1. Missouri Hospital Association Meaningful Use Quality Measure Update

2. Glass Half Full?

3. Agenda Background  Current state  Stage 1 lessons learned Stage 2 Meaningful Use  Hospital/CAH  Eligible Professional (EP) Certification Looking Ahead

4. Update On EHR Incentive Programs Medicare and Medicaid EHR incentive program registrations: –3,247 Hospitals –About 188,400 Physicians/EPs A growing number, but still small share, have been paid for meeting meaningful use requirements –712 Hospitals (40 CAH) –22,937 Physicians 43 states have opened Medicaid programs Data from CMS, as of January 2012

5. Most, but not all, states have now established Medicaid EHR incentive programs Red = Made Payments (34); Blue = Accepting Registrations (9) Data from CMS as of January 2012

6. Cost In 2010, the average capital IT expense per bed was over $12,000, while the average IT operating expense was over $45,000. Together, hospitals are spending $57,000 a year per bed on IT. For a 200-bed hospital, that would translate to over $11.4 million per year.

7. The Bottom Line Stage 1 = Getting it started Stage 2 = Getting it right

8. Transition to Automation Fiscal Year 20122013201420152016201720182019 Inpatient Quality Reporting Program (Pay for reporting) MB – 2.0 If Failure to Report MB – 2.0 If Failure to Report MB – 2.0 If Failure to Report MB – ¼ of MB If Failure to Report Health Information Technology Meaningful Use (MU) MB – ¼ of MB If Failure to Meet MU MB – ½ of MB If Failure to Meet MU MB – ¾ of MB If Failure to Meet MU MB – ¾ of MB If Failure to Meet MU MB – ¾ of MB If Failure to Meet MU

9. Problems with Stage 1 Improperly developed e-measure specifications e-measure

10. Problems with Stage 1 Improperly developed e-measure specifications No measure steward e-measure

11. Problems with Stage 1 Improperly developed e-measure specifications No measure steward No testing Lack of clinical information

12. Musts for Stage 2 IQR Automation IQR Automation IQR Automation =

13. Musts for Stage 2 Hospital sends Data to Vendor QIO Data Warehouse Feedback Reports Data Submission Hospital sends Data to Vendor Vendor Validation TJC Validation Validation #1 CMS Requests Cases Hospital Sends Records CMS Re- Abstracts Data Validation #2

14. Proposed Quality Reporting Requirements for Stage 2 – Linked to National Quality Strategy 34 new measures 15 measures from Stage 1 1. Menu of 49 Measures available for Stage 2 2. Hospitals and CAHs choose 24 measures to report, to include one from each of six domains Efficiency (4) Patient and Family Engagement (8) Clinical Processes (24) Care Coordina- tion (2) Patient Safety (9) Population/ Public Health (2)

15. Quality Measure Domains Care Coordination (2) Stage 2 Proposed Measures for Care Coordination NQF Number Measure TitleUse in other CMS Quality Programs 0441Stroke – assessed for rehabilitationIQR 0496ED – median time from ED arrival to ED departure for discharged ED patients OQR, MAP

16. Quality Measure Domains Population/ Public Health (2) Stage 2 Proposed Measures for Population and Public Health NQF Number Measure TitleUse in other CMS Quality Programs 1653Pneumococcal immunizationIQR, MAP 1659Influenza immunizationIQR, MAP

17. Quality Measure Domains Efficiency (4) Stage 2 Proposed Measures for Efficient Use of Healthcare Resources NQF Number Measure TitleUse in other CMS Quality Programs 0148Pneumonia (PN) – blood cultures performed in the ED prior to initial antibiotic received in hospital IQR, HVBP, MAP 0147PN – initial antibiotic selection for community-acquired PN in immunocompetent patients IQR, HVBP, MAP 0528SCIP – prophylactic antibiotic selection for surgical patients IQR, HVBP, MAP 0529SCIP – prophylactic antibiotics discontinued within 24 hours after surgery end time IQR, HVBP, MAP

18. Quality Measure Domains Patient and Family Engagement (8) Stage 2 Proposed Measures for Patient and Family Engagement NQF Number Measure TitleUse in other CMS Quality Programs 0495Emergency Department (ED) Throughput – Median time from ED arrival to ED departure for admitted patients IQR, Stage 1 MU 0497ED Throughput – admit decision time to ED departure time for admitted patients IQR, Stage 1 MU 0440Stroke – educationIQR, Stage 1 MU 0375Venous Thromboembolism (VTE) – discharge instructions IQR, Stage 1 MU

19. Quality Measure Domains Patient and Family Engagement (8) Stage 2 Proposed Measures for Patient and Family Engagement NQF Number Measure TitleUse in other CMS Quality Programs 0136Heart Failure (HF) – discharge instructions IQR, HVBP 0338Home management plan of care document given to patient/caregiver MAP 0341Pediatric Intensive Care Unit (ICU) – pain assessment on admission MAP 0342Pediatric ICU – periodic pain assessment MAP

20. Quality Measure Domains Patient Safety (9) Stage 2 Proposed Measures for Patient Safety NQF Number Measure TitleUse in other CMS Quality Programs 0371VTE – prophylaxisIQR, Stage 1 MU 0372VTE – ICU prophylaxisIQR, Stage 1 MU 0375VTE – incidence of potentially preventable VTE IQR, Stage 1 MU 0527Surgical Care Improvement Project (SCIP) – prophylactic antibiotic received one hour prior to surgical incision IQR, HVBP, MAP 0301SCIP – surgery patients with appropriate hair removal IQR

21. Quality Measure Domains Patient Safety (9) Stage 2 Proposed Measures for Patient Safety NQF Number Measure TitleUse in other CMS Quality Programs 0453SCIP – urinary catheter removed on postoperative day one or postoperative day 2 with day of surgery being day zero IQR, MAP 0434Stroke – VTE prophylaxisIQR, MAP 0218SCIP – surgery patients who received appropriate VTE prophylaxis with 24 hours prior to surgery to 24 hours after surgery end time IQR, HVBP, MAP 0716Healthy term newbornMAP

22. Quality Measure Domains Clinical Processes (24) Stage 2 Proposed Measures for Clinical Processes/Effectiveness NQF Number Measure TitleUse in other CMS Quality Programs 0435Stroke – discharge on anti-thrombotic therapy at hospital discharge IQR, Stage 1 MU 0436Stroke – anticoagulation therapy for atrial fibrillation/flutter IQR, Stage 1 MU 0437Stroke – thrombolytic therapyIQR, Stage 1 MU 0438Stroke – antithrombotic therapy by end of hospital day two IQR, Stage 1 MU 0439Stroke – discharged on statin medication IQR, Stage 1 MU 0373VTE – patients with overlap of anticoagulation therapy IQR, Stage 1 MU

23. Quality Measure Domains Clinical Processes (24) Stage 2 Proposed Measures for Clinical Processes/Effectiveness NQF Number Measure TitleUse in other CMS Quality Programs 0374VTE – patients unfractionated heparin dosages/platelet count monitoring by protocol receiving dosages/platelet count monitored by protocol IQR, Stage 1 MU 0132Acute Myocardial Infarction (AMI) – aspirin at arrival IQR 0142AMI – aspirin prescribed at dischargeIQR, MAP 0469Elective delivery prior to 39 completed weeks gestation MAP 0137AMI – ACE/ARB for left ventricular systolic dysfunction IQR

24. Quality Measure Domains Clinical Processes (24) Stage 2 Proposed Measures for Clinical Processes/Effectiveness NQF Number Measure TitleUse in other CMS Quality Programs 0160AMI – beta blocker prescribed at discharge IQR 0164AMI – fibrinolytic therapy received within 30 minutes of hospital arrival IQR, HVBP, MAP 0163AMI – primary percutaneous coronary intervention IQR, HVBP, MAP 0639AMI – statin prescribed at dischargeIQR, MAP 0300SCIP – cardiac patients with controlled 6 AM postoperative serum glucose IQR, HVBP, MAP

25. Quality Measure Domains Clinical Processes (24) Stage 2 Proposed Measures for Clinical Processes/Effectiveness NQF Number Measure TitleUse in other CMS Quality Programs 0284SCIP – surgery patients on a beta blocker therapy prior to admission who received a beta blocker during the perioperative period IQR, HVBP, MAP 0480Exclusive breastfeeding at hospital discharge N/A 0481First temperature measured within one hour of admission of the neonatal ICU N/A 0482First neonatal ICU temperature less than 36 degrees Celsius N/A 0143Use of relievers for inpatient asthmaMAP 0144Use of systemic corticosteroids for inpatient asthma MAP 0484Proportion of infants 22 to 29 weeks gestation treated with surfactant who are treated within 2 hours of birth MAP 1354Hearing screening prior to hospital discharge MAP

26. Quality Measurement Domain Framework Efficiency (4) Patient and Family Engagement (8) Clinical Processes (24) Care Coordination (2) Patient Safety (9) Population/ Public Health (2) X X

27. Measurement CHOICE Quality Measurement Domain Framework

28. Measure Submission Sampling of patients to populate quality measures –Short-term –Long-term Minimum case count

29. Proposed Quality Reporting Requirements for EPs for Stage 2 CMS seeks comments on three options: Option 1A – Report 12 measures from a menu set of 125 measures, with at least one measure in each of 6 domains Option 1b – Report 11 “core” measures and choose 1 from the menu of 125 measures Option 2 – Choose 3 quality measures to report under the Physician Quality Reporting System (PQRS) for EHRs

30. Option 1a – Linked to National Quality Strategy 83 new measures 42 measures from Stage 1 1. Menu of 125 Measures available for Stage 2 2. EPs must choose 12 measures to report, with at least one from each of six domains Efficiency Patient and Family Engagement Clinical Processes Care Coordina- tion Patient Safety Population/ Public Health

31. Option 1b – 11 core measures plus 1 choice Choose 1 from menu of 125 measures available for Stage 2 Report 11 “core” measures 1.Closing the referral loop 2.Functional status assessment for complex chronic conditions 3.Controlling high blood pressure 4.Medication reconciliation 5.Screening for clinical depressing 6.Tobacco use screening and cessation 7.Cholesterol screening 8.Use of aspirin/antithrombotic for Ischemic Vascular Disease 9.Weight assessment and counseling of children 10.Use of high-risk medications in the elderly 11.Adverse drug event prevention

32. Certification Overview Certification distorts the EHR market and raises costs. Requiring health care providers to purchase certified products (or certify their self-developed systems) fundamentally changes the market dynamics in favor of the vendor.

33. Certification Round #1 CMS proposes 49 measures for hospitals and 125 measures for EPs Vendors must demonstrate a single CQM can be calculated CMS requires one measure from six different quality domains

34. Certification Round #2 CMS proposes submission of patient-level or aggregate CQM data EHRs are not required to calculate CQMs in any specific format

35. Certification Round #3 QUALITY DATA MODEL

36. Glass Half Full?

37. What Next? HIT Efforts Measure Application Partnership

38. CQM Process Mapping Measure previously specified Measure Authoring Tool (MAT) New Specification Medical Record Abstraction Spec e-Measure Spec

39. CQM Process Mapping Measure Authoring Tool (MAT) Measure previously specified New Specification Medical Record Abstraction Spec e-Measure Spec Quality Data Model (QDM) Hospitals EHR Vendors

40. CQM Process Mapping Measure Authoring Tool (MAT) Quality Data Model (QDM) Hospitals EHR Vendors Where is the measure developer? X e-Measure Developer

41. IPPS Proposed Rule Measure Application PartnershipHACsXXX

42. Resources AHA Member Materials on Meaningful Use http://www.aha.org/meaningfuluse Office of Civil Rights – HIPAA resources http://www.hhs.gov/ocr/privacy Office of the National Coordinator for HIT - Certification program http://healthit.hhs.gov/portal/server.pt?open=512&objID=1 153&mode=2 Centers for Medicare and Medicaid Services – Medicare and Medicaid EHR Incentive Programs http://www.cms.gov/EHRIncentivePrograms

43. Missouri Hospital Association Meaningful Use Quality Measure Update