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 1U24OC

Quality Reporting Learning 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 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting How do you quantify the ‘goodness’ in health care? “Every system is perfectly designed to achieve exactly the results it gets.” –Avedis Donabedian Structure Infrastructure Staffing Facilities Policies Process Services Diagnostic Tests Documentation Outcomes Life Expectancy Health Patient Experiences Costs

Principles for Quality Measure Development 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting How many people does the measure impact? How much health benefit could be achieved? Relevance/Meaningfulness How strong is the association between the intervention/clinical service and health benefit? Scientific Evidence Does the burden of data collection exceed the benefit of measurement? Are the available data reliable and validate for assessing this indicator? Feasibility How broadly is this measure adopted by health care professionals or settings ? Usability

Reasons to Measure Quality 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting Improving Quality of Care Process Underuse (e.g. Chlamydia screening) Overuse (e.g. antibiotic prescriptions) Misuse (e.g. medications to avoid in the elderly) Outcomes (e.g. control of blood pressure) Safety Informing Purchasers/Consumers Comparison of providers or organizations with regional or national averages Ranking of providers or organization Improving Value of Care Access & utilization (e.g. well child visits, hospital stays) Efficiency (e.g. cost per diabetic to control A1c) Payment (e.g. pay-for- performance)

Health Care Quality Measurement in Use by the Health Care Industry Table Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting Resources for Validated Performance MeasuresTypes 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 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting How reliable are these data sources for the different types of measurement? Administrative data sources Operations (call logs, wait times, complaints) Claims (payment for services rendered) Diagnostics (labs, imaging) Clinical information (chart review, electronic health records)Surveys (patient perception/experiences)

Using EHRs for Automated 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.) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Quality Measures in Data Warehouse Example: Smoking (Shih, 2010.) 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

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 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Distribution of Documentation Smoking Status & Cessation Intervention Chart Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting 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 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Pay for Performance Design Considerations: Avoiding Unintended Consequences Table Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting Barriers in Payment StrategiesRe-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 forTransparent 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 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting ExamplesProsCons ParticipationData 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 tierScore or performance is in the top 10 th 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 Increasing Difficulty in Achievement

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 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Quality Measures for Rewards – The “ABCS” Table Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting Aspirin Therapy Ages 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 years of age with Hypertension, without Ischemic Vascular Disease or Diabetes who have a BP < 140/90 Patients years of age with a diagnosis of Diabetes AND Hypertension with the most recent BP below 130 systolic and 80 diastolic Patients 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 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 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting Measures ( ABCS ) Medicaid or Un-Insured Commercial, Medicare, or Other Insurance Antithrombotic Therapy$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

Sample Provider Quality Reports From Health eHearts (NYCDOH, 2010.) 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

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 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

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 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Measures in Achieve Meaningful Use Table Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting 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 Reporting Summary 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 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Quality Reporting References References: 1.Brown, L., Franco, L.M., Rafeh, N. Quality assurance of health care in developing countries. Retrieved on October 1st, 2010 from 2.Donabedian, A. Evaluating the Quality of Medical (reprinted in Milbank Quarterly, 2005, visit: Retrieved on October 1 st, 2010 from What is evidence based medicine? 4.Desirable Attributes of HEDIS. Retrieved on October 1 st, 2010 from Desirable NQF Measures Evaluation Criteria. Retrieved on October 1 st, 2010 from Desirable Lee TH. (2007). Eulogy for a Quality Measure. N Engl J Med 357: Retrieved on October 1 st, 2010 from 8.Retrieved on October 1 st, 2010 from 9.Retrieved on October 1 st, 2010 from 10.Retrieved on October 1 st, 2010 from Retrieved on October 1 st, 2010 from 12.Retrieved on October 1 st, 2010 from 13.Retrieved on October 1 st, 2010 from 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, AHRQ Pub. No Retrieved on October 1 st, 2010 from 15.Retrieved on October 1 st, 2010 from PCIP 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting

Quality Reporting References 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 1 st, 2010 from Table: NQF Measures Evaluation Criteria. Retrieved on October 1 st, 2010 from 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. 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Public Health IT Quality Reporting