Meaningful Use & Physician Quality Reporting System (PQRS)

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Missouri’s Federally-designated Regional Extension Center  University of Missouri:  Department of Health Management and Informatics  Center for Health Policy  Department of Family and Community Medicine  Missouri School of Journalism  Partners:  EHR Pathway  Hospital Industry Data Institute (Critical Access Hospitals)  Missouri Primary Care Association  Missouri Telehealth Network  Primaris

Assist Missouri's health care providers in using electronic health records to improve the access and quality of health services; to reduce inefficiencies and avoidable costs; and to optimize the health outcomes of Missourians

 For providers who do not have a certified EHR system - We help you choose and implement one in your office  For providers who already have a system - We help eligible providers meet the Medicare or Medicaid criteria for incentive payments 5

 Contact MO HIT Assistance Center for details and pricing

 Instructions provided after today’s presentation

 The Office of Continuing Education, School of Medicine, University of Missouri is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.  The Office of Continuing Education, School of Medicine, University of Missouri designates this live Internet educational activity for a maximum of one AMA PRA Category 1 Credit™. Physicians should only claim the credit commensurate with the extent of their participation in the activity. The learning objectives of this live Internet educational activity are:  Choose an appropriate electronic health record for the practice, create a change team, redesign practice workflow and successfully implement transition to electronic records.  Appropriately track quality measures in electronic health records and to create accurate reports of quality indicators; physicians will understand how to use indicators to improve patient outcomes.  Identify potential privacy and security issues in individual practices that are utilizing electronic health records and provide tools for practices to use to assess their security measures to see if they are appropriate.  Measure and track the way individual practices are reporting on the meaningful use requirements in the federal HI Tech Act; understand additional clinical reporting requirements contained in meaningful use phases two and three.  Appropriately design and implement patient portals for patients to access their health care information and learn how to better take care of their health conditions.  The planning members for this activity have no commercial relationships to disclose. However, the presenter of today’s Webinar, Sandy Pogones is a Primaris employee.

Cerner and the University of Missouri Health System have an independent strategic alliance to provide unique support for the Tiger Institute for Health Innovation, a collaborative venture to promote innovative health care solutions to drive down cost and dramatically increase quality of care for the state of Missouri. The Missouri Health Information Technology Assistance Center at the University of Missouri, however, is vendor neutral in its support of the adoption and implementation of EMRs by health care providers in Missouri as they move toward meaningful use. This regional extension center is funded through an award from the Office of the National Coordinator for Health Information Technology, Department of Health and Human Services Award Number 90RC0039/01

Publication MO PC This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy Physician Quality Reporting System: Beyond an Incentive Payment Sandra Pogones Program Manager, Physician Services Primaris – Columbia, MO

Slide 11 of 33 Who is Primaris Primaris was founded in 1983 by the Missouri State Medical Association, Missouri Hospital Association and Missouri Association of Osteopathic Physicians and Surgeons Among other roles, Primaris serves as the federally- designated Quality Improvement Organization (QIO) for the state of Missouri. – Mission of QIOs: To improve the effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries. – Services provided under the QIO contract are free-of-charge to providers.

Slide 12 of 33 Objectives Establish the importance of Physician Quality Reporting to the physician practice Identify PQRS program requirements in terms of eligibility, incentives, reporting mechanisms and requirements Examine specifications for a sample measure Propose a workflow plan to incorporate quality measurement into daily practice List resources to assist physician practices in successfully reporting PQRS Question & Answer

Slide 13 of 33 Quality Reporting is First Step toward “Real Goals” Success of Practice – Sense of Accomplishment/Professional Achievement – Improved Productivity/Set Practice Priorities – Move away from Defensive Medicine to Evidence-Based Service to Patients – Improved Outcomes, Prevention, Diagnosis, Remediation – More engaged, self-responsibility – Improved Satisfaction, Better Coordination Benefits for the Population – Efficacious Care and Improved Population Health – Less waste, right incentives—Drive Change

Slide 14 of 33 Where do PQRS Measures Come From? National Quality Forum (NQF) measures are at the center of PQRS. – Experts in the clinical area and stakeholders are convened to define quality and standards through consensus process – Measures are adopted that are important, scientifically acceptable, useable, relevant, and feasible to track – Caregivers adopt and apply measures to improve their own practice – Measures provide benchmarks and best practices

Slide 15 of 33 Why Participate in PQRS? Financial PQRS Incentives through 2014 – 2011 : 1% of provider’s allowable Part B PFS incentive – 2012, 2013, 2014: 0.5% incentive Penalties beginning in 2015 for those who do not satisfactorily report – 2015: 1.5% payment reduction – 2016 and subsequent years: 2.0% payment reduction Brings money into the practice—Medicare pays for many preventive services as first-dollar

Slide 16 of 33 Why Participate in PQRS? Financial (cont.) We are moving away from Fee-for-Service to Value-based purchasing – Accountable Care Organizations – Patient-Centered Medical Homes – Missouri Foundation for Health/Healthcare Foundation of Greater KC/BCBS GKC (2011+) – Missouri HealthNet – Medicaid (2011+) – CMS “Comprehensive Primary Care Initiative (Sept 2011)

Slide 17 of 33 Why Participate in PQRS? Financial (cont.) Value-based modifier is required for specific physicians by 1/1/2015 and all providers by 1/1/2017. Initial performance data is Physicians in IA, KS, MO and NE will receive individual “Value-based” Reports late in 2011 – PQRS measures reported – Clinical measures derived from Claims data – Compare average per capita costs among physicians – Compare total per capita costs for patients with COPD, heart failure, CAD and diabetes Reports will be refined for future Value-based reports and for public reporting

Slide 18 of 33 Why Participate in PQRS? Accountability Close scrutiny of health care spending—accountability – Public outcry toward national spending has brought all federal programs to the forefront – Healthcare is the biggest ticket of federal budget & Medicare largest payer – PQRS performance can demonstrate that practice met standard of care – PQRS measures serve as window for evidence-based measure of quality upon which payment will be based

Slide 19 of 33 Why Participate in PQRS? Reputation Supports public reporting of quality data – Quality reporting measures are becoming more closely aligned for all CMS initiatives—Meaningful Use, PQRS, Medicare Advantage, PCMHs, ACOs, etc. – CMS website contains a listing of all physicians that satisfactorily completed PQRI in 2009: – CMS sends a letter to your patients telling them their physician is participating in PQRS Physician Compare quality reporting begins in 2013 for Groups; later for individual physicians –

Slide 20 of 33 Physician Compare Website

Slide 21 of 33 Why Participate in PQRS? Excellence Provides a way to measure and monitor the quality of care you provide your patients – Identify gaps in performance and take steps to correct – Provide better, more comprehensive care that meets professional standards – “You improve what you measure” – Build trust in your patients, engage them in care

Slide 22 of 33 Three Separate and Distinct CMS Programs EHR Incentive Program (“Meaningful Use” of an EHR) E-Prescribe Incentive Program (electronically transmit prescriptions) PQRS Incentive Program (“Physician Quality Reporting System”—formerly PQRI; report quality measures to CMS via claims, registry or EHR) EPs may participate in all programs for incentives and MUST participate to avoid payment penalties. (Only Medicare EHR incentives and e-prescribe incentives are mutually exclusive. Otherwise, eligible providers can collect all three.)

Slide 23 of 33 Physician Quality Reporting System PQRS requires reporting of clinical measures to CMS Annual program, rules/measures change every year PQRS incentives are independent of other CMS programs Eligible professionals include physicians, NPs, PAs, therapists Incentives based on Medicare Part B PFS allowable charges – incentives smaller/non-existent for RHC/FQHC providers

Slide 24 of 33 Reporting Mechanisms Measures--EPs may report: – 3 individual PQRS measures (194 possible), OR – 1 measures group (14 different Measures Groups) – A group consists of 4-9 clinically-related measures Reporting Options – Claims—traditional option – Qualified Registry—list not yet available for 2011 – Qualified EHR (20 individual measures—no measures groups)—28 EHRs are qualified in 2011

Slide 25 of 33 Participation Options In 2011 Providers may participate as: – Individuals--No registration is required – Groups – Self-nomination by first of the year required and approval needed – Groups report 26 measures Additional incentive (0.5%) for Maintenance of Certification Program – professional bodies only

Slide 26 of 33 Reporting through Part B Claims 12-month (1/1– 12/ )6-month (7/1 – 12/ ) 3 individual measures for >50% Medicare Part B PFS patients Same 1 Measure Group for >=30 Medicare Part B PFS patients N/A (As long as you report 30 Medicare Part B PFS patients, you qualify for full year, regardless of when claims were submitted) 1 Measure Group for >50% Medicare Part B PFS patients (at least 15) 1 Measure Group for >50% Medicare Part B PFS patients (at least 8) Submit daily on the claim Designed for paper-based clinical systems Some practice management systems have alerts to assist reporting

Slide 27 of 33 Reporting through a Qualified Registry 12-month (1/1 – 12/ month (7/1 – 12/ ) 3 individual measures for > 80% Medicare Part B PFS patients Same 1 Measures Group for >= 30 Medicare Part B PFS patients N/A (As long as you report 30 Medicare Part B PFS patients you qualify for full year) 1 Measure Group for >80% Medicare Part B PFS patients (at least 15) 1 Measure Group for >80% Medicare Part B PFS patients (at least 8) Provider submits data to registry, or registry pulls data from EHR Registry submits aggregate data to CMS on behalf of provider Done once a year, usually with a cost

Slide 28 of 33 Reporting through a Qualified EHR 12-month (1/1 – 12/ )6-month (7/1 – 12/ ) 3 individual measures for > 80% Medicare Part B PFS patients No six month reporting option There is NO Measures Group OptionSame EHR must be Qualified by CMS EHR pulls raw data from the EHR and submits to CMS Done once a year – may be a cost from vendor CMS calculates performance rate

Slide 29 of 33 Deadlines All claims must be submitted by the end of February 2012 Registry, EHR and GPRO must submit all data by the end of March 2012

Slide 30 of 33 Quality Measures--Analysis Each measure has a denominator that defines the population included. e.g. Pneumococcal Vaccine – Denominator: All patients greater than or equal to 65 years at the beginning of the measurement period. Patients must have at least one face-to-face office visit during the measurement period. Each measure has a numerator that defines the portion of population that met the measure – Patients who received a pneumococcal vaccination before the end of the measurement period

Slide 31 of 33 Quality Measure Analysis (continued) Some measures have exclusions that remove a patient from both the numerator and denominator: – Medical reason for not having the vaccination, such as Allergy or Adverse effect Reporting Rate: Accurately identifying all patients in the denominator Performance Rate: Numerator/Denominator – Currently incentives are based only on Reporting. There is no threshold for Performance--yet. – 2011 and 2012 are “free years” to master the fundamentals of quality measurement and reporting using the EHR

Slide 32 of 33 What’s Required for Quality Measurement Structured Data Capture in Defined Fields – Drop-down Lists- Dates – Checkboxes- Positive/Negative – Numerical values NOT—scanned documents, dictation, narrative notes May continue to use non-structured data but must be able to add underlying coding/structured element – Requires change to workflow and documentation habits – Requires team approach to accomplish change efficiently – Find a balance between structured/unstructured

Slide 33 of 33 Crosswalk between Prevention PQRS Measures and MU CQMs 2011 PQRS-EHR Based Measure PQRS DescriptionMeaningful Use Measure #110Influenza Vaccination Patient Aged 50+Alt. Core #111Pneumococcal Vaccine for Patients Aged 65+Menu #112Screening Mammogram Women Aged 40-69Menu #113Colorectal Cancer Screen Aged 50-75Menu #226Tobacco Use and Cessation Counsel Aged 18+Core #237Hypertension: BP MeasurementCore

Slide 34 of 33 Workflow for EHR-Based Reporting Adult Patient Workflow Pre- Appt & Check in— Front Desk Results that have come in are scanned and entered structurally If patient completed online pre-registration, front desk updates EHR based on patient-submitted data. If not, registration completed. Registration form asks about preventive screens and front desk updates EHR If mammogram or colonoscopy was done elsewhere, sends electronic request for a copy of report to specialist using standard electronic template and secure . Note made to provider. (PQRS #112 & 113) Updates flu and pneumococcal vaccine if done elsewhere. Note made to provider. (PQRS #110 and #111) Updates smoking status as indicated on registration form

Slide 35 of 33 Workflow (Continued) Adult Patient Workflow Nurse Review Nurse takes blood pressure and documents (PQRS #237) Nurse reviews allergies and documents from pick list/template (PQRS #110 and #111) Nurse reviews alerts for preventive screens that are overdue (these must be activated). If patient is due for flu or pneumococcal vaccine, nurse review for allergy/adverse event and administers as per standing order. Documents via template (PQRS #110 and #111) Nurse reviews about tobacco use and provides cessation counseling. Makes note to doctor and documents all via template (PQRS #226)

Slide 36 of 33 Workflow (Continued) Adult Patient Workflow Physician Review After completing entire visit, physician reviews alerts for preventive screens that are due. If mammogram due, physician orders using CPOE and sends to Referral Coordinator to schedule. Physician makes strong case for importance of mammograms. If colorectal cancer screening due, physician discusses options, makes strong recommendation and orders using CPOE. If FOBT or FIT, sends order to nurse to provide test kit and instructions. If colonoscopy, sends order to Referral Clerk to schedule. Physician addresses other preventive screens that are due but that patient may have refused. Provides educational information and documents

Slide 37 of 33 Workflow (Continued) Adult Patient Workflow Referral Clerk Referral Clerk asks patient if have a preference for where/when to schedule mammogram and/or colonoscopy (PQRS #112, #113) Sends CCD to specialist with explanatory notes/preferences Tells patient specialist will be contacting to schedule Front Desk or Clinical Staff Reviews open orders daily. If patient has not followed- through on preventive screening, sends reminder to patient.

Slide 38 of 33 Workflow (Continued) Adult Patient Workflow Scheduled Tasks Monthly: Run PQRS reports. Drill-down into measure and generate patient lists to determine which patients are overdue. Send reminders to patients as per patient preference. Discuss quality reports at staff/provider meetings. Identify root cause of performance rates that are lower than expected. Suggest strategies for improving performance. Assign specific responsibilities to staff. Test strategies and re-measure for next meeting.

Slide 39 of 33 Bottom Line Quality measures are being aligned Financial Reasons Reputation Accountability Culture of Excellence “The healthcare organization that seeks merely to meet minimal standards may not ever reach any higher, and certainly will not achieve excellence.” (Janet Brown, RN, CPHQ, The Healthcare Quality Handbook, )

Slide 40 of 33 Resources Primaris – Primaris has just received funding to assist 74 Missouri physicians to report PQRS using their EHR as part of our national QIO 10 th Scope of Word (began August 2011). – Free onsite and/or remote assistance for reporting Preventive Care Screening (flu/pneumonia vaccines, Colorectal Cancer Screens, Mammograms, BP measurement, Tobacco cessation) – Earn PQRS Incentives for 2012 (and possibly 2011) – Complete and return Interest Form to reserve your spot today. Eligibility criteria apply. – Primaris will offer best practices and consultation to any practice attempting to improve performance on the above measures

Slide 41 of 33 Resources (cont) Missouri Health Information Technology Assistance Center – Website: – – Phone: CMS INFORMATION RESOURCES: – How to Get Started – Measure Specifications for individual measure reporting – Measures Groups Specifications – EHR Specifications – GPRO Specifications – 2011 Implementation Guide

Slide 42 of 33 Resources (cont) Also see: – Frequently Asked Questions – Supplemental education materials – National Provider Calls – Special Open Door Forums QualityNet Help Desk – – 7:00 a.m. - 7:00 p.m. CST at or

Slide 43 of 33 Thank You! Questions? Contact: – PQRS and Improvement on Quality Measures: – Sandy Pogones, – Cardiac Learning and Action Network: – Kristen Bird, Websites: – Primaris.org – PQRSMO.org Primaris: Your Local Connection to Achieving National Health Goals

Slide 44 of 33 Disclaimer This presentation was prepared as a tool to assist providers. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Primaris employees, agents and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently so links to the source documents have been provided for your reference to the most up-to-date information.

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