1. FIHN PCP Pod Meeting
April 6, 2017

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

3. 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. “

4. 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 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

5. 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

6. Abstraction concerns
FIHN MSSP is just above benchmark for DM Composite: Hemoglobin A1C Poor Control and Retinal Eye Exam (31.2%)
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

7. 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

8. Changes to MSSP 2017 Quality Measures

9. 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

10. 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 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)

11. Depression Screening with follow-up
At least once in 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

12. 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

13. 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

14. NextGen Charting vs eClinicalWorks

15. 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

16. eCW Fall Screening

17. eCW Fall Screening

18. Fall Screening Exceptions

19. Exception/Exclusion documentation

20. Depression Screening (c Follow-up)
(A) Part of Annual Wellness Visit exam (PHQ-2 on AWV Patient Assessment)
- OR -
(B) Consider using the Medicare Screening Questionnaire
for all Medicare patients
If PHQ-2 is positive, please complete PHQ-9 and
CREATE A FOLLOW-UP PLAN
May consider using z13.89 (encounter for screening of other disorder)

21. AWV Patient Assessment

22. Depression Follow-up Plan
Additional evaluation for depression (can also be 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

23. eCW

24. Additional Plan or Exclusions

25. Documenting Exclusions

26. document if patient refuses plan)
BMI (Body Mass Index)
BMI (65yo and older)
If BMI < 23 write a plan to increase weight
If BMI 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)

27. eCW

28. Exclusions

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

30. eCW

31. Diabetes Composite – Retinal Exam
Letter sent out to all Optometrists and Ophthalmologists on 5/11/16
Check with patients to be sure they have had a yearly
eye exam
We will report out to you a list of your attributed patients with diabetes who need an HbA1c and/or a retinal exam.
Must have a copy of the retinal exam / report on the chart

32. eCW

33. Eye Exam Referral & Fax Form

34. 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

35. Medicare Screening Questionnaire
Use in place of the Annual Wellness Exam
Have patient fill out the form in the Waiting Room
Consider allowing your nurse / MA automatically order any test that needs to get done (standing order sets)
Review by MD, then gets scanned into chart (e.g. Chart Documents)

36. 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:
( )

37. 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.)

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

39. Exceptions

40. 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
( )

41. 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) - $ per dose
Medicare Reimbursement:
Pneumovax (90732) - $88.80
Prevnar-13 (90670) - $177.44
Immun Single Injection (G0009) – $25.67

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

43. eCW

44. Exceptions/Exclusions

45. Mammogram For ages 50-74 yrs old, within 27 month period.
Use Medicare Screening Questionnaire
Officially, report does not need to be in chart.
Exclusion: Bilateral mastectomies

46. eCW

47. Exclusions

48. Colorectal Cancer Screening
For ages 50 – 75 years old.
Use Medicare Screening Questionnaire
Officially, report does not need to be in chart.
Encourage FOBT (x3) for those who refuse colonoscopy
Cologuard not currently accepted

49. eCW

50. Exclusions

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

52. MH-1 Depression Remission
Depression Remission – do PHQ-9 for every visit on a patient with depression; or schedule on a yearly basis (e.g. at the time of the MC Wellness Visit)

53. eCW
Use the same Smart Forms for the depression screening except administer PHQ-9 only

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

55. 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)

56. eCW

57. Statin Therapy for Prevention and Treatment of Cardiovascular Disease

58. Exclusions

59. Exceptions

60. Questions