HIT Policy Committee Quality Measures Workgroup Tiger Team Summary David Lansky, PhD Pacific Business Group on Health October 20, 2010

Care Coordination –Tim Ferris, chairperson –Marsha Lillie-Blanton, Helen Burstin, Daniel Green, Rainu Kaushal, David Kendrick, Laura Peterson, Eva Powell, Martin Rice, Sarah Scholle, James Walker Efficiency Including Underuse and Overuse –Charles Kennedy and Robert Kocher, chairpersons –Richard Bankowitz, Niall Brennan, Kate Goodrich, Rob Greene, Karen Kmetik, Jon White Patient Safety –Neil Calman, chairperson –Peter Basch, Tripp Bradd, Russ Branzell, Peter Briss, Marc Overhage, Jacob Reider, Leah Marcotte Patient and Family Engagement –Christine Bechtel and David Lansky, chairpersons –Michael Barry, Susan Edgman-Levitan, Judy Hibbard, Lew Kazis, Gene Nelson, Dana Safran, Paul Tang, Kalahn Taylor-Clark, Paul Wallace, Jim Weinstein Population and Public Health –Jessie Singer, chairperson –Ahmed Calvo, H. Westley Clark, Theresa Cullen, Carol Diamond, Patrick Gordon, Cary Sennett, Steve Solomon Methodological Issues –TBD, chairpersons –David Baker, Rachel Behrman, Helen Burstin, Bob Dolin, Abel Kho, Ross Lazarus, Dan Malone, John Moquin, Phil Renner, Mitra Rocca, Danny Rosenthal, Mark Weiner, Jonathan White 2 Quality Measures Workgroup Tiger Teams

The Care Coordination tiger team identified four priority sub- domains to focus their efforts. –Effective Care Plans – An effective care plan is a partnership between the patient, his/her family, and the health care team. This may be known as a self management plan. –Care Transitions – A care transition is the movement of a patient between health care providers or health care settings. A care transition occurs anytime there is a patient handoff. –Appropriate and Timely Follow-Up – Appropriate and timely follow- up includes the response from the recipient (physician), such as taking a follow-up action, and acknowledgment of the receipt of the information to the patient and/or sender (specialty provider, etc). –Intervention Coordination - Intervention coordination includes medication management and intervention management, such as diagnostic imaging, testing and other services (OT/PT). Coordination should be appropriate, affordable, and be communicated to the patient. 3 Care Coordination

4 Sub-DomainMeasure ConceptsExample Measures Effective Care Plan Care plan is defined as a partnership between the patient, his/her family, and the health care team. This may be known as a self management plan. Comprehensive Clinical Summary, including summary of treatment for adults and children with chronic conditions (build on Stage 1 MU Measure for Clinical Summary) Care Model Process/After visit summary (AVS)/ % of completed visits where an after visit summary was printed. Asthma- Use of appropriate medications for people with asthma. More than 50% of all unique patients 65 years old or older admitted to the eligible hospital’s or critical access hospital’s inpatient department have an indication of an advance directive status recorded 80% of your active patients have a health care proxy in their medical record. Self Management Plan – Adults and children with leading conditions Advance Care Plan (build on Stage 1 MU Measure for advance care plan) Palliative Care Plan (symptom management, family engagement) Care Transitions The movement of a patient between health care providers or health care settings. Elements of successful care transitions (medication reconciliation, problem list, diagnostics) NQF # 97: Medication reconciliation for Patients 65 and Older NQF #647,648,649: Transition Record with Specified Elements Received by Facility or Discharged Patients (Inpatient Discharges, ED Discharges to Home/Self Care or Any Other Site of Care) NQF #228: Care Transitions Measure (CTM) 3-item survey Critical Information Included with PCP Request for Specialist Referral; Critical Information Re PCP Referral Received by Specialist; Primary Care Communication about Referral to Patient/Family; Specialist Communication of Results to Patient/Family; Primary Care Clinician Review of Specialist Report; Specialist Report to Primary Care Physician Transition between settings of care (inpatient to outpatient, PCP to Specialist or any referral between outpatient services) Transition experience (patient focused measures) Outcomes of poor care transitions (readmissions) Care Coordination

5 Sub-DomainMeasure ConceptsExample Measures Appropriate and Timely Follow-Up Response from the recipient (physician), such as taking a follow-up action and acknowledging receipt of the information to the patient and/or sender (specialty provider, etc) Appropriate medication reconciliation for leading conditions for all transitions and intervals between transitions Appropriate use of medication for hyperglycemia, hyperlipidemia, hypertension in patients with diabetes - Numerator: Patients on treatment medication for HbA1c Denominator: patients with diagnosis of diabetes (ICD- 9 code 250.XX) active over specified time period and identified as having inadequate control of HbA1c (Chan- Weiner JHU Measure) % of providers who send relevant patient reminders for preventive/follow- up care to ≥50% of patients Reduce the number of duplicative lab, x-ray and diagnostic exams Provider follow-up on lab and diagnostic results Patient follow up after care transitions Intervention Coordination Intervention Coordination will include medication management and intervention management, such as diagnostic imaging, testing, and other services (OT/PT). Coordination in this category should be appropriate, affordable and be communicated to the patient. Medication Management (including reconciliation) The percentage of patients 18–56 years of age who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year 90% of the diabetic patients who have been seen by their clinician at least once during the last 12 months will have a current medication list in the EHR that includes documentation of allergies and adverse reactions NQF Polypharmacy – elderly who consume ten or more drugs Diagnostic Management Communication with Patient Patient Experience Care Coordination

The Efficiency tiger team identified five sub-domains to focus their efforts. –Person-Centered Better Care – Measures that show impacts to patients as they move through the entire care delivery system in an efficient manner. –Proven Care — Measures evaluating the use of effective care based on practice guideline. –Leading Conditions: Longitudinal Care Dashboards – Measures related to Leading Conditions which would enable the creation of a longitudinal dashboard that follows patient progress, including medications, diagnostics, proven care, readmissions, functional status, and patient education. –Value-Based Population and Preventative Health – Measures focused on effective use of preventative health measures. –Appropriate Care - Measures that focus on underused clinical tools or stinting of care. 6 Efficiency Including Underuse and Overuse

7 Sub-DomainMeasure ConceptsExample Measures Person-Centered Better Care Measures that show impacts to patients as they move through the entire care delivery system in an efficient manner. Readmission All cause readmission rate paired with adjusted length of stay. Appropriate use of diagnostic imaging procedures (redundancy, cumulative exposure, and appropriateness) Diagnostic Imaging Proven Care Measures evaluating the use of effective care based on practice guidelines Medication Generic vs. brand medication usage rates Medication usage (antihypertensives, aspirin, statins, and ACE inhibitors) Generic Medication Use Leading Conditions Measures related to Leading Conditions which would enable the creation of a longitudinal dashboard that follows patient progress, including medications, diagnostics, proven care, readmissions, functional status, and patient education Leading Conditions Composite measure set that check for key action items for congestive heart failure (CHF) across the continuum of care Measures that check for key action items for pneumonia across the continuum of care Value-Based Population and Preventive Health Measures focused on effective use of preventative health measures Immunizations Patients receiving flu shots Age and gender-appropriate cancer screening rates Oncology Appropriate Care Measures that focus on underused clinical tools or stinting of care Access to Care Patients diagnosed with coronary artery disease and prescribed aspirin Palliative care consults ordered for ICU patients Palliative Care Efficiency Including Underuse and Overuse

The Patient Safety tiger team identified three priority sub-domains to focus their efforts. –Medication Safety — Measures that show the prevention and reporting of Adverse Drug Events (ADEs) and use of evidence based medicine. –Hospital Associated Events — Measures related to the prevention and reporting of Hospital Acquired Infections (HAIs) and Venous Thromboembolism (VTEs). –Falls — Measures related to the prevention and reporting of falls. 8 Patient Safety

9 Sub-DomainMeasure ConceptsExample Measures Medication Safety Measures that show the prevention and reporting of Adverse Drug Events (ADEs) and use of evidence based medicine Documentation of adverse events JCAHO: percent of patients with documented allergy and adverse reactions HRSA Quality e-Measures Inventory: Adverse Drug Event (injury resulting from use of a drug) Percent of medication errors reported to FDA Adverse Event Reporting System (AERS) Percentage of medications administered using proper medication verification technique Examining number of evidence based recommendations when prescribing high risk medications Percent of medication reconciliation completed at each relevant encounter and each transition of care Reporting of adverse events Reporting medication errors Bedside medication verification Using CDS for high risk medications Correct medication reconciliation for EPs as well as hospitals Hospital Associated Events Measures related to the prevention and reporting of Hospital Acquired Infections (HAIs) and Venous Thromboembolism (VTEs) Reporting of HAIs and VTE National Healthcare Safety Network (NHSN): reporting catheter associated urinary tract infections (CAUTI) and central line associated bloodstream infections (CLABSI) VAMC: patients receiving VTE prophylaxis at risk for VTE / all patients at risk for VTE NQF 302: Ventilator bundle; NQF 298: central line bundle Utilizing CDS to increase number of patients at risk for VTE receiving VTE prophylaxis Utilizing CDS to reduce HAIs Falls Measures related to the prevention and reporting of falls Utilizing CDS to determine and alert providers to fall risk Identifying high risk patients using indicators in the patient’s chart High risk patients with falls assessment/ total high risk patients Brigham patient safety reporting database: slip or fall incidents/ 1000 patient days Measure the compliance of conducting falls assessments for high risk patients Reporting on the number of falls Patient Safety

The Patient and Family Engagement tiger team identified five priority sub- domains to focus their efforts. –Self-Management/Activation—Measures that show that the patient understands what their role is in their own care process and has the knowledge, skills and confidence to move forward in this role, including resources & support for self-management. –Honoring Patient Preferences and Shared-Decision Making—Measures that demonstrate that the patient has the knowledge, resources and confidence in making informed decisions about their care. Also includes the quality of decision making, connecting patients to resources, assessing patient preferences and whether the care that was delivered is in line with patients’ preferences. –Patient Health Outcomes—Measures that focus on optimizing three States (Disease/disability, Health Risk, and Functioning Health) at the individual patient level and/or population level. –Health Activities Coordination—Measures that show if a patient was connected to community resources. –Family/Caregiver Engagement—Measure that show that a patient’s family/caregiver was engaged in/during the other four sub-domains listed above. 10 Patient and Family Engagement

11 Sub-DomainMeasure ConceptsExample Measures Self-Management/Activation Measures that show that the patient understands what their role is in their own care process and has the knowledge, skills and confidence to move forward in this role, including resources & support for self- management Patient Activation Patient Activation Measure (PAM) Self management of health risk behaviors, preventive care in general, not just chronic conditions CAHPS family of instruments and other patient experience surveys Measure Activation: 2013: % of patients with activation score recorded? 2015: % of patients with (positive) change in activation? Resources and Support for Self-Management Self-Management and Patient Activation Outcomes of Activation Honoring Patient Preferences and Shared Decision Making Measures that demonstrate that the patient has the knowledge, resources and confidence in making informed decisions about their care. Also includes the quality of decision making, connecting patients to resources, assessing patient preferences and whether the care that was delivered is in line with patients’ preferences. Shared Decision Making and Patient Preferences Measure at 3 levels: 1.) Did shared decision making occur, 2.) Was shared decision making done well, and 3.) Did shared decision making make a difference Decision quality measures, CAHPS family of instruments, other patient experience surveys Measures that capture how people prefer to communicate (paper, portal, USB, s, PHR, etc) Shared Decision Making, Patient Preferences and Patient Experience of Care Patient Preferences Patient and Family Engagement

12 Sub-DomainMeasure ConceptsExample Measures Patient Health Outcomes Measures that focus on optimizing three States (Disease/disability, Health Risk, and Functioning Health) at the individual patient level and/or population level Patient Health Outcomes – Disease/Disability State Measure patient-reported outcomes and how HIT can enable that for high volume, high cost conditions with appropriate outcome tools Health of Seniors Survey (including VR-12 and/or VR 36), PROMIS survey from NIH for adults General measure of avoidable risk of death that is based on both biometric variables and lifestyle variables Patient Health Outcomes – Functional Health State Patient Health Outcomes – Health Risk State Health Activities Coordination Measures that show if a patient was connected to community resources Was the patient connected to community resources Connecting to community resources for health promotion, complex chronic disease management and care, and social/other non-medical needs/support, including online patient/caregiver communities Caregiver as a proxy for patient In situations where caregiver present, measure caregiver’s engagement, health status, communication preferences, etc Family/Caregiver Engagement Measure that show that a patient’s family/caregiver was engaged in/during the other four sub-domains Patient/Family Engagement should be represented in all sub-domains Family/Caregiver Engagement should be represented in all sub-domains Patient and Family Engagement

The Population and Public Health tiger team identified three priority sub-domains to focus their efforts. –Healthy Lifestyle Behaviors - Longitudinal outcome measures of improvement (or lack of improvement) resulting from patient health-related behaviors –Effective Preventive Services - Longitudinal outcome measures of improvement (or lack of improvement) resulting from the use of preventive health care. –Health Equity - Longitudinal outcome measures that evaluate the quality of health care across priority populations to track and prevent inequities and health care disparities. 13 Population and Public Health

14 Sub-DomainMeasure ConceptsExample Measures Healthy Lifestyle Behaviors Measures that allow trending the progress (or lack of progress) in attaining positive patient outcomes. Smoking Cessation Numerator: Number of patients in the denominator with smoking status of "former smoker" as their most recent status within the reporting period. Denominator: Number of patients with smoking status of "current smoker" as their earliest status within the reporting period Numerator: Number of patients in the denominator with BMI of "overweight" or "normal weight" or >= 10% weight loss as their most recent status within the reporting period. Denominator: Number of patients with a BMI of obese as their earliest status within the reporting period BMI Alcohol Use Effective Preventive Services Measures that focus on the impact of the continuum of care. Blood Pressure Numerator: Number of patients in the denominator with a JNC7 classification of Stage 1 ( /90-99) or controlled ( =160/>=100) and no diagnosis of diabetes mellitus or renal disease, as their earliest status within the reporting period : Number of patients in the denominator with a hemoglobin A1c = 9% as their earliest status within the reporting period Diabetes Population and Public Health

Sub-DomainMeasure ConceptsExample Measures Effective Preventive Services (continued) Measures that focus on the impact of continuum of care. Mental Health Numerator: The number of patients in the denominator who were screened at least once during the past year for depression using a validated screening instrument. Denominator: The number of active clinical patients, aged 12 years and older who were seen for a visit within the reporting period (PHQ2 and PHQ9) Health Equity Measures that look at overall populations to evaluate health inequities Healthy Lifestyles The measure calculation consists of the % of domains where there was no discrepancy. Numerator: # of domains where no discrepancy exists among the measures included in Sub domain #1 - Healthy Lifestyle Behaviors. Denominator: Total # of domains applicable The measure calculation consists of the % of domains where there was no discrepancy. Numerator: # of domains where no discrepancy exists among the measures included in Sub domain #2 – Effective Preventive Services. Denominator: Total # of domains applicable Numerator: Number of patients in the denominator with insurance status of "insured" as their most recent status within the reporting period. Denominator: Number of patients with insurance status of "uninsured" as their earliest status within the reporting period Care Access Insurance Population and Public Health 15

The Methodological Issues tiger team will focus on the following three areas: –Longitudinal measures –Delta measures –Adverse event reporting 16 Methodological Issues

Tiger Teams report to Quality Measures Workgroup (October 28, 2010) Quality Measures Workgroup presents recommendation to HIT Policy Committee (December) Send Request for Information (RFI) to identify measures in use or measures that need retooling that meet priorities and fill gaps (early November) Develop RFP for innovative measure development, testing, and validation to fill in gaps (mid-December) 17 Next Steps