1. How to Achieve Successful Reporting of the CMS Quality Measures
Frederick Integrated Healthcare Network
Phil Stiff Sean Shillinger
Tracey Specht

2. Agenda Review of ACO Quality Measures
Recommendations for Capturing the Measures in your EHR
Methods to improve quality performance
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3. Measures from CMS Claims Data
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4. Domain: Patient/Caregiver Experience
ACO 1: Getting Timely Care, Appointments, and Information
ACO 2: How Well Your Doctors Communicate
ACO 3: Patients’ Rating of Doctor
ACO 4: Access to Specialist
ACO 5: Health Promotion and Education
ACO 6: Shared Decision Making
ACO 7: Health Status/Functional Status
ACO 34: Stewardship of Patient Resources
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5. Domain: Care Coordination/Patient Safety
ACO 8: Risk-Standardized, All-Condition Readmissions
ACO 35: Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)
ACO 36: All-Cause Unplanned Admissions for Patients with Diabetes
ACO 37: All-Cause Unplanned Admissions for Patients with Heart Failure
ACO 38: All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
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6. Domain: Care Coordination/Patient Safety
ACO 9: ASC Admissions: COPD or Asthma in Older Adults
ACO 10: ASC Admission: Heart Failure
ACO 11: Percent of PCPs who Successfully Meet Meaningful Use Requirements
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7. Measures from your EHR
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8. Domain: Care Coordination/Patient Safety
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9. GPRO CARE 2: Falls Screening
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-13
GPRO CARE 2: Falls Screening
Patients screened for fall risk once during measurement period
Patients aged 65 and older with a visit in the last 12 months (year 2015).
Denominator Exceptions: medical reason for not screening (non- ambulatory)
Patients are considered at risk if they have fallen 2 or more times in the last year; or any fall with injury in same period.
Health Promotion Plan  Fall Risk panel OR
Social History  Lifestyle (Home Environment/Safety)
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10. GPRO CARE 3: Current Meds Documentation
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-39
GPRO CARE 3: Current Meds Documentation
Attests to updating or reviewing ALL meds on date of visit. List must include all known meds and dosage, freq, route.
All visits during measurement year for patients 18 and older.
Denominator Exceptions: Visit was for emergency and med rec not feasible.
Medication Module /Panel
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11. Domain: Preventive Health
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12. GPRO PREV-5: Breast CA Screening
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-20
GPRO PREV-5: Breast CA Screening
Women who had one or more mammograms any time on or between October 1, 27 months prior to December 31st of the measurement period, not to precede the patient’s 50th birthday.
Women age 50 through 75 with a visit during the measurement period.
Denominator Exclusions: Bilateral mastectomy, or two unilateral mastectomies
Care GuidelinesHealth MaintenanceClinical Guidelines PanelClinical Guidelines updateLast addressed date
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13. GPRO PREV-6: Colorectal Cancer Screening
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-19
GPRO PREV-6: Colorectal Cancer Screening
Patients with appropriate screening for colorectal cancer
FOBT in measurement year
Flex Sig in current or 4 years prior
Colonoscopy in current or 9 years prior
Patients 50 to 75 with a visit in the measurement period.
Denominator Exclusions: dx/PMH of total colectomy or colorectal cancer
Care GuidelinesHealth Maintenance Clinical Guidelines PanelClinical Guidelines updateLast addressed date
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14. GPRO PREV-7: Influenza Immunization
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-14
GPRO PREV-7: Influenza Immunization
Patients who received a flu vaccination OR reported receiving one
Patients 6 months and older seen for at least two visits or at least one preventive visit in the measurement period; and seen for a visit between Oct 1 and March 31.
Denominator Exceptions: Documentation of medical, patient, or system reason for not receiving immunization (eg allergy, refusal, lack of drug availability)
Orders Module Immunization tab New Order or Historical
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15. GPRO PREV-8: Pneumonia Vaccination for Older Adults
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-15
GPRO PREV-8: Pneumonia Vaccination for Older Adults
Patients who have ever received a pneumonia vaccination
Patients 65 and older with a visit during the measurement period
Orders Module Immunization tab New Order or Historical
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16. GPRO PREV-9: BMI Screening and Follow-up Plan
Measure Description
Numerator
Denominator
Comments*
Where in EHR?
ACO-16
GPRO PREV-9: BMI Screening and Follow-up Plan
Patients with a documented BMI during the encounter or during the previous 6 months; AND when abnormal, a follow-up plan is documented during the encounter or the previous 6 months
Patients 18 and older at the beginning of the measurement period
Denominator Exceptions: Visit was for emergency and BMI measurement was not feasible, OR patient refused; OR any other reason documented as to why not done
*Intake  Vitals panel
Navigation Pane  ACO  Health Promotion Plan Health Promotion Plan PanelBMI Plan
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17. *Normal BMI parameters
Age 65 and older BMI >23<30kg/m2
Age 18 to 64 BMI >18.5 and <25 kg/m2
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18. GPRO PREV-10: Tobacco Use and Screening
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-17
GPRO PREV-10: Tobacco Use and Screening
Patients who were screened for tobacco use at least once in 24 months AND who received cessation intervention if positive
Patients 18 and older seen for at least two visits or one preventive visit during the measurement period.
Denominator Exceptions: Documentation of medical reason for not screening
Tobacco use:
Histories TabSocial HistoryTobacco
Tobacco Use Panel (or Screening Summary Tobacco Usage Tobacco Use Panel)
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19. GPRO PREV-11: Screening for High Blood Pressure and Follow-up
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-21
GPRO PREV-11: Screening for High Blood Pressure and Follow-up
Patients who were screened for HTN AND have a recommended follow-up plan documented as indicated if BP is pre- hypertensive or hypertensive.
Patients 18 and older before the start of the measurement period with a visit during the measurement period.
Denominator Exceptions: Visit was for emergency and BP measurement was not feasible.
Plan MUST include one or more: Decrease weight, sodium, or ETOH; Increase activity, DASH diet
Follow-up: Navigation Pane  ACO  Health Promotion Plan Health Promotion Plan Panel HTN Plan
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20. GPRO PREV-12: Screening for Clinical Depression and Follow-up Plan
Measure Description
Numerator
Denominator
Comments*
Where in EHR?
ACO-18
GPRO PREV-12: Screening for Clinical Depression and Follow-up Plan
Patients screened for clinical depression on the date of the encounter using an age- appropriate tool AND if positive, a follow-up plan is documented on that date.
Patients 12 and older before the beginning of the measurement period with an encounter during the measurement period
Denominator Exclusions: Active dx of Bipolar Disorder or Depression
Denominator Exceptions: Patient refuses, OR Visit was for emergency and screening was not feasible, OR patient mental capacity would affect the screening
Screening: Navigation Pane  ACO  PHQ2PHQ9
Follow-up plan: Navigation Pane  ACO  Health Promotion Plan Depression Plan Diagnosis + Follow up plan
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21. *Follow-up MUST include:
Follow-up MUST include one or more of the following:
Additional evaluation for depression
Suicide risk assessment
Referral to specialist qualified to dx and treat depression
Pharmacological intervention
Other interventions or follow-up for the dx and treatment of depression
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22. Domain: At-Risk Population
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23. GPRO DM 2: Diabetes Composite (all or none) HbA1C Poor Control
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-27
GPRO DM 2: Diabetes Composite (all or none) HbA1C Poor Control
Patients whose most recent HbA1c (during measurement period) is <9%.
Patients with a visit in measurement period.
BOTH GPRO 2 and GPRO 7 MUST be met to get credit for these measures (all or none)
Order Module Order SummaryLabs
New Order
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24. GPRO DM 7: Diabetes Composite (all or none)
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-41
GPRO DM 7: Diabetes Composite (all or none)
Eye Exam
Patients who have had an eye screening for retinal disease (retinal exam or dilated eye exam) in the measurement period OR had a negative exam (no evidence of retinal disease) in the year prior.
Patients with a visit in measurement period.
Must be done by an ophthalmologist or optometrist.
Navigation Pane  ACO  Care Guideline Clinical Guidelines panel Clinical Guideline Update
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25. GPRO HTN- 2: Controlling High Blood Pressure
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-28
GPRO HTN- 2: Controlling High Blood Pressure
Patients whose most recent BP (at last visit) was <140/90 during the measurement period.
Initial patient population.
Denominator Exclusions: ESRD, dialysis, renal tx, or pregnancy during measurement period
Intake Vital signs
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26. Measure Description Numerator Denominator Comments Where in EHR?
ACO-30
GPRO IVD-2: Ischemic Vascular Disease: Use of Aspirin or Antithrombotic
Documented use of aspirin or other antithrombotic in the measurement period.
Patients 18 and older with a visit in the measurement period, and an active dx of IVD, OR were d/c’d alive for AMI, CABG, or PCI in the 12 months prior to the measurement period.
Medication module
Problem module
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27. GPRO HF6: Beta- blocker for LVSD
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-31
GPRO HF6: Beta- blocker for LVSD
Patients prescribed beta- blocker therapy at one or more OP visits or after hospital discharge OR already on beta- blocker per the medication list and continuing the therapy.
All patients 18 years and older with dx of HF.
Denominator Exceptions: Documentation of medical, patient, or system reason for not prescribing (eg allergy, refusal, lack of drug availability)
Medication module
Problem module
Diagnostic History Entry for LVEF
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28. GPRO CAD 7: ACE/ARB for CAD and LVEF <40% or Diabetes
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-33
GPRO CAD 7: ACE/ARB for CAD and LVEF <40% or Diabetes
Patients prescribed ACE or ARB
All patients 18 or older seen in last 12 months with dx of CAD and LVEF<40% OR dx of diabetes
Denominator Exceptions: Documentation of medical, patient, or system reason for not prescribing (eg allergy, refusal, lack of drug availability)
Medication module
Problem module
Diagnostic History Entry for LVEF
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29. GPRO MH-1: Depression Remission at 12 Months
Measure Description
Numerator
Denominator
Comments
Where in EHR?
ACO-40
GPRO MH-1: Depression Remission at 12 Months
Adults with a PHQ9 score of less than 5 at 12 months (+/- 30 days).
Patients age 18 and older with a dx of major depression or dysthymia AND an initial PHQ9 score >9 during an OP visit.
Denominator Exclusions: Death, in hospice, permanent NH resident, dx of bipolar, dx of personality disorder
Problems ModuleProblem Status
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30. EHR Examples
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31. ACO Measure 13 / GPRO CARE 2: Falls Screening
On the left navigation bar (or from Vitals Panel), select Health Promotion Plan.

32. ACO Measure 13 / GPRO CARE 2: Falls Screening, cont’d
Open Falls Risk panel and complete fields 1, 2, and 3.
Fields 4-6 should be used for follow-up plan if pt is at risk.
Patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury.

33. ACO Measure 13 / GPRO CARE 2: Falls Screening, cont’d
Falls Risk is also available as part of the Medicare preventive HPI:

34. ACO Measure 13 / GPRO CARE 2: Falls Screening, cont’d
Falls Risk is also available in Social History under Lifestyle. The Fall Risk Plan link opens the Health Promotion Plan.

35. ACO Measure 13 / GPRO CARE 2: Falls Screening
On the Progress Note, click Preventive Medicine > select Screening > select “Falls Risk Screening”

36. ACO Measure 20 / PREV 5: Breast Cancer Screening
Document Mammogram done elsewhere or order new mammogram at least once within 27 months.
If patient has not had a Mammogram done elsewhere, create a new Radiology order in the Orders Module.
If Mammogram has been completed elsewhere, document this information in the Diagnostic History Entry panel or Care Guidelines.

37. ACO Measure 19/ PREV 6: Colorectal Cancer Screening
Document screening done elsewhere or order new mammogram at least once within 27 months.
If patient has not had a screening done elsewhere, create a new order in the Orders Module.
If screening has been completed elsewhere, document this information in the Diagnostic History Entry panel or Care Guidelines.

38. Entry for Mammography and Colorectal Screening

39. ACO 20 – GPRO PREV-5 (NQF N/A): Breast Cancer Screening
Treatment > Diagnostic Imaging>Search for Diagnostic Imaging (Mammogram)

40. ACO 19 – GPRO PREV-6 (NQF 0034): Colorectal Cancer Screening
Treatment > Diagnostic Imaging>Search for Diagnostic Imaging (Colonoscopy/FOBT/Sigmoidoscopy)

41. ACO Measure 16 / PREV 9 : BMI Screening and Follow-Up
Record height and weight in Vitals AND when BMI is abnormal, a follow-up plan is documented during the encounter or the previous 6 months.
On the left navigation bar (or from Vitals Panel), select Health Promotion Plan or select from Vital Signs panel.

42. ACO Measure 16 / PREV 9 : BMI Screening and Follow-Up
Preventive Medicine> ACO/Counseling>BMI Counseling

43. ACO Measure 17/ PREV 10: Tobacco Use and Screening

44. ACO Measure 17/ PREV 10: Tobacco Use and Screening, cont.

45. ACO Measure 17/ PREV 10: Tobacco Use and Screening
Preventive Medicine>ACO/Counseling>Smoking

46. ACO Measure 21/ PREV 11: Screening for High BP and Follow-up

47. ACO Measure 21/ PREV 11: Screening for High BP and Follow-up
Preventive Medicine>ACO/Counseling>BP Management

48. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan

49. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan, cont

50. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan, cont

51. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan, cont

52. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan, cont

53. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan
Click “SF” and select PHQ9

54. ACO Measure 18/PREV 12: Screening for Clinical Depression and Follow up Plan – Cont’d
Preventive Medicine>ACO/Counseling>Depression Follow-Up

55. ACO Measure 41/ DM 7: Diabetes composite (all or none) Eye Exam (must accompany ACO 27/ DM 2: HbA1C)

56. ACO Measure 41/ DM 7: Diabetes composite (all or none) Eye Exam (must accompany ACO 27/ DM 2: HbA1C)
Examination>Ophthalmology>Ophthalmology>Diabetic Eye Exam>Diabetic Retinopathy Screening

57. ACO Measure 31 / GPRO HF6 & ACO Measure 33 / GPRO CAD 7
Documentation in the Medication Module of ACE or ARB therapy
Document LVEF % - On the Histories Template, expand Diagnostic Studies panel, click the Add button. The Office Services pop up will appear.

58. ACO Measure 31 / GPRO HF6 & ACO Measure 33 / GPRO CAD 7, cont’d
On the Diagnostic History Entry panel, click Diagnostic study type field to launch Ngkbm Get Dbpicklist Items pick list.
Select the appropriate Diagnostic study type from the pick list type (Cardiology studies is selected as an example), and click OK.

59. ACO Measure 31 / GPRO HF6 & ACO Measure 33 / GPRO CAD 7, cont’d
In the Study Performed section, Click Diagnostic study field to launch Service Item Mstr picklist
Select the appropriate study (ECHO EXAM OF HEART is selected as an example), click OK.
Complete the Study Date fields if available.

60. ACO Measure 31 / GPRO HF6 & ACO Measure 33 / GPRO CAD 7, cont’d
Click Details button . On the Diagnostic Number Pad pop up, click the radio button EF%. Enter the EF% using the number pad, click Save and Close.
Interpretation field can be used to select the appropriate interpretation.
Click Add to Grid button. The study name and details will be displayed in the grid. Click Save & Close.

61. ACO 40/MH -1: Depression Remission at 12 Months (+/- 30 days)

62. Documenting Exclusions
Select ‘exclude’ and click OK. CQM Results template will be launched.

63. Documenting Exclusions, cont’d
On CQM Results template, Complete Item Excluded, Exclusion and Exclusion details.

64. Methods to improve quality performance
Medicare Wellness Visit
Free to patients annually; designed to capture all measures
Patient Registries
Lists of the patients who fall into the numerator for these populations; eg CAD, Diabetes, HTN, CHF, Depression
Patient reminder campaigns fill 30% of gaps in care
Screening Tools
PHQ2, PHQ 9, Medicare Patient Questionnaire, Diabetes Eye Exam Referral Form, Medicare Well Visit Information, Medicare Patient Intake Form, Medicare Visit Health Risk Assessment, Medicare Visit Provider Assessment Form
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65. Methods to improve quality performance
Preventive Health Reminders
Reminders in EHR to complete measures (Mammography, Colorectal, etc)
FIHN Care Management Referral
Choosing Wisely – reduce overutilization of tests/procedures
Manage Transitions –contact within 48 hours of discharge for follow-up appointment
Access to Care – Reduce Emergency Room use
End of Life Care – increase Advanced Directives and hospice use
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66. Medicare Annual Wellness Visits (AWV)
Best way to capture most of the measures
Welcome to Medicare
Annual Medicare Wellness
Learning-Network- MLN/MLNProducts/downloads/AWV_chart_ICN pdf
Makes sure we have all the preventative measures

67. Medicare AWV
Medicare covers Annual Wellness Visits (AWV) for all Medicare beneficiaries
No co-pay for this preventive service
Can be performed by a non-physician member of the care team
There are two codes for AWV –the initial is slightly higher than the subsequent
G0438 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit (average reimbursement -~$172)
G0439 Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit (average reimbursement -~$111)
This is a “Visit” not a “History and Physical” or an “Exam”
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68. From CMS: A health professional, meaning a physician (a doctor of medicine or osteopathy), a qualified non- physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist), or a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner), or a team of such medical professionals who are working under the direct supervision of a physician, must furnish the AWV.
Direct supervision means that the billing physician must be in the same office suite and immediately available
Who can perform the AWV?
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69. Other Information about the AWV
How often can a patient receive this service?
•Subsequent AWV must fall at least 11 full calendar months after the last AWV
Does this replace the annual physical? NO
Are laboratory tests included? NO
Can other services be provided on the same day as the AWV? YES
In their first year of coverage, Medicare beneficiaries can have “Welcome to Medicare Preventive Visits” which is billed at a higher rate than annual wellness visits (IPPE)
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70. Questions? Sean Shillinger Phil Stiff sshillinger@fmh.org 240-379-6078
Phil Stiff
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