PCP POD Meeting January 5, 2017 1 Agenda Call to order Richard - - PowerPoint PPT Presentation
PCP POD Meeting January 5, 2017 1 Agenda Call to order Richard Gough, MD Quality Reporting Timeline Shelley Grant 2017 MSSP Quality Measures Richard Gough, MD Johnson Koilpillai, MD CY2016 Performance Results Richard Gough, MD
Richard Gough, MD
Shelley Grant
Richard Gough, MD Johnson Koilpillai, MD
Richard Gough, MD Johnson Koilpillai, MD
Richard Gough, MD
Richard Gough, MD
and Sleep Medicine
Services
Pulmonology
Hematology Associates
Advanced Cardiology
Hagerstown
Total Points Earned Per Domain Total Possible Points Per Domain = Overall Domain Score Overall Domain Scores are averaged and divided by number of domains (4) to determine overall quality performance score – affects shared savings rate!
Both Attainment and Improvement in performance is taken into account when calculating our final sharing rate. Rewarded up to 4 additional points in each domain, if we demonstrate quality improvement. Not to exceed the maximum points per domain
2013, 2014, and 2015)
and 2015)
CAHPS (2012, 2013, 2014, and 2015)
through the EHR Incentive Program (2013 and 2014)
eligible for shared savings)
must score above the minimum attainment level on at least one measure in each domain.
avoid compliance action)
measures in a domain or CMS will take compliance action. Previously ‐ achieve 70% on performance measures only
1. Sit at eye level when talking to patients, do not interrupt 2. Acknowledge concerns and emotions verbally ‐
“Let’s talk more about your concerns/fears”, “Let’s write down the next steps for you and your family”, “If you have questions please do not hesitate to call the office”
3. Reference information from the last visit and history Demonstrating communication between providers 4. Ask the patient to repeat instructions – teach back approach
ALL Providers (PCP & Specialists)
effective
Numerator Denominator Comments EHR Documentation Medication reconciliation conducted by a physician, prescribing practitioner, registered nurse, or clinical pharmacist on
discharge
**medication reconciliation is defined as a review of the discharge medication list with the most recent medication list in the outpatient record
All discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years
within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on‐going care.
denominator is based on discharges followed by an
patients – patients may appear in the denominator more than once if there was more than one discharge in the reporting period
Medication Module for quality reporting – check box for medications “reconciled” or “verified”
Numerator Denominator Comments EHR Documentation Patients who were screened for future fall risk at least once within the measurement period
Future Fall Risk Definition ‐ if patient has had 2 or more falls in the past year or any fall with injury in the past year A specific screening tool is not required for this measure, however potential screening tools include the Morse Fall Scale and the timed Get‐Up‐&‐ Go test.
Patients aged 65 years and older with a visit during the measurement period
documentation of medical reason for not screening (e.g. patient is not ambulatory) NG ‐ Health Promotion Plan Fall Risk panel OR Social History Lifestyle (Home Environment/Safety eCW ‐ Preventive Medicine> Screening/Special Tests> Fall Risk Screening OR Medicare Preventative Screening Questionnaire
Numerator Denominator Comments EHR Documentation Patients who received an imaging study (e.g. plain x‐ray, MRI, CT Scan) conducted on the episode start date or in the 28 days following. All patients 18 ‐50 years of age who had an outpatient or ER encounter with a principal diagnosis of low back pain during the start of the measurement period through 28 days prior to the end of the measurement period.
patients with a low back pain diagnosis during the 180 days prior; patients with cancer; recent trauma, intravenous drug abuse, neurological impairment
via claims.
as inverted measure (i.e. higher percentage indicates appropriate treatment (proportion for whom imaging studies didn’t
minutes or less
Numerator Denominator Comments EHR Documentation Patients who received an influenza immunization or who reported previous receipt of an influenza immunization
**Previous Receipt Definition – receipt of the current seasons influenza immunization from another provider OR from the same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza given since August 1)
Patients 6 months and older seen for at least two visits or at least one preventative visit during the measurement period between October 1 and March 31 (i.e. For 2017, October 1, 2016 to March 31, 2017)
documentation of medical reason for not receiving (e.g. allergy); documentation of patient reason for not receiving (e.g. refused); documentation of system reason (e.g. vaccine not available) NG ‐ Orders Module Immunization tab New Order or Historical eCW ‐ Immunization >Add>Select
some other provider during flu season, click Vaccination Given in the past “Y”
Numerator Denominator Comments EHR Documentation Patients 65 years of age and older who have ever received a pneumococcal vaccination Patients 65 years of age and older with a visit during the measurement year
NG ‐ Orders Module Immunization tab New Order or Historical eCW - Immunization‐ Add>Select
given in the past then click “Y” and enter the past date
Numerator Denominator Comments EHR Documentation Patients with a documented BMI during the visit or during the previous 6 months, AND when the BMI is outside of normal, a follow‐up plan is documented.
** Normal Parameters
> 23 and <30 kg/m2
and < 25 kg/m2 **Follow‐up Plan – includes education; referral to RD, PT, OT, PCP; diet; exercise; or pharmacological
Patients 18 years of age and older with at least one visit during the measurement period
pregnancy, palliative care, emergent medical situation, patient refuses
NG ‐ Intake Vitals panel Navigation Pane ACO Health Promotion Plan Health Promotion Plan PanelBMI Plan eCW ‐ Capture BMI in Vital section. If BMI is Outside normal parameters, document a follow up in: Social Hx> Counselling> BMI Follow‐Up Plan
Numerator Denominator Comments EHR Documentation Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.
**Tobacco Use – Includes any type of tobacco **Cessation Intervention – Includes brief counseling ( 3 minutes or less) and/or pharmacotherapy
Patients 18 years and
two visits or at least
during the measurement period
documentation of medical reason (e.g. limited life expectancy) NG ‐ Tobacco use: Histories TabSocial HistoryTobacco Tobacco Use Panel (or Screening Summary Tobacco Usage Tobacco Use Panel) eCW ‐ Use “Tobacco Control” Smart Form to identify if Patient is a Tobacco User. If yes, perform Cessation counseling: Social Hx> Counselling> Smoking Education
Numerator Denominator Comments EHR Documentation Patients screened for depression on the date of the visit using an age appropriate standardized tool AND if positive, a follow‐up plan is documented on the same date.
**Follow‐up plan must include
additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions,
Patients aged 12 years and older before the beginning
year with at least one visit during the measurement year.
Patients with an active diagnosis for Depression or Bi‐polar Disorder
Patient refuses; emergent medical situation; functional capacity
improve may impact accuracy (e.g. court appointed cases or cases of delirium)
NG ‐ Screening: Navigation Pane ACO PHQ2PHQ9 Follow‐up plan: Navigation Pane ACO Health Promotion Plan Depression Plan Diagnosis + Follow up plan eCW ‐ Perform Depression screening using PHQ2 and / or PHQ9 Smart Forms. If patient is Positive, then document Follow Up plan: Social History>Counselling>Foll
Numerator Denominator Comments EHR Documentation Patients with one or more screenings for colorectal cancer
(FOBT) during the measurement period
during the measurement period or 4 years prior
measurement period or 9 years prior
ColoGuard) during the measurement year or 2 years prior
virtual colonoscopy during the measurement year or 4 years prior
Patients 50 – 75 years of age with a visit during the measurement period
Patients with a diagnosis or total colectomy or colorectal cancer
none NG ‐ Care GuidelinesHealth Maintenance Clinical Guidelines PanelClinical Guidelines updateLast addressed date eCW ‐ Treatment>DI> Order Colonoscopy, or a Flexible Sigmoidoscopy: Once the report is received, check the box “received”
Numerator Denominator Comments EHR Documentation Women 50 ‐ 75 years
mammogram to screen for breast cancer within 27 months prior to the end of the measurement period (i.e. October 1, 2015 ‐ December 31, 2017) Women 50 – 75 years
during the measurement year
bilateral mastectomy or evidence of two unilateral mastectomies
none NG ‐ Care GuidelinesHealth MaintenanceClinical Guidelines PanelClinical Guidelines updateLast addressed date eCW ‐ Treatment>DI> Oder Mammogram: Once the report is received, check the box “received”
Numerator Denominator Comments EHR Documentation Patients who are statin therapy users during the measurement period
to receive statin therapy at any point during the measurement year Three Criteria: Patients aged >21 years with a DX of ASCVD; OR Patients aged >21 years who ever had a LDL‐C >190 mg/dL; OR Patients aged 40‐75 years with Type 1 or 2 diabetes and with an LDL‐C of 70‐189 md/dL recorded during the measurement year or 2 years prior.
Patients with adverse effect, allergy, or intolerance to statins; palliative care; active liver disease; ESRD Medication module Problem module
Numerator Denominator Comments EHR Documentation Patients who achieved remission at twelve months as demonstrated by a twelve months (+/‐ 30 days) PHQ‐9 score less than 5. Patients 18 years and
initial PHQ‐9 score >9 during an outpatient encounter.
hospice or palliative care, permanent nursing home residents, diagnosis of bipolar or personality disorder NG ‐ Problems ModuleProblem Status Screening: Navigation Pane ACO PHQ9 eCW ‐ Smart Form‐ PHQ 9‐ Score less than 5
Numerator Denominator Comments EHR Documentation Patients whose most recent HbA1c level (performed during the measurement period) is >9.0% or not reported Patients 18 – 75 years
with a visit during the measurement period
BOTH ACO 27 & 41 MUST be met to get credit for these measures “all or nothing” NG ‐ Order Module Order SummaryLabs New Order eCW ‐ Order a Hemoglobin A1C and result it: Note: For HgbA1c, value needs to be entered and “received” box needs to be checked to get the credit. This is if Result doesn’t come through interface.
Numerator Denominator Comments EHR Documentation Patients with one of the following eye screenings: a retinal
in the measurement period, or a negative retinal exam (no evidence of retinopathy) in the year prior to the measurement period. Patients 18 – 75 years
with a visit during the measurement period
eye exam must be performed by an
BOTH ACO 27 & 41 MUST be met to get credit for these measures “all or nothing” NG ‐ Navigation Pane ACO Care Guideline Clinical Guidelines panel Clinical Guideline Update eCW – Examination>ophthal mology>ophthalmolo gy>diabetic eye exam>diabetic retinopathy screening
Numerator Denominator Comments EHR Documentation Patients whose blood pressure at the most recent visit is adequately controlled during the measurement period
**Adequately controlled – SBP <140 mmHg and DBP <90 mmHg
Patients 18 – 85 years
diagnosis of essential hypertension within the first 6 months of the measurement period or any time prior to the measurement period
dialysis or renal transplant before
measurement period, and pregnancy
NG ‐ Intake Vital signs eCW ‐ Capture BP in the Vitals section
Numerator Denominator Comments EHR Documentation Patients who have documentation of use
antithrombotic therapy during the measurement year Patients 18 years of age and older with a visit during the measurement year, and an active dx of ischemic vascular disease (IVD) or who were d/c’d alive for acute myocardial infarctions (AMI), coronary artery bypass graft (CABG)
coronary interventions (PCI) in the past 12 months prior to the measurement year
NG ‐ Medication module Problem module eCW ‐ Document the use of Aspirin or Antithrombotic in the current medications list
feedback reports from FIHN
available, or other internal reports
Depression)
Measure NextGen eClinicalWorks
Falls: Screening for Future Fall Risk (min goal= 25.26%) P 60% 61% Breast Cancer Screening (min goal= 30%) R 51% 15% Colorectal Cancer Screening (min goal = 30%) R 41% 6% Heart Failure: Beta‐Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) *Need HF Dx AND LVEF<40%/systolic dysfunction recorded to avoid skips R 366 Not Counted *LVEF not recorded or >40% 113 Not Counted *LVEF not recorded or >40% Depression Remission at 12 months (min goal not yet set) R 6% 0% Diabetes Composite Measure (HbA1C >9% / Retinal Exam) (min goal= 27.81%) P 30% / 11.6% 63% / 6% *only X’Cel recording retinal exam in structured data field
Practice Fall Risk Screening Depression Screening Influenza Immunization Pneumococcal Immunization Diabetes Composite (HbA1c<=9/Retinal Exam Sajjad Aziz, MD 44.8% 46.9% 70.0% 73.9% 29.5% / 0.0% Syed Haque, MD 70.2% 82.5% 44.2% 74.6% 39.7% / 0.0% Primary Medical Services, PC, Dr. Zaidi 56.4% 55.1% 44.0% 58.2% 66.9% / 0.0% X’Cel Primary Care 77.1% 0.0% 44.7% 74.1% 7.6% / 19.1% MHP Internal Medicine Associates 80.5% 62.3% 52.0% 67.4% 74.5% / 17.4% Middletown Valley Family Medicine 66.5% 47.6% 55.0% 86.6% 74.0% / 32.7% Parkview Medical Group 48.1% 24.7% 24.0% 72.0% 67.4% / 6.2% Sibte Kazmi, MD LLC 52.1% 8.9% 26.3% 32.4% 70.1% / 6.6% Union Bridge Family Practice 78.9% 59.9% 37.1% 83.7% 73.5% / 6.1%