1. Making “Meaningful Use” Truly Meaningful to our Patient-Centered Medical Home with a Quality Data Team Scott A. Fields, M.D., M.H.A. Vice Chair OHSU Family Medicine Brett White, MD Associate Residency Director and Medical Director

2. Objectives Explain “meaningful use” based on the most recent definition of the federal government Describe the process of building a set of quality indicators from the ground up, with an understanding of how each new question builds upon the previous inquiry. Define the skill set of a functional Quality Data Team

3. Learner-centered What are your objectives???

4. Meaningful Use Purpose Encourage hospitals and clinics across the nation to not only install electronic health record technology but also… Reward the “meaningful use” by physicians of that technology in ways that demonstrably improve individual and community health

5. Meaningful use carrot Eligible Professional (EP) – Either Medicare ($44,000) or Medicaid ($63,750) – Qualify as soon as 1/1/11; no later than 10/1/12 – Paid to practice entity based on MD-level accounting – Maximum potential OHSU incentive: ~ $20M Hospital – Based on Medicare/Medicaid/Charity Care formula – Qualify as soon as 10/1/10; no later than 7/1/13 – Maximum potential OHSU incentive: ~ $7M

6. Meaningful Use Legislation Final Rule (July 13 th ) Core Set of objectives (15) 5 objectives out of 10 from menu set 6 total Clinical Quality Measures (3 core or alternate core, and 3 of 38 from menu set) Compared to the interim rule Fewer core objectives & more choice Thresholds for use reduced Administrative requirements removed Decision Support requirements reduced Reduced Quality Metrics Additional Quality options

7. Core Objectives ObjectiveMeasure 1Record patient demographics (sex, race, ethnicity, date of birth & preferred language) More than 50% of patients’ demographic data recorded as structured data 2Record vital signs & chart changes (height, weight, blood pressure, BMI & growth charts for children) More than 50% of patients 2 years of age and older have height, weight and blood pressure recorded as structured data. 3Maintain up-to-date problem list of current & active diagnoses More than 80% of patients have at least one entry recorded as structured data 4Maintain active medication listMore than 80% of patients have at least one entry recorded as structured data 5Maintain active medication allergy list More than 80% of patients have at least one entry recorded as structured data 6Record smoking status for patients 13 years of age or older More than 50% of patients 13 years of age and older have at least one entry recorded as structured data

8. ObjectiveMeasure 7Provide patients with clinical summaries of each office visit Clinical summaries provided to patients for more than 50% of all office visits within 3 business days 8On request, provide patients with an electronic copy of their health information (diagnostic test results, problem list, medication list & allergies) More than 50% of requesting patients receive electronic copy within 3 business days 9Generate and transmit permissible prescriptions electronically More than 40% are transmitted electronically using certified EHR technology. 10Computer provider order entry (CPOE) for medication orders More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE 11Implement drug-drug and drug-allergy interaction checks Functionality is enabled for these checks for the entire reporting period 12Implement capability to electronically exchange key clinical information among providers and patient- authorized entities Perform at least one test of EHR’s capacity to electronically exchange information Core Objectives 7-12

9. ObjectiveMeasure 13Implement a clinical decision support rule and ability to track compliance with the rule One clinical decision support rule implemented 14Implement systems to protect privacy and security of patient data in the EHR Conduct or review security analysis, implement security updates as necessary and correct identified security deficiencies 15Report clinical quality measure to CMS or states* For 2011, provide aggregate numerator & denominator through attestation; for 2012, electronically submit measures Core Objectives 13-15

10. Core ObjectivesIndicator type 1Record patient demographicsOperations 2Record vital signsOperations 3Up to date problem listOperations 4Maintain active medication listOperations 5Maintain active allergy listOperations 6Record smoking status, age >=13Operations 7Provide patient with after visit summaryOperations 8On request, provide patient with health informationOperations 9Generate and transmit prescriptions electronicallyOperations 10Computer provider order entry (CPOE) for med. ordersOperations 11Implement drug-drug; drug-allergy interaction checksOperations 12Implement capability to electronically exchange information among providers and authorized entities Operations 13Implement a clinical decision support rule and track compliance with the rule Operations 14Implement systems to protect privacy and securityOperations 15Report clinical quality measure to CMS or states*Operations

11. Threshold Objectives ObjectiveProposedFinal Problem list, medication list, allergy list80% Provide pts with electronic copy of health info, discharge instructions 80%50% Demographics, vital signs, smoking status, clinical summaries for office visits, medication reconciliation (M), summary of care provided for transitions in care (M) 80%50% Advanced directives (M)NA50% E-prescribing75%40% Lab test results as structured data (M)50%40% CPOEEPs 80% Hospitals 10% 30% Send reminders to patients (M)50%20% Patient-specific education (M)NA10% Timely, electronic access to health information (M)10%

12. “Binary” Objectives Objective Drug-drug and drug-allergy checks Drug-formulary checks (M) Generate lists of patients by specific conditions (M) Capability to exchange key clinical information Electronic data to immunization registries (M) Electronic submission of reportable lab results to public health agencies Electronic syndromic surveillance data to public health agencies (M) Protect electronic health information Implement 1 clinical decision support rule

13. Menu items (choose 5) ObjectiveMeasure 1Implement drug formulary checksDrug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period 2Incorporate clinical laboratory test results into EHRs as structured data More than 40% of laboratory test results whose results are in +/- or numerical format are incorporated into EHRs as structured data. 3Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Generate at least one listing of patients with a specific condition 4Use EHR technology to identify patient- specific education resources and provide those to patient as appropriate More than 10% of patients are provided patient-specific education resources 5Perform medication reconciliation between care settings Medication reconciliation is performed for more than 50% of transitions of care

14. Menu items 6-10 ObjectiveMeasure 6Provide summary of care record for patients referred or transitioned to another provider or setting Summary of care record is provide for more than 50% of patient care transitions or referrals. 7Submit electronic immunization data to immunization registries or immunization information systems Perform at least one test of data submission and follow-up submission (where registries can accept electronic data) 8Submit electronic syndromic surveillance data to public health agencies Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) 9Send reminders to patients (per patient preference) for preventive and follow-up care More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders 10Provide patients with timely electronic access to their health information (laboratory results, problem list, medication list & allergies) More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

15. Eligible Professional Core Measures – Blood Pressure Measurement – Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention – Adult Weight Screening and Follow-Up Eligible Professional Alternate Core Measures – Weight Assessment and Counseling for Children and Adolescents – Childhood Immunization Status – Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old Eligible Professional Non-Core Measures – Asthma Assessment – Appropriate Testing for Children with Pharyngitis – Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement – Prenatal Screening for Human Immunodeficiency Virus (HIV) – Prenatal Anti-D Immune Globulin – Controlling High Blood Pressure – Preventive Care and Screening: Advising Smokers to Quit – Breast Cancer Screening – Cervical Cancer Screening – Chlamydia Screening for Women – Colorectal Cancer Screening – Use of Appropriate Medications for Asthma – Pneumonia Vaccination Status for Older Adults – Asthma: Pharmacologic Therapy – Low Back Pain: Use of Imaging Studies – Diabetes: Eye Exam – Diabetes: Foot Exam – Diabetes: HbA1c Poor Control – Diabetes: Blood Pressure Management – Diabetes: Urine Screening – Diabetes: LDL Management & Control – Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD – Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic – Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) – Ischemic Vascular Disease (IVD): Blood Pressure Management – Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol – Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control – Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) – Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) – Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation – Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation – Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy – Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (PQRI 19) – Anti‐depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment – Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients – Oncology Breast Cancer: Hormonal Therapy for Stage IC‐IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer – Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients – Diabetes: HbA1c Control (<8.0%) Quality indicators All EPs must report on three core measures. If an EP does not have a significant patient population for one or more of the core measures, he can select one or more of the alternate core measures. In addition to the three core (or alternate core measures), each EP must select three additional measures from a menu of 38 quality measures. (If an EP does not replace a core measure with an alternate, he can select one or more of the alternate core measures as part of the three additional measures.)

16. Eligible Professional Core Measures – Blood Pressure Measurement – Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention – Adult Weight Screening and Follow-Up

17. Quality Measures for Eligible Hospitals All hospitals must report on a set of 15 quality measures. General Build and Workflows for Stroke and VTE Measures – Stroke Measures – Discharged on Antithrombotic Therapy – Ischemic stroke – Anticoagulation for A-fib/flutter – Thrombolytic Therapy – Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 – Ischemic stroke – Discharge on statins – Stroke Education – Assessed for Rehabilitation VTE Measures – VTE Prophylaxis within 24 Hours of Arrival – VTE Prophylaxis – Anticoagulation Overlap Therapy – Platelet Monitoring on Unfractionated Heparin – Venous Thromboembolism Discharge Instructions – Incidence of Potentially Preventable Venous Thromboembolism ED Throughput Measures – Emergency Department Throughput – Median Time from ED Arrival to ED Departure for Admitted ED Patients – Emergency Department Throughput – Admission Decision Time to ED Departure for Admitted Patients

18. Strategic Integrity

19. Strategic integrity Aligning strategy and execution at all levels of the organization. Matching bottom-up tasks with top-down strategy. Includes integrity of character, organization, product, and of management. Strategic integrity requires adaptation, and adaptation requires innovation. Integrity in what and how we measure.

20. Strategic Integrity Explicit – official strategy Implicit – defined by actions Is there a disconnect? Three drivers of strategic integrity – Planning – Organization – Decision making Sinofsky S, Iansiti M. One Strategy. Hoboken, NJ. 2010. ISBN 978-0-470-56045-7.

21. Strategic Integrity Framework OrganizationPlanningDecision Making Pervasive Quality Efficiency Transparency Integration Participation Realistic Commitment Empowerment Grounded Consensus Design Structure Connected Flat Clear boundaries Clear connections Multidisciplinary Top down, bottom up, middle out Pervasive Clear roles Clear responsibilities Plan-based Shared load FoundationsExecution capability Functionally deep Skills driven Technically passionate Market driven Scenario based planning Adaptive, flexible processes Analytical methods Accountability System-focus Quality conscious Measurement and learning driven values Sinofsky S, Iansiti M. One Strategy. Hoboken, NJ. 2010. ISBN 978-0-470-56045-7.

22. Disruptive Transformation of the Practice Environment The Innovator's Prescription: A Disruptive Solution for Health Care Christensen CM, Grossman JH, Hwang New York, McGraw-Hill, 2009. ISBN: 978-0-07-159208-6

23. Types of innovation sustaining innovation - incremental improvements implemented to serve existing customers disruptive innovation, fundamentally new offerings that are cheaper and simpler than anything on the market that in turn create new markets that undermine incumbent firms.

24. Defining our Product Only by defining the product do we know what we are supposed to produce. What is our product(s)? – Health – Caring relationships – Prevention – Diagnosis – Cure

25. The customer defines the product Help the customer/patient obtain something more efficiently, conveniently, and affordably, that they want.

26. Diagnosis and Treatment Patients want: – to know diagnosis – to receive definitive treatment – accessibility – convenience – affordability

27. Building a product

28. Disruptors Making products and service more affordable to a larger population, and to enable people with less training to provide them. Technology – Simplify, routinize; replacing intuitive experimentation Business model – Simplify methods of delivering products that makes them affordable and convenient Value networks – New way of providing resources that reduce overhead costs and better integration

29. Building a product Business Model Technology Value Networks

30. Diagnosis and Treatment Patients want: – to know diagnosis – to receive definitive treatment – accessibility – convenience – affordability

31. Methods of diagnosis Intuitive Empirical Precision

32. Evolution of diagnosis continuum

33. Intuitive Medicine Based on the clinician opinion Use of “solution shops” or “diagnostic teams” Little evidence about what is the best approach

34. Empirical Medicine Evidence based medicine Taking the best information available and interpreting it for use with your specific patient

35. Precision Medicine Technology exists to make a definitive diagnosis And when a definitive diagnosis is made, there is a definitive treatment available

36. Technology – Moving along the continuum

37. Business models Solution Shops – designed to diagnose and solve problems Value added processes – – diagnosis has already been made; new set of inputs (resources and processes) to create the desired output Facilitated networks – – uses the knowledge of the patient(s) The Innovator's Prescription: A Disruptive Solution for Health Care Christensen CM, Grossman JH, Hwang New York, McGraw-Hill, 2009. ISBN: 978-0-07-159208-6

38. The Data

39. Key issues to be addressed Data relevance Data sourcing Data quantity Data quality Data governance

40. Qualities of Data that are of Quality Correct Complete Current Consistent Contextual Controlled

41. Data governance What rules and processes are needed to manage data from its creation to its “retirement” Acquiring the data Cleaning the data Organizing and storing the data Maintaining the data

42. Management of a Clinical Enterprise with Balanced Scorecards

43. The balanced scorecard – measures that drive performance. Kaplan RS, Norton DP. Harv Bus Rev 1992;70:71–9. “… managers should not have to choose between financial and operational measures.” “They realize that no single measure can provide a clear performance target or focus attention on the critical areas of the business.”

44. The balanced scorecard allows our leaders to review the clinical enterprise from four perspectives: customer perspective internal perspective innovation and learning perspective financial perspective

45. Why use a Balanced Scorecard? The process of creating the balanced scorecard “guards against sub-optimization.” By considering multiple performance measures at the same time, the balanced scorecard lets leadership see whether improvement in one area may have been achieved at the expense of another.

46. Why use a Balanced Scorecard? “The customer-based and internal business process measures on the balanced scorecard identify the parameters that the company considers most important for competitive success.” “That is, only through the ability to launch new products, create more value for customers, and improve operating efficiencies continually can a company penetrate new markets and increase revenues and margins – in short, grow and thereby increase shareholder value.”

47. Think of Meaningful Use indicators as simply as components of a Balanced Scorecard.

48. Taking population-based data and drilling down to the level of the individual patient

49. Who are our patients? Are we seeing our own patients? - continuity

52. Why are we seeing our patients? Problems Visit diagnoses Procedures

56. How well are we doing caring for our patients? Health maintenance Disease management Hospital care Maternity care

63. Meaningful Use

64. Balanced Scorecard Clinic level Team level Clinician level

65. Clinical Data Team Access Structured approach to data Clinician guidance Data recovery expertise Data presentation expertise Respected by customers

66. Clinical Data Team Skill set Quality set Sustainability

67. We measure what we care about and we care about what we measure. Strategic integrity