The Culture of Healthcare Welcome to The Culture of Healthcare: Quality Measurement and Improvement. This is lecture (b). The component, The Culture of Healthcare, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace. Quality Measurement and Improvement Lecture b This material (Comp2_Unit7b) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

Quality Measurement and Improvement Learning Objectives Define healthcare quality and the major types of quality measures: structural, process, and outcome measures (Lecture a) Describe the current state of healthcare quality in the United States (Lecture a) Discuss the current healthcare quality measures used in various healthcare settings in the US, including those required for the HITECH meaningful use program (Lecture b) Describe the role of information technology in measuring and improving healthcare quality (Lecture c) Describe the results of current healthcare quality efforts in the US (Lecture c) The objectives for Quality Measurement and Improvement are to: Define healthcare quality and the major types of quality measures: structural, process, and outcome measures Describe the current state of healthcare quality in the United States Discuss the current healthcare quality measures used in various healthcare settings in the United States, including those required for the HITECH meaningful use program Describe the role of information technology in measuring and improving healthcare quality Describe the results of current healthcare quality efforts in the United States Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Sampling of Current Quality Programs and Measures Warning: There are many sets and acronyms, and they change constantly We are still “early” in the science of quality improvement (Berwick, 2008) “Science” defined in an IOM report (2006) Many measurements in use (Damberg, 2011) but still need improvement (Pronovost, 2011) Many measures have been developed, reflecting various perspectives AHRQ maintains clearinghouse www.qualitymeasures.ahrq.gov Growing consensus that standard sets are needed for each perspective We will view them from following perspectives Health plans Outpatient Inpatient Quality measures in HITECH Stage 1 meaningful use program This lecture will examine quality measures that are currently used, including those required under the stage-one meaningful use rules of the Heath Information and Technology (HITECH) [high-tech] Act. A sampling of current quality programs and measures in use appears on the screen. Berwick has noted that we are “early” in the science of quality improvement. What exactly is that science? There is an Institute of Medicine report that describes the science behind healthcare quality assessment. Many measures have been developed, all reflecting different perspectives, somewhat like standards. AHRQ [A-H-R-Q] maintains a clearinghouse of the different types of measures that are available, where they are being used, and so forth. But there is clearly a growing consensus that we need to develop standardized sets so that we can implement them in standardized ways and obtain value from them. In the following slides, we will talk about specific quality measures from different perspectives―the perspective of health plans, the perspective of outpatient medicine, the perspective of inpatient medicine, and those required under the stage-one meaningful use rules of the HITECH Act. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Quality Reporting for Health Plans Called out because of historic role Health Plan Employer Data and Information Set (HEDIS) by NCQA provides 60 measures that evaluate health plans, particularly health maintenance organizations NCQA annual reports calculate lives saved based on outcomes from adherence The first topic is health plans. Why health plans? There is a historic role here. Health plans were among the first to measure quality, at least as process measures, and act on the findings. They should be noted and commended for being pioneers in this area, and in fact, there is a healthcare quality measurement set called HEDIS [hee-diss], the Health Plan Employer Data and Information Set, developed by NCQA [N-C-Q-A], the National Committee for Quality Assurance, which has sixty measures that are mainly healthcare process measures used to evaluate health plans and particularly health maintenance organizations. The NCQA reports, which were covered in the previous lecture, calculate lives saved based on outcomes that occur from adherence to these process measures. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

HEDIS Categories and Example Measures Effectiveness of care Childhood and adult immunizations Use of beta blockers after myocardial infarction Screening for various types of cancer Comprehensive diabetes care Access/availability of care Access to preventive health services Availability of primary care providers Initiation of prenatal care Satisfaction with care Member satisfaction surveys Use of service Rate trends HEDIS has a number of categories and then specific measures within those categories. There are effectiveness-of-care measures, such as childhood and adult immunization; use of beta blockers after myocardial infarction ([my-o-car-dee-ul in-farc-shun]) or MI [M-I]; screening for various types of cancer; and a number of measures related to chronic diabetes care. There are also measures on access and availability to care such as access to preventive health measures, how available primary care providers are, and how soon prenatal care is initiated after a woman has been diagnosed as being pregnant. There are also measures related to satisfaction with care, including member satisfaction surveys and the use of various services such as preventive measures. These measures allow health plans to compare themselves to other health plans. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Reporting for Outpatient Setting In US, major efforts led by Centers for Medicare and Medicaid Services (CMS, www.cms.hhs.gov) in Medicare program Physician Quality Reporting System (PQRS, formerly PQRI, http://www.cms.hhs.gov/pqri/) Extra 1% reimbursement for reporting on large number of measures (194 in 2011) Also receive 0.5% for maintenance of certification Bonus changes to penalty starting in 2015 Electronic Prescribing (eRx) Incentive Program (http://www.cms.gov/ERxIncentive/ ) Extra 1% reimbursement for use of e-prescribing Bonus continues through 2013; penalty starts in 2012 These quality measures are separate from meaningful use regulations, for which the Government Accountability Office (GAO, 2011) has criticized CMS for inconsistencies across the programs What about quality reporting in the outpatient setting? In the United States, major efforts in this setting are led by the Centers for Medicare and Medicaid Services (CMS, [C-M-S]), mostly in the Medicare program. The major CMS program is the Physician Quality Reporting System (PQRS, [P-Q-R-S]), which was formerly called PQRI [P-Q-R-I]. The program provides physicians participating in Medicare an extra 1% reimbursement for reporting on a large number of measures (a total of 194 in 2011). They also receive 0.5% for maintenance of certification in their medical specialty. It should be noted that the bonus changes to a penalty starting in 2015. Another CMS program is the Electronic Prescribing (eRx, [E-R-X]) Incentive Program. This program provides an additional extra 1% reimbursement for use of e-prescribing. The bonus continues through 2013; a penalty starts in 2012. The quality measures in this program are separate from meaningful use regulations, for which the Government Accountability Office (GAO, 2011) has criticized CMS for inconsistencies across the programs. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Some example PQRS measures Hemoglobin a1c poor control in diabetes mellitus Percentage of patients aged 18 to 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% Thoracic surgery: recording of clinical stage for lung cancer and esophageal cancer resection Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical TNM staging prior to surgery Weight assessment and counseling for children and adolescents Percentage of children 2 to 18 years of age whose weight is classified based on BMI percentile for age and gender Some sample PQRS measures include these to measure the following conditions. For diabetes mellitus, the quality measure is the percentage of patients aged 18 to 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0%. For patients undergoing resection for lung or esophageal cancer and requiring thoracic surgery, the measure is the percentage of surgical patients aged 18 years and older who had clinical TNM ([T-N-M] Classification of Malignant Tumors) staging prior to surgery. For weight assessment and counseling for children and adolescents, the quality measurement is the percentage of children aged 2 to 18 years whose weight is classified based on BMI ([B-M-I], body mass index) percentile for age and gender. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Reporting for inpatient setting Hospital Quality Alliance (HQA, www.hospitalqualityalliance.org) Collaboration among CMS, Joint Commission, and others to create a starter set of quality measures for various conditions In Hospital Compare Project, hospitals voluntarily provide quality information that can be accessed via a Web site–www.hospitalcompare.hhs.gov Consists of two programs based on reporting to CMS Inpatient Quality Reporting (IQR) – for HQA data; not participating results in 2% Medicare reimbursement reduction Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) – reporting of patient satisfaction at hospitals There are also quality measures for inpatient settings. Much of this activity focuses on an organization (actually a collaboration of organizations) called the Hospital Quality Alliance or HQA [H-Q-A]. The HQA includes the CMS, the Joint Commission, and others who have created a starter set of quality measures for various conditions initially focused in four areas. The Hospital Compare Project is a voluntary program where organizations that submit these quality measures have them published on a website so individuals can compare one hospital with another with regards to these quality measures. The HQA Project actually consists of two programs based on reporting that is done to CMS. One part is the Inpatient Quality Reporting (IQR). This is for the HQA data in the four areas, and hospitals that do not participate actually have a 2% reduction in their Medicare reimbursement. There is another collection of information that does not measure process quality but patient satisfaction. This is the Hospital Consumer Assessment of Healthcare Providers, or HCAPHS [H-caps], a measure of patient satisfaction, that is also reported as part of the Hospital Compare Project. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

HQA Categories and Examples Myocardial infarction Aspirin at arrival and discharge Inpatient mortality Heart failure Discharge instructions Evaluation of left ventricular systolic function Pneumonia Time to blood cultures and antibiotics Pneumococcal and influenza vaccinations Surgical infection prevention Prophylactic antibiotics Prophylaxis for deep venous thrombosis Children’s asthma care Reliever medication while hospitalized Home Management Plan of Care Document Here are the HQA categories and some examples within them. The broad categories are MI, heart failure, pneumonia, surgical infection prevention, and children’s asthma care. Within them are a variety of mainly process measures; these are the quality measures that are reported within HQA and made available on the Hospital Compare website. Among the measures for MI are actions such as aspirin at arrival to the hospital; when the diagnosis is made and discharged; and inpatient mortality. For heart failure, the provision of discharge instructions and the evaluation of the patient's left ventricular systolic [si-stol-ik] function are measures. For pneumonia, the measures include time to blood cultures and antibiotics as well as vaccinations for pneumococcus [noo-muh-kok-uh s] and influenza. For surgical infection prevention, the measures look at prophylactic antibiotics as well as prophylaxis for deep venous [vee-nuhs] thrombosis. For childhood asthma, the measures are the need for reliever medication while hospitalized and the development of a Home Management Plan of Care Document. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Other Inpatient Quality Initiatives National Surgical Quality Improvement Program (NSQIP – www.acsnsqip.org) Effort of American College of Surgeons to measure, risk-adjust, and improve quality of surgical care University HealthSystem Consortium (UHC – www.uhc.edu) Quality measurements to benchmark academic medical centers Measured by “green dots” and “red dots” (½ to 2) There are some other quality initiatives in the inpatient setting that are not tied into the US government and Medicare reimbursement. A long-standing ongoing project is the National Surgical Quality Improvement Program or NSQIP [niss-quip]. This is an effort led mainly by the American College of Surgeons to measure, risk-adjust, and improve the quality of surgical care. For organizations that are academic medical centers, there is the University Health System Consortium or UAC [U-A-C] which was once called the University Hospital Consortium. The focus of UAC is on quality measurements for benchmarking academic medical centers. Data is provided to UAC and reports are returned to each organization. Viewers of this training may be part of these organizations and be familiar with the green and red dots (anywhere from one-half to one or two of each of these representing positive deviation or negative deviation from the standard of quality). Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Clinical Quality Measures and “Meaningful Use” (Blumenthal, 2010) One of the five healthcare goals for meaningful use is improving quality, safety, and efficiency One of the 15 core measures for eligible professionals (EPs) is reporting of clinical quality measures to CMS or the states One of the 14 core measures for eligible hospitals (EHs) is reporting of clinical quality measures to CMS or the states The meaningful use rules are predicated on five healthcare goals for the United States. One of these goals is improving quality, safety, and efficiency with core measures for both eligible professionals (EPs) and eligible hospitals (EHs). For professionals and hospitals, one of the core measures is the reporting of clinical quality measures to the CMS or their respective states. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Specific Quality Measures in Meaningful Use Criteria EPs must report on 3 core measures Can substitute alternate core measures if denominator of any core measure is 0 3 of 38 additional measures EHs must report on 15 measures Reporting by attestation in 2011 and provision of data in 2012 and beyond CMS aims to align all quality reporting programs, i.e., PQRI, CHIPRA, IQR, etc. What are the specific clinical quality measures in the meaningful use rules for eligible professionals and hospitals? Eligible professionals must report on three core measures; they are allowed to substitute alternative core measures if the denominator or number measured by any of the three core measures is zero. Then they must also report on 3 of 38 additional quality measures. Eligible hospitals must report on 15 measures. The reporting in the first year of meaningful use is by attestation of the numbers, but in 2012 and beyond, the actual quality data must be provided. CMS is aiming to align all of its quality reporting programs–PQRI; CHIPPRA [chip-ruh] or Children’s Health Insurance Program Reauthorization Act; IQR [I-Q-R] or interquartile [inter-kwawr-tahyl] range, and others–so that they are consistent and that measures required for one program are common with measures required in another. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

EP core/alternative quality measures Hypertension: Blood Pressure Measurement Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention Adult Weight Screening and Follow-up Alternative Weight Assessment and Counseling for Children and Adolescents Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older Childhood Immunization Status This slide shows the three core quality measures for eligible professionals. The first of these measures is blood pressure measurement for patients with hypertension. The second measure is assessment of tobacco use and, if it is used, whether a cessation intervention has been made. The third quality measure is adult weight screening and follow-up undertaken for patients who are overweight. Some practices, especially pediatric practices, will not be able to report on the three required core measures, so three additional core measures are allowed to be substituted in their place. One of them is weight assessment and counseling for children and adolescents. Another is influenza immunization for patients 50 years or older. A final alternative core measure is childhood immunization status for the major immunizations of childhood. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

EP additional quality measures (1-12) Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b)Effective Continuation Phase Treatment Appropriate Testing for Children with Pharyngitis Asthma Assessment Asthma Pharmacologic Therapy Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening for Women Colorectal Cancer Screening Controlling High Blood Pressure Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD There are 38 additional quality measures, of which at least three must be reported by the eligible professional. In these measures, the eligible professional has to report on what proportion of patients have met these measures, both the numerator of how many patients meet them and the denominator of how many patients are eligible to meet them. For example, the appropriate depression medication management method is considered in patients with depression. Other measures include breast cancer screening, cervical screening, colorectal screening, and various types of treatment for coronary artery disease. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

EP additional quality measures (13-25) Diabetes: Blood Pressure Management Diabetes: Eye Exam Diabetes: Foot Exam Diabetes: Hemoglobin A1c Control (<8.0%) Diabetes: Hemoglobin A1c Poor Control Diabetes: Low Density Lipoprotein (LDL) Management and Control Diabetes: Urine Screening Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement Continuing the additional quality measures for eligible professionals, there are a substantial number of measures for diabetic patients such as how well blood pressure is under control, whether they have had a foot exam, and other aspects of treatment of diabetes. There are also a number of measures for patients with heart failure that are listed here. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

EP additional quality measures (26-38) Ischemic Vascular Disease (IVD): Blood Pressure Management Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Low Back Pain: Use of Imaging Studies Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients Pneumonia Vaccination Status for Older Adults Prenatal Care: Anti-D Immune Globulin Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Smoking and Tobacco Use Cessation, Medical Assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies Use of Appropriate Medications for Asthma There are additional quality measures for other conditions such as ischemic vascular disease, breast or colon cancer, glaucoma, and prostate cancer. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

EH quality measures Anticoagulation overlap therapy Emergency Department Throughput – admitted patients – Admission decision time to ED departure time for admitted patients Emergency Department Throughput – admitted patients – Median time from ED arrival to ED departure for admitted patients Incidence of potentially preventable venous thromboembolism Intensive Care Unit venous thromboembolism prophylaxis Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 Ischemic or hemorrhagic stroke – Rehabilitation assessment Ischemic or hemorrhagic stroke – Stroke education Ischemic stroke – Anticoagulation for atrial fibrillation/flutter Ischemic stroke – Discharge on anti-thrombotics Ischemic stroke – Discharge on statins Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset Platelet monitoring on unfractionated heparin Venous thromboembolism discharge instructions Venous thromboembolism prophylaxis within 24 hours of arrival Eligible hospitals must report on 15 quality measures. Like the other measures, these are vetted either by NQF [N-Q-F], the National Qualifications Framework, or PQRI, and they vary for different conditions or parts of the hospital. This slide shows a broad range of hospital measures, from emergency department throughput to stroke to venous thromboembolism [throm-boh-ehm-buh-lizm]. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Quality Measurement and Improvement Summary – Lecture b Many different healthcare quality measures are used in a variety of settings from health plans to inpatient to outpatient Health plans most commonly have quality assessed using the HEDIS measures of NCQA Outpatient settings most often use measures in the PQRS program Inpatient settings have a variety of measures, but most commonly used are those of the HQA One of the core meaningful use criteria for EPs and EHs is a series of quality measures This concludes Lecture (b) of Quality Measurement and Improvement. This lecture has discussed many different healthcare quality measures that are used in a variety of settings from health plans to inpatient to outpatient. Health plans most commonly have quality assessed by using the HEDIS measures of NCQA. Outpatient settings most often use measures in the PQRS program. Inpatient settings have a variety of measures, but most commonly used are those of the HQA. One of the core meaningful use criteria for Eligible Professionals (EPs) and Eligible Hospitals (EHs) is a series of quality measures. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b

Quality Measurement and Improvement References – Lecture b Anonymous. (2006). Performance Measurement: Accelerating Improvement. Washington, DC: National Academies Press. Anonymous. (2011). CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use of Health Information Technology. Washington, DC: Government Accountability Office. Retrieved from http://www.gao.gov/new.items/d11159.pdf Berwick, D. (2008). The science of improvement. Journal of the American Medical Association, 299, 1182-1184. Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363, 501-504. Damberg, C., Sorbero, M., Lovejoy, S., Lauderdale, K., Wertheimer, S., Smith, A., . . . Schnyer, C. (2011). An Evaluation of the Use of Performance Measures in Healthcare. Santa Monica, CA: RAND Corp. Retrieved from http://www.rand.org/pubs/technical_reports/TR1148.html Pronovost, P., & Lilford, R. (2011). A road map for improving the performance of performance measures. Health Affairs, 30, 569-573. References slide. No Audio. Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Quality Measurement and Improvement Lecture b