1. Putting the Pieces Together – GPRA, CRS and Education Mary Wachacha 2010

2. GPRA is a Federal Law Government Performance and Results Act of 1993 A Federal law Requires Federal agencies to demonstrate that they are using their funds effectively toward meeting their missions Government Performance and Results Act of 1993 A Federal law Requires Federal agencies to demonstrate that they are using their funds effectively toward meeting their missions

3. GPRA = Government Performance and Results Act GPRA is a reporting requirement for all federal programs (including IHS) GPRA statistics go to Congress Any site that uses the RPMS is reporting GPRA (and CRS) GPRA statistics assist in budget formulation GPRA statistics provide an audit trail of dollars to outcomes GPRA is a reporting requirement for all federal programs (including IHS) GPRA statistics go to Congress Any site that uses the RPMS is reporting GPRA (and CRS) GPRA statistics assist in budget formulation GPRA statistics provide an audit trail of dollars to outcomes

4. GPRA Requires a Data- Supported Audit Trail Requires a data-supported audit trail from appropriated dollars to activities and ultimately to customer benefits or outcomes consistent with the IHS mission

5. CRS – Clinical Reporting System The IHS Director has designated the Clinical Reporting System (CRS) as the national tool for reporting of all GPRA clinical measures CRS is used within IHS to track new or emerging health problems CRS is used internally to predict trends in health for the future Any site that is reporting via RPMS is reporting on CRS (and GPRA) Tribal facilities are not required to use CRS but are encouraged to use it The IHS Director has designated the Clinical Reporting System (CRS) as the national tool for reporting of all GPRA clinical measures CRS is used within IHS to track new or emerging health problems CRS is used internally to predict trends in health for the future Any site that is reporting via RPMS is reporting on CRS (and GPRA) Tribal facilities are not required to use CRS but are encouraged to use it

6. Clinical Reporting System (CRS) Reports on many non-GPRA measures, including Asthma Chronic Kidney Disease Assessment Treatment for Upper Respiratory Infection in Children Includes other clinical reports Elder Care HEDIS Patient Education CMS Reports on many non-GPRA measures, including Asthma Chronic Kidney Disease Assessment Treatment for Upper Respiratory Infection in Children Includes other clinical reports Elder Care HEDIS Patient Education CMS

7. Where does the GRPA and CRS data come from? From provider documentation: from the patient chart or the Electronic Health Record (EHR)

8. Some Examples of Current GPRA Indicators

9. 2011 GPRA Indicators Diabetes PAP Smears Mammograms Colorectal Cancer Screening FAS Screening Tracked by education IPV/DV Tracked by education Diabetes PAP Smears Mammograms Colorectal Cancer Screening FAS Screening Tracked by education IPV/DV Tracked by education Comprehensive CVD Screening Depression Screening Childhood Weight Breastfeeding Rates HIV Screening Dental Tobacco Cessation Immunizations: Flu, Pneumovax, childhood immunizations

10. Let’s take a closer look at a few GPRA Indicators: Tobacco Cessation Childhood Obesity - Breastfeeding Comprehensive CVD Assessment Tobacco Cessation Childhood Obesity - Breastfeeding Comprehensive CVD Assessment

11. Tobacco Cessation Please note this Indicator is not about simple prevalence: Prevalence is: Do you smoke? Yes or No? Although you must ask: Do you Smoke? Yes or No? If the patient answers “Yes” – your next step is to move the patient to cessation. Cessation is: Patients who have received tobacco cessation counseling: Patient Education on Tobacco Referral to a Stop Smoking Clinic Referral to a State Quit Line Prescribed cessation medications Please note this Indicator is not about simple prevalence: Prevalence is: Do you smoke? Yes or No? Although you must ask: Do you Smoke? Yes or No? If the patient answers “Yes” – your next step is to move the patient to cessation. Cessation is: Patients who have received tobacco cessation counseling: Patient Education on Tobacco Referral to a Stop Smoking Clinic Referral to a State Quit Line Prescribed cessation medications

12. Childhood Weight Control Childhood Weight Control was replaced to a long-term measure (breastfeeding) and the new Breastfeeding Rates measure will become an annual GPRA measure.

13. Breastfeeding Patients 60-425 days old. Babies who have been screened for infant feeding choice.  Babies two months (60-89 days) old, either exclusively or mostly breastfed.  Babies six months (180-209 days) old, either exclusively or mostly breastfed.  Babies nine months (270-299 days) old, either exclusively or mostly breastfed.  Babies 1 year (365-425 days), either exclusively or mostly breastfed. Patients 60-425 days old. Babies who have been screened for infant feeding choice.  Babies two months (60-89 days) old, either exclusively or mostly breastfed.  Babies six months (180-209 days) old, either exclusively or mostly breastfed.  Babies nine months (270-299 days) old, either exclusively or mostly breastfed.  Babies 1 year (365-425 days), either exclusively or mostly breastfed.

14. FEEDING CHOICE (today) XOne time data Fields BREAST ONLYBirth Weight (kg)Birth Order Mostly BREASTFEEDING Weeks/Months ½ BreastfeedingAGE – Started Formula ½ Formula Mostly FORMULAAGE – Stopped Breast FORMULA ONLYAGE – Started Solid Foods Breastfeeding and Bottle Feeding

15. Documenting in the Electronic Health Record

16. Comprehensive CVD-Related Assessment Blood Pressure value documented at least twice With LDL completed Screened for tobacco use Body Mass Index (BMI) could be calculated (height X weight =BMI) Received patient education: lifestyle adaptation (LA) Medical Nutrition Therapy (MNT) Nutrition (N) Exercise (EX) Patients with ALL assessments above. Blood Pressure value documented at least twice With LDL completed Screened for tobacco use Body Mass Index (BMI) could be calculated (height X weight =BMI) Received patient education: lifestyle adaptation (LA) Medical Nutrition Therapy (MNT) Nutrition (N) Exercise (EX) Patients with ALL assessments above.

17. Examples of CRS Indicators

18. Other CRS Clinical Measures Topics Osteoporosis Management Osteoporosis Screening in Women Rheumatoid Arthritis Medication Monitoring Osteoarthritis Medication Monitoring Asthma Asthma Quality of Care Asthma/Inhaled Steroid Use Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation Osteoporosis Management Osteoporosis Screening in Women Rheumatoid Arthritis Medication Monitoring Osteoarthritis Medication Monitoring Asthma Asthma Quality of Care Asthma/Inhaled Steroid Use Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation Chronic Kidney Disease Assessment Pre- diabetes/Metabolic Syndrome Medications Education Public Health Nursing Breastfeeding Rates Use of High-Risk Medications in the Elderly Functional Status Assessment in Elders Fall Risk Assessment in Elders Palliative Care

19. Let’s take a closer look at a few CRS Indicators: Osteoporosis Arthritis Asthma Chronic Kidney Disease Drugs to be Avoided in the Elderly Osteoporosis Arthritis Asthma Chronic Kidney Disease Drugs to be Avoided in the Elderly

20. Osteoporosis Management Female patients ages 67 and older who have a new fracture with no osteoporosis screening or treatment. Patients treated or tested for osteoporosis after the fracture. Fracture: Does not include fractures of finger, toe, face, or skull (i.e., pelvis, arms, leg) Female patients ages 67 and older who have a new fracture with no osteoporosis screening or treatment. Patients treated or tested for osteoporosis after the fracture. Fracture: Does not include fractures of finger, toe, face, or skull (i.e., pelvis, arms, leg)

21. Osteoporosis Screening in Women Female patients ages 65 and older without or history of osteoporosis who had osteoporosis screening No osteoporosis diagnosis ever Osteoporosis Screening: Central DEXA: Peripheral DEXA: Central CT: Peripheral CT: US Bone Density: Quantitative CT: Special screening for other conditions, Osteoporosis. Female patients ages 65 and older without or history of osteoporosis who had osteoporosis screening No osteoporosis diagnosis ever Osteoporosis Screening: Central DEXA: Peripheral DEXA: Central CT: Peripheral CT: US Bone Density: Quantitative CT: Special screening for other conditions, Osteoporosis.

22. Arthritis Medications Rheumatoid Arthritis Medication Monitoring Osteoarthritis Medication Monitoring Rheumatoid Arthritis Medication Monitoring Osteoarthritis Medication Monitoring

23. Asthma Quality of Care Patients ages 5-56 with persistent asthma without a documented history of emphysema or chronic obstructive pulmonary disease (COPD) Patients who had at least one dispensed prescription for primary asthma therapy medication Patients ages 5-56 with persistent asthma without a documented history of emphysema or chronic obstructive pulmonary disease (COPD) Patients who had at least one dispensed prescription for primary asthma therapy medication

24. Asthma and Inhaled Steroid Use Patients ages 1 or older who have had two asthma-related visits in ARS (Asthma Reporting System) Patients prescribed an inhaled corticosteroid Patients ages 1 or older who have had two asthma-related visits in ARS (Asthma Reporting System) Patients prescribed an inhaled corticosteroid

25. Chronic Kidney Disease Assessment Patients 18 and older with serum creatinine test in past year. Patients with Estimated GFR result (lab test Estimated GFR). A) with GFR <60 Patients 18 and older with serum creatinine test in past year. Patients with Estimated GFR result (lab test Estimated GFR). A) with GFR <60

26. Drugs to be Avoided in the Elderly Patients ages 65 and older – male and female Patients who received at least one drug to be avoided in the elderly. Patients who received at least two different drugs to be avoided in the elderly Patients ages 65 and older – male and female Patients who received at least one drug to be avoided in the elderly. Patients who received at least two different drugs to be avoided in the elderly

27. Functional Status in Elders Patients ages 55 and older, male and female Patients screened for functional status at any time during the Report period. Functional Status: at least one of the following Activities of Daily Living (ADL) fields: toileting, bathing, dressing, transfers, feeding, or continence AND 2) at least one of the following Instrumental Activities of Daily Living (IADL) fields: finances, cooking, shopping, housework/chores, medications or transportation Patients ages 55 and older, male and female Patients screened for functional status at any time during the Report period. Functional Status: at least one of the following Activities of Daily Living (ADL) fields: toileting, bathing, dressing, transfers, feeding, or continence AND 2) at least one of the following Instrumental Activities of Daily Living (IADL) fields: finances, cooking, shopping, housework/chores, medications or transportation

28. Fall Risk Assessment in Elders Patients ages 65 and older, male and female Patients who have been screened for fall risk or with a fall-related diagnosis (in the past year). A) Patients who have been screened for fall risk. B) Patients with a documented history of falling. C) Patients with a fall-related injury diagnosis. D) Patients with abnormality of gait/balance or mobility diagnosis E) Patients with a documented refusal of fall risk screening exam. Patients ages 65 and older, male and female Patients who have been screened for fall risk or with a fall-related diagnosis (in the past year). A) Patients who have been screened for fall risk. B) Patients with a documented history of falling. C) Patients with a fall-related injury diagnosis. D) Patients with abnormality of gait/balance or mobility diagnosis E) Patients with a documented refusal of fall risk screening exam.

29. Appropriate Medication Therapy after a Heart Attack Patients who have had a MI recently and need to be on medications (Heart attack) with an: Active prescription for beta-blockers. Active prescription for ASA (aspirin) or other anti- platelet agent. Active prescription for to ACEIs/ARBs. Active prescription for to statins. Patients have to have a prescription, refusal or a contraindication for the medication (s) Patients who have had a MI recently and need to be on medications (Heart attack) with an: Active prescription for beta-blockers. Active prescription for ASA (aspirin) or other anti- platelet agent. Active prescription for to ACEIs/ARBs. Active prescription for to statins. Patients have to have a prescription, refusal or a contraindication for the medication (s)

30. Persistence of Appropriate Medication Therapy after a Heart Attack People who have had a MI sin past but still need to taking these medications: Aspirin Beta-blockers ACEI/ARBs Statins Patients have to have a prescription, refusal or a contraindication for the medication (s) People who have had a MI sin past but still need to taking these medications: Aspirin Beta-blockers ACEI/ARBs Statins Patients have to have a prescription, refusal or a contraindication for the medication (s)

31. Appropriate Medication Therapy in High Risk Patients Patients who are at high risk for heart disease, such as have had IHD (heart attack, heart failure, other heart problems) Or Diabetes supposed to be taking medications: Aspirin Beta-blockers ACEI/ARBs Statins Patients have to have a prescription, refusal or a contraindication for the medication (s) Patients who are at high risk for heart disease, such as have had IHD (heart attack, heart failure, other heart problems) Or Diabetes supposed to be taking medications: Aspirin Beta-blockers ACEI/ARBs Statins Patients have to have a prescription, refusal or a contraindication for the medication (s)

32. Cholesterol Management for Patients with Cardiovascular Conditions Patients who have had 1) a heart attack, 2) heart catherization, 3) heart surgery, who have appropriate cholesterol control (LDL) Ensure patient has their labs completed Patients who have had 1) a heart attack, 2) heart catherization, 3) heart surgery, who have appropriate cholesterol control (LDL) Ensure patient has their labs completed

33. Appropriate Treatment for Children with Upper Respiratory Infection Patients who were ages 3 months through 18 years who were diagnosed in the outpatient setting with an upper respiratory infection (URI) Patients who were NOT prescribed an antibiotic on or within three days after diagnosis. In this measure, appropriate treatment is not to receive an antibiotic. Patients who were ages 3 months through 18 years who were diagnosed in the outpatient setting with an upper respiratory infection (URI) Patients who were NOT prescribed an antibiotic on or within three days after diagnosis. In this measure, appropriate treatment is not to receive an antibiotic.

34. Appropriate Testing for Children with Pharyngitis Patients ages 2-18 years who were diagnosed with pharyngitis and prescribed an antibiotic. Patients who received a Group A strep test. Patients ages 2-18 years who were diagnosed with pharyngitis and prescribed an antibiotic. Patients who received a Group A strep test.

35. Improving GPRA/CRS Performance Requires a Team Effort! GPRA Results Provider Data Entry IT Staff GPRA Coordinators/QI Management Staff

36. Questions? Contact: Mary.Wachacha@ihs.gov Mary.Wachacha@ihs.gov or Chris.Lamer@ihs.gov or Chris.Lamer@ihs.govChris.Lamer@ihs.gov Contact: Mary.Wachacha@ihs.gov Mary.Wachacha@ihs.gov or Chris.Lamer@ihs.gov or Chris.Lamer@ihs.govChris.Lamer@ihs.gov