Continuous Quality Improvement Using Clinical Quality Reporting Brian Martin, MD, Director, Medical Informatics, GE Healthcare IT/CBS Nancy Munoz, Senior.

Continuous Quality Improvement Using Clinical Quality ReportingBrian Martin, MD, Director, Medical Informatics, GE Healthcare IT/CBSNancy Munoz, Senior Product Manager, GE Healthcare IT/CBSLorna Eades, Business Analyst, GE Healthcare IT/CBS

©2015 General Electric Company – All rights reserved.

This does not constitute a representation or warranty or documentation regarding the product or service featured. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE.

DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE.

Customer is responsible for understanding and meeting the requirements of achieving meaningful use through use of HHS certified EHR technology and associated standards. Customer is responsible for understanding applicable GE documentation regarding Meaningful Use functionality and reporting specifications, and for using that information to confirm the accuracy of meaningful use attestation. Customer is responsible for ensuring an accurate attestation is made and GE does not guarantee incentive payments. Use of the product does not ensure customer will be eligible to receive payments.

*GE, the GE Monogram, Centricity and imagination at work are trademarks of General Electric Company.

General Electric Company, by and through its GE Healthcare division.

Centricity Practice Solution v12.0 and Centricity EMR v9.8 are certified ONC 2014 Edition compliant complete and modular EHRs. For additional certification and transparency information, visit www.gehealthcare.com/certifications.

http://www3.gehealthcare.com/en/Products/Categories/Healthcare_IT/HITECH

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Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009

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HITECH’s National Policy Objective: To Encourage Physicians to Adopt and Use EMRs

Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010 Aug 5;363(6):501-4.

HITECH's goal is not adoption alone but “meaningful use” of EHRs — that is, their use by providers to achieve significant improvements in care. The legislation ties payments specifically to the achievement of advances in health care processes and outcomes… [via] ...incentive payments… [of] ... as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician.

$34 billion in incentive payments!

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Meaningful Use: Measuring HITECH’s Success

Stage 1: process evaluation. Measures physician adoption of EMR technology.

Stage 2: process evaluation. Measures physician adherence to evidence-based best practices for:

• Preventing disease onset

• Screening for and detecting disease at its most treatable stage

• Managing chronic disease to minimize disease progression

Stage 3: outcomes evaluation. Measures patient outcomes

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Clinical Quality Reporting (CQR)

Centricity EMR or CPS database

Internet

Convert EMR data to standard clinical

vocabularies: SNOMED CT, ICD-10-CM, LOINC,

CVX, RxNorm, etc.

Encode summary patient record

in CCDA format

Transform CCDA-encoded summary patient records to

Quality Data Model format

Clinical Quality Reporting Data

Repository

Calculate Clinical Quality

Measures(CQMs)

Create various reports and gather insights to enhance you practice’s

quality.

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Use Clinical Quality Reporting To:

• Create & download Meaningful Use attestation reports

• Create & file Physician Quality Reporting System (PQRS) reports with CMS

• Identify patient cohorts for primary and secondary prevention services

• Identify patient cohorts for chronic disease management services

• Find answers to questions about the health status of your patients

• Find answers to questions about how frequently your physicians adhere to evidence-based best practices for patient care

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CQR Supports Preventive Medicine Interventions

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Primary Prevention:Reducing the Risk for Disease Onset

Use CQR to incorporate disease prevention practices into your organization:

• Identify patient cohorts for tobacco use cessation interventions: CMS138

• Identify patient cohorts for diet, weight loss and/or exercise interventions: CMS69, CMS61, CMS64

• Identify patient cohorts for influenza vaccination: CMS147

• Identify patient cohorts for pneumonia vaccination: CMS127

• Identify patient cohorts for screening for risk of “falls” injury: CMS139

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Secondary Prevention:Detecting Disease at its Earliest Stage

Use CQR to incorporate secondary prevention practices into your organization:

• Identify patient cohorts for breast cancer screening: CMS125

• Identify patient cohorts for cervical cancer screening: CMS124

• Identify patient cohorts for colon cancer screening: CMS141

• Identify patient cohorts for prostate cancer screening: CMS129

• Identify patient cohorts for chlamydia screening: CMS153

• Identify patient cohorts for hypertension screening: CMS22

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Tertiary Prevention:Preventing Disease Progression

Use CQR to manage care plans & gaps in care for patients with chronic disease:

• Identify diabetic patients whose HbA1c is poorly controlled: CMS122

• Identify diabetic patients whose LDL is poorly controlled: CMS163

• Identify diabetic patients with microalbuminuria: CMS134

• Identify diabetic patients who have not had screening exams for diabetic retinopathy or diabetic foot disease: CMS123, CMS131

• Identify congestive heart failure patients who are not on ACE or ARB therapy: CMS135

• Identify asthmatic patients who are not on appropriate medications: CMS126

• Identify patients with hypertension for blood pressure control: CMS65, CMS165

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The Anatomy of a Clinical Quality Measure

CMS126: Use of appropriate medications for asthma

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What CMS126 Measures

Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.

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Rationale

Asthma is one of the most prevalent chronic diseases, becoming increasingly more commonplace over the past twenty years. Approximately 24.6 million Americans have asthma, and it is responsible for over 3,000 deaths in the U.S. annually (American Lung Association 2010). In 2006, 13.3 million clinical visits (hospital, outpatient, emergency department, and physician offices) were attributed to asthma (Centers for Disease Control and Prevention 2009). The incidence rate, and subsequently the number of asthma-related health visits, is expected to increase by an additional 100 million globally by 2025 (World Health Organization 2007).

Asthma accounts for over $20 billion spent on health care in the United States. Direct costs, including prescriptions, make up $15.6 billion of that total. Indirect costs, such as lost productivity, add an additional $5.1 billion (Centers for Disease Control and Prevention 2009). Inpatient hospitalization accounts for over 50 percent of overall asthma-related costs (Bahadori et al. 2009). In addition to the direct financial burden, asthma is also a leading cause of absenteeism and productivity, accounting for an estimated 14.2 million missed workdays for adults and over 14 million missed school days for children (Akinbami et al. 2009). Studies have shown that the indirect costs of asthma are becoming a growing financial burden on patients, and resulting in significant additional costs (Bahadori et al. 2009).

Appropriate medication management could potentially prevent a significant proportion of asthma-related costs (hospitalizations, emergency room visits and missed work and school days) (Akinbami et al. 2009). The Asthma Regional Council supported this inference, stating that proper management could potentially save at least 25 percent of total asthma costs, or $5 billion, nationally by reducing health care costs (American Lung Association 2009).

Another initiative, the Children’s Health Fund’s Childhood Asthma Initiative, examined patients enrolled in an asthma intervention program. Results illustrated that treatment that aligned with clinical guidelines reduced the severity of symptoms experienced, as well as asthma-related events (e.g., hospitalizations, emergency room visits, etc.) (Columbia University 2010). Additionally, subsequent savings attributed to improved clinical outcomes totaled to nearly $4.2 million or $4,525 per patient. This translated to a significant reduction in federally subsidized and private insurance-based costs for this population (Columbia University 2010).

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Clinical Recommendation Statement

National Heart Lung and Blood Institute/National Asthma and Education Prevention Program (2007)

• Long-term control medications (include inhaled corticosteroids (ICSs), inhaled long-acting bronchodilators, leukotriene modifiers, cromolyn, theophylline, and immunomodulators) are used daily to achieve and maintain control of persistent asthma. The most effective are those that attenuate the underlying inflammation characteristic of asthma. The Expert Panel defines anti-inflammatory medications as those that cause a reduction in the markers of airway inflammation in airway tissue or airway secretions (e.g., eosinophils, mast cells, activated lymphocytes, macrophages, and cytokines; or Eosinophil cationic protein (ECP) and tryptase; or extravascular leakage of albumin, fibrinogen, or other vascular protein).

• Inhaled corticosteroids are the preferred treatment option for mild persistent asthma in adults and children. Leukotriene Receptor Antagonists (LTRAs) are an alternative, although not preferred, treatment.

• Long-acting beta-2 agonists (LABAs) should only be used in combination with ICSs for long-term control and prevention of symptoms in moderate or severe persistent asthma (step 3 care or higher in children =5 years of age and adults). There is a strong recommendation against the use of LABAs as monotherapy. Of the adjunctive therapies available, long-acting beta-2 agonists is the preferred therapy to combine with ICS in youths =12 years of age and adults.

• The beneficial effects of long-acting beta-2 agonists in combination therapy for the great majority of patients who require more therapy than low-dose ICS alone to control asthma (i.e., require step 3 care or higher) should be weighed against the increased risk of severe exacerbations, although uncommon, associated with the daily use of long-acting beta-2 agonists .

• The NHLBI/NAEPP guideline strongly recommends against the use of long-acting beta-2 agonists for the treatment of acute symptoms or exacerbations.

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Reporting (Attestation) Criteria

Patients who were dispensed at least one

prescription for a preferred therapy during the

measurement period

Patients 5-64 years of age with persistent asthma and a visit

during the measurement period

Patients with emphysema, COPD, cystic fibrosis or acute respiratory failure during or prior to the measurement

period

Report a total score, and for each of the following age strata:• Stratum 1: Patients age 5-11 • Stratum 2: Patients age 12-18• Stratum 3: Patients age 19-50• Stratum 4: Patients age 51-64

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CQM Clinical Data Warehouse Logic for CMS126

Numerator = "Medication, Dispensed: Preferred Asthma Therapy" during "Measurement Period“

Denominator = "Patient Characteristic Birthdate: birth date" >= 5 year(s) starts before start of "Measurement Period" AND "Patient Characteristic Birthdate: birth date" < 64 year(s) starts before start of "Measurement Period" AND "Occurrence of Diagnosis, Active: Persistent Asthma" starts before or during "Measurement Period" AND NOT "Occurrence of Diagnosis, Active: Persistent Asthma" ends before start of "Measurement Period" AND ("Encounter, Performed: Office Visit" during "Measurement Period" OR "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period" OR "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" during "Measurement Period" OR "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" during "Measurement Period" OR "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" during "Measurement Period" OR "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" during "Measurement Period" OR "Encounter, Performed: Home Healthcare Services" during "Measurement Period")

Denominator Exclusions =("Occurrence of Diagnosis, Active: Chronic Obstructive Pulmonary Disease" starts before or during "Measurement Period" AND NOT "Occurrence of Diagnosis, Active: Chronic Obstructive Pulmonary Disease" ends before start of "Measurement Period“)OR ("Occurrence of Diagnosis, Active: Emphysema" starts before or during "Measurement Period" AND NOT "Occurrence of Diagnosis, Active: Emphysema" ends before start of "Measurement Period“)OR ("Occurrence of Diagnosis, Active: Cystic Fibrosis" starts before or during "Measurement Period" AND NOT "Occurrence of Diagnosis, Active: Cystic Fibrosis" ends before start of "Measurement Period“)OR ("Occurrence of Diagnosis, Active: Acute Respiratory Failure" starts before or during "Measurement Period" AND NOT "Occurrence of Diagnosis, Active: Acute Respiratory Failure" ends before start of "Measurement Period“)

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Value Sets: Analytics “Roll-ups”

Preferred Asthma Therapy Medication Codes

Clinical Vocabulary

Code Medication

RXNORM 966536100 ACTUAT Beclomethasone Dipropionate 0.04 MG/ACTUAT Metered Dose Inhaler

RXNORM 746336 100 ACTUAT Cromolyn Sodium 5.2 MG/ACTUAT Nasal Inhaler

RXNORM 828927 100 ACTUAT flunisolide 0.25 MG/ACTUAT Metered Dose Inhaler

RXNORM 1085795 100 ACTUAT Triamcinolone Acetonide 0.055 MG/ACTUAT Nasal Inhaler

RXNORM 897296 104 ACTUAT Nedocromil Sodium 1.75 MG/ACTUAT Metered Dose Inhaler

RXNORM 434226 12 HR Aminophylline 225 MG Extended Release Tablet

RXNORM 730834 12 HR zileuton 600 MG Extended Release Tablet

RXNORM 1248840120 ACTUAT Beclomethasone Dipropionate 0.08 MG/ACTUAT Nasal Inhaler

RXNORM 966675120 ACTUAT Beclomethasone Dipropionate 0.084 MG/ACTUAT Metered Dose Inhaler

RXNORM 746821 120 ACTUAT Budesonide 0.032 MG/ACTUAT Nasal Inhaler

RXNORM 1246288120 ACTUAT Budesonide 0.08 MG/ACTUAT / formoterol fumarate 0.0045 MG/ACTUAT Metered Dose Inhaler

RXNORM 966522 120 ACTUAT Budesonide 0.16 MG/ACTUAT Dry Powder Inhaler

RXNORM 1245276 120 ACTUAT flunisolide 0.078 MG/ACTUAT Metered Dose Inhaler

RXNORM 895994120 ACTUAT Fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler

RXNORM 896236120 ACTUAT Fluticasone propionate 0.045 MG/ACTUAT / salmeterol 0.021 MG/ACTUAT Metered Dose Inhaler

RXNORM 746199 120 ACTUAT mometasone furoate 0.05 MG/ACTUAT Nasal Inhaler

RXNORM 746803 120 ACTUAT mometasone furoate 0.2 MG/ACTUAT Dry Powder Inhaler

Persistent Asthma Diagnosis Codes

Clinical Vocabulary

Code Diagnosis

SNOMEDCT 426979002 Mild persistent asthma (disorder)

SNOMEDCT 427295004Moderate persistent asthma (disorder)

SNOMEDCT52810001241

03 Persistent asthma (disorder)

SNOMEDCT 426656000Severe persistent asthma (disorder)

ICD10CM J45.31Mild persistent asthma with (acute) exacerbation

ICD10CM J45.32Mild persistent asthma with status asthmaticus

ICD10CM J45.30Mild persistent asthma, uncomplicated

ICD10CM J45.41Moderate persistent asthma with (acute) exacerbation

ICD10CM J45.42Moderate persistent asthma with status asthmaticus

ICD10CM J45.40Moderate persistent asthma, uncomplicated

ICD10CM J45.51Severe persistent asthma with (acute) exacerbation

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Features in CQR

Customize Your Dashboard

© 2015 General Electric Company. All rights reserved. GE confidential and proprietary.

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Provider Performance at a Glance…


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Measure Logic at Your Fingertips…


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Workflows & Best Practices

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Transparency: Drill Down for All Data Elements


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Configuration: Control User Access


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Configuration: Customize Your Organization Structure


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Configuration: Customize a Provider’s Measures


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Visualizing End to End Data Flow

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Visualizing End-to-end Data Flow

• Capture data in the EMR

• Submit data to CQR

• Review CQR dashboard data

• Create reports on clinical quality measures for submission to CMS

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Calculate Now & Insight Tab: Drill Down into a Provider’s Data


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Transparency: Measure calculations


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Transparency: Data Types & Patient Events


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Transparency: Data ingestion


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Standardization & Increasing Granularity: ‘Seen By’

MU Functional Measures

Document Type

E&M Service Order

SNOMED-CT Order

Clinical Quality Measures

E&M Service Order

SNOMED-CT Order

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Monitoring Progress Towards Quality and Measurement Goals with CQR

Use CQR for reporting and participation in federal programs:

• PQRS

• Meaningful Use

Use CQR to automate the measurement process from extraction to visualization and submission of measure data to CMS.

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Overview of Essential CQR Tasks

• Manage providers

• Create and run reports

• View CQR dashboards

• Create and download QRDA I and III documents (QRDA I is being phased out)

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Questions?

Thank You for Joining Us

For further information:Brian Martin, MD

[email protected]

Continuous Quality Improvement Using Clinical Quality Reporting Brian Martin, MD, Director, Medical Informatics, GE Healthcare IT/CBS Nancy Munoz, Senior.

Documents

meaningful use functionality

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