1. Stage 3 Update Paul Tang, Chair George Hripcsak, Co-Chair Meaningful Use Workgroup August 29, 2013

2. Agenda Review what we heard last month Re-confirm our focus on outcomes Outline the outcomes-oriented framework Connect the dots Seek approval of outcomes-oriented framework to flesh out details 1

3. What We Heard Stage 3 focuses on outcomes; how do the functional objective recommendations link to outcomes? How does MU3 link to HHS initiatives (e.g. NQS, Million Hearts) and future payment models (e.g., ACO, MSSP, PCMH)? Deeming pathway is a good direction – Emphasizes outcomes – Reduces burden – Aligns with other federal programs – BUT, need appropriate QMs 2

4. Updated Recommendations Based Upon Feedback from HITPC 1.Focus on improving care outcomes 2.Use of quality measures to assess identified outcomes 3.Incorporate functional deeming as an option for stage 3 compliance 4.Align with CMS and future payment priorities 3

5. 2009 - National Priorities Partnership Improve the Safety and Reliability of America's Healthcare Engage Patients and Families Well-Coordinated Care Across All Providers, Settings, and Levels of Care Improve the Health of the Population Appropriate and Compassionate Care for Patients With Life- Limiting Illnesses Eliminate Waste While Ensuring the Delivery of Appropriate Care 2011 - National Quality Strategy Making care safer Ensuring that each person and family are engaged as partners Promoting effective communication and coordination of care Promoting effective prevention and treatment practices Working with communities to promote healthy living Making quality care more affordable Meaningful Use Improving quality, safety, and reducing health disparities Engaging patients and families in their care Improving care coordination Improving population and public health Privacy and Security Harmonizing Meaningful Use and National Quality Strategy: National Priorities Partnership – Common Roots 4 National Quality Strategy: Serves as a catalyst and compass for a nationwide focus on quality improvement efforts and a national approach to measuring quality. The NQS concurrently pursues three aims to provide better, more affordable care for the individual and the community. To advance these aims, the NQS focuses on six priorities for health and health care quality that have an impact on most Americans. National Priorities Partnership: Convened by NQF, is composed of 28 organizations and is focused on a core list of priorities that will yield change in the form of improved care, equity, safety, and efficiency. NPP provides input on goals, measure concepts and strategic opportunities to achieve the NQS aims. Initially published in March 2011. 4

6. Importance of an Outcomes-Based Framework Placeholder for Scenario 5

7. Recommendation 1: Focus on improving care outcomes 6

8. Revised Care Outcomes Aligned with NQS 7 2011 - National Quality Strategy Priorities Making care safer Ensuring that each person and family are engaged as partners Promoting effective communication and coordination of care Promoting effective prevention and treatment practices Working with communities to promote healthy living Making quality care more affordable Revised MU3 Priority Outcomes Improving quality of care and safety Engaging patients and families in their care Improving care coordination Healthier living and disease prevention Improving population and public health Affordable Care Equitable Care for All

9. Improving Quality of Care and Safety: Linking Outcomes with Stage 3 Functions Stage 1 + 2 Structured data – Problem, Meds, Allergy lists – Vitals, smoking status – Lab results, Hospital labs – Imaging CPOE CDS Progress notes Safety – eRx, drug-allergy checks – Medication reconciliation Population management – Patient lists – Patient reminders Stage 3 CDS++ Order tracking (e.g., closing the loop) Real-time dynamic dashboards (for clinical and population health management) Medication adherence Patient safety – Common Format for registry reports (e.g. healthcare associated infections) – Sharing radiation dosing information – Capture FDA Unique Device Identifier (UDI) Outcome Goals Quality of care – Better control of chronic diseases – Improved efficiencies to prevent inappropriate care (overuse, underuse, and misuse) – Reduce preventable hospital admissions and readmissions Improved population management Patient safety – Reduced incidence of adverse events 8

10. Clinical summary Online access Patient education View, download, transmit Secure messaging Engaging patients and families in their care: Linking Outcomes with Stage 3 Functions 9 Stage 1 + 2 Stage 3 Patient education, clinical summary, & reminders provided to patients in their preferred means of communication Patient generated health data Communication preferences Amendments Outcome Goals Improved access/sharing of information for the patient and caregiver Patients and caregivers recognized as partners – Shared decision- making, care planning/goals Improved patient and caregiver experience

11. Improving care coordination: Linking Outcomes with Stage 3 Functions CDS+ Cancer registry Family history Electronic lab reporting 10 Stage 1 + 2 Summary of care Stage 3 Health event notification (e.g., ED visit, admission to hospital) Close the referral loop Outcome Goals Improved communication across care settings Improved coordination of care across the continuum Improved accountability across settings and reduction in health disparities

12. Disease Prevention: Linking Outcomes with Stage 3 Functions CDS+ Cancer registry Family history Electronic lab reporting 11 Stage 1 + 2 CDS Immunization Patient education PH reporting Cancer registry Family history Electronic lab reporting Stage 3 CDS+ interventions to manage chronic conditions Outcome Goals Increased adherence with preventive health recommendations

13. Improving Population and Public Health: Linking Outcomes with Stage 3 Functions CDS+ Cancer registry Family history Electronic lab reporting 12 Stage 1 + 2 Immunization PH reporting Cancer registry Electronic lab reporting Submission of electronic syndromic surveillance data Stage 3 Common Format for registry reports (e.g. healthcare associated infections) Case reports submitted to the state/local jurisdiction Outcome Goals Improved population health

14. Affordable Care Linking Outcomes with Stage 3 Functions CDS+ Cancer registry Family history Electronic lab reporting 13 Stage 1 + 2 Formulary checks Generics Stage 3 Imaging results Outcome Goals Improved efficiencies to prevent inappropriate care (overuse, underuse, and misuse)

15. Race Ethnicity Language Equitable Care for All Linking Outcomes with Stage 3 Functions 14 Stage 1 + 2 Stage 3 Occupation Sexual orientation and gender identity Veteran status Patient education in a language other than English Outcome Goals Equitable care for all by reducing health disparities

16. Recommendation 2: Use of quality measures to assess identified outcomes 15

17. Recommendation 2: Use of quality measures to assess identified outcomes (I) Improving quality of care and safety CV Risks Blood pressure control LDL control Falls Pressure ulcer HAI Morphine equivalent “Never Give Together” Time in therapeutic range for Warfrin Increased Patient Engagement Knee Hip Heart Failure (functional status) Improved Care Coordination Close the referral loop Reciprocal referrals Care transitions for hospitals Readmissions Care Outcomes Proposed CQMs 16

18. Recommendation 2: Use of quality measures to assess identified outcomes (II) Healthier living and disease prevention Immunization (i.e., flu, pneumonia, childhood vaccinations) Cancer screening (i.e., colon, prostate, cervical) Improving population and public health HIV medical visit frequency Immunizations by 13 Affordable Care Choosing Wisely Do not overtreat A1C Reduce CT scans for headache ED throughput MRI back pain Radiation dosing Adherence (reference CBO) Equitable Care Care Outcomes Proposed CQMs 17

19. Recommendation 3: Incorporate functional deeming as an option for stage 3 compliance 18

20. Recommendations on Functional Deeming Providers who have already met all functional objectives in stages 1 and 2 should be allowed to “deem” Deeming allows high MU performers (or significant improvers) to attest for MU by satisfying a subset of MU objectives; this would be an optional pathway to achieve MU “Deeming” promotes innovation, reduces burden, and rewards good performance CMS should survey the landscape for available eCQMs that are outcomes-oriented and consider their use as deeming measures; in addition, new development of eCQMs may be necessary 19

21. Accountable Care Clinical Quality Measures Subgroup Tasks 1.Develop recommendations for ‘HIT-sensitive’ eCQM concepts and specific measures that could be used to deem” EPs and EHs as meaningful users through their ability to perform on quality outcomes 2.HIT-sensitive outcome measures are ideal for deeming – Which measures that currently exist in CMS programs are appropriate to use for deeming? (charge to QM WG) – Which measures in the pipeline for MU3 time frame are appropriate to use for deeming? What measure gaps exist, that could be filled in time for MU3, that are exemplars of HIT sensitive measures for deeming? 3.Eligible professionals and group reporting – What parameters should be used for a group reporting option for MU overall (including deeming) – If there is a group reporting option, how do you attribute a provider's membership in a group and his/her ability to receive incentives (or avoid penalties)? 20

22. Recommendation 4: Align with CMS and future payment priorities 21

23. Alignment Across National Initiatives NQF #NQF Measure TitleMU- EPs SSP - ACOsPQRS 0018Controlling High Blood Pressure111 0028Measure Pair: a. Tobacco Use Assessment, b. Tobacco Cessation Intervention 111 0068Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic 111 0075IVD: Complete Lipid Profile and LDL Control < 100 111 0031Breast Cancer Screening111 0034Colorectal Cancer Screening111 0041Influenza Vaccination111 0043Pneumonia vaccination status for older adults111 0074Chronic Stable Coronary Artery Disease: Lipid Control 111 0421Adult Weight Screening and Follow-Up111 22

24. Questions?