Reconciliation Post Discharge Should include all medication including prescriptions, OTCs, vitamins, and supplements Should include strength, dose, route, timing (sig) (SEE SUPERUSER POD SLIDE)

NextGen

Fall Screening Must ask the patient: Have you had two (2) or more falls in the past year, or one (1) or more with an injury? (A) Part of Annual Wellness Visit exam (AWV HRA #17) - OR - (B) Consider using the Medicare Screening Questionnaire for all Medicare patients

NextGen Fall Screening

NextGen Fall Screening

Fall Screening Exceptions

Additional Plan or Exclusions

Flu Immunization Flu season runs from Fall (8/1/15) to Spring (3/31/16) – already done for 2016 report: CAN go back and record refusals and allergies Record date if / when given in EMR If done at a pharmacy / elsewhere record the closest date possible (eg October 1st) and note that it was given there Vaccine Registry can be accessed: www.mdimmunet.org (410-767-6606)

Flu Immunization Exceptions Record Vaccine refusals (make sure your EMR has a “refusal” element if patient declines the shot) Also record if the patient is allergic to flu shots (list under “Allergies”), or cannot receive it due to other medical reasons (Can also list other System issues, such as the vaccine is not available, if appropriate.)

NextGen Exclusions may be documented by selecting “Not Administered” and selecting the reason.

Exceptions

Pneumococcal Vaccination No Exclusions Give Prevnar-13 or Pneumovax to all pts > 65yo No exceptions or exclusions (for vaccination refusal) If given this year, must document specific type May use state Vaccine Registry www.mdimmunet.org (410-767-6606)

Pneumococcal Vaccination It is encouraged for all practices to give the vaccine Cost (10 doses per box): Pneumovax (90732) - $76.53 per dose Prevnar-13 (90670) - $159.57 per dose Medicare Reimbursement: Pneumovax (90732) - $88.80 Prevnar-13 (90670) - $177.44 Immun Single Injection (G0009) – $25.67

document if patient refuses plan) BMI (Body Mass Index) BMI (65yo and older) If BMI < 23 write a plan to increase weight If BMI 23-30 no plan needed; weight satisfactory If BMI > 30 write a plan to decrease weight (for under 65yo BMI’s should be >18.5 and < 25; document if patient refuses plan)

NextGen

Exclusions

Tobacco Use Must Document Smoking and Smokeless tobacco use/non-use Offer counseling Refer to an established smoking cessation program – FMH Outpatient Cessation Program (240-566-3622) With proper documentation can bill in office 99406 (Smoking and tobacco use cessation counseling visit; 3-10 minutes) or 99407 (>10 minutes); use modifier 25

NextGen

Exceptions/Exclusions

HTN Control Hypertension Control – must keep BP < 140 / 90; one exclusion is ESRD

IVD IVD – document baby ASA, anti-thrombotics. No exceptions

Statin Therapy for Prevention and Treatment of Cardiovascular Disease

Exclusions

Exceptions

Questions