Public Health IT Quality Reporting This material (Comp 13_Unit 9) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1 U 24 OC 000003.
Quality Reporting Learning Objectives 1. 2. 3. 4. 5. 6. Identify/describe important characteristics and components of useful health care quality measurement systems Identify the past and present efforts to transform medical practice through pay-for-performance initiatives Identify national group efforts involved in the establishment of quality standards/metrics (NCQA, NQF, etc. ) based upon claims and EHR data Describe how quality metrics are integrated, tracked, and used in EHRs and describe real-world implementations in e. Clinical. Works, EPIC, Next. Gen Describe the use of EHR-based quality metrics in pay-for-performance incentive projects Summarize the preliminary findings/conclusions from the EHR pay-forperformance project and possible future directions Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 2
Health Systems and Quality of Care • How do you quantify the ‘goodness’ in health care? Structure Process Outcomes • • • Services • Diagnostic Tests • Documentation • Life Expectancy • Health • Patient Experiences • Costs Infrastructure Staffing Facilities Policies • “Every system is perfectly designed to achieve exactly the results it gets. ” – Avedis Donabedian Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 3
Principles for Quality Measure Development Relevance/Meaningfulness • How many people does the measure impact? • How much health benefit could be achieved? Scientific Evidence • How strong is the association between the intervention/clinical service and health benefit? Feasibility • Does the burden of data collection exceed the benefit of measurement? • Are the available data reliable and validate for assessing this indicator? Usability • How broadly is this measure adopted by health care professionals or settings? Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 4
Reasons to Measure Quality Improving Quality of Care Process • Underuse (e. g. Chlamydia screening) • Overuse (e. g. antibiotic prescriptions) • Misuse (e. g. medications to avoid in the elderly) Informing Purchasers/Consumers Comparison of providers or organizations with regional or national averages Ranking of providers or organization Improving Value of Care Access & utilization (e. g. well child visits, hospital stays) Efficiency (e. g. cost per diabetic to control A 1 c) Payment (e. g. pay-forperformance) Outcomes (e. g. control of blood pressure) Safety Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 5
Health Care Quality Measurement in Use by the Health Care Industry Resources for Validated Performance Measures Types of Measures Ambulatory Quality Alliance (AQA) • Physician and other Clinician Performance • Acute/ Chronic Care • Surgery/ Procedures Joint Commission on Accreditation of health care Organizations (JCAHO) • Hospital Accreditation and Certification • Patient Safety National Committee for Quality Assurance (NCQA) • Health care Effectiveness Data and Information Set (HEDIS) • Health Care Organization Accreditation • Provider Recognition Programs National Quality Forum (NQF) • Patient and Family Engagement • Population Health • Safety National Quality Measures Clearinghouse sponsored by the Agency for health care Research and Quality (AHRQ) Resource for clinical practice guidelines for • health care providers --integrated delivery systems • health plans --purchasers Table 1. 1 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting • Consumer Assessment of Health Providers Survey (CAHPS®) - Clinician and Group Survey • Cost of Care • Care Coordination • Palliative and End-of-Life Care • Overuse 6
Data Sources • How reliable are these data sources for the different types of measurement? Administrative data sources • Operations (call logs, wait times, complaints) • Claims (payment for services rendered) • Diagnostics (labs, imaging) Clinical information (chart review, electronic health records) Surveys (patient perception/experiences) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 7
Using EHRs for Automated Quality Reporting • EHR users document patient data into EHR • Patient data are aggregated & formatted into standardized quality measures & transmitted to NYC health department • Some EHR users have systems that aggregate patient data into a standardized format • Others require another entity/software program to aggregate data prior to transmitting to NYC health department (Shih, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 8
Quality Measures in Data Warehouse Example: Smoking (Shih, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 9
Caveat • Having electronic medical records doesnt mean quality reporting accurately reflects practice performance – Example: Majority of smoking status and smoking cessation intervention not captured for automated quality measure reporting Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 10
Distribution of Documentation Smoking Status & Cessation Intervention Population 2854 Smoking Status Recorded Denominator Loss Yes 2435 No 419 Current Smoker 297 Non. Smoker 2138 Smart Form 178 Cessation Intervention Given Yes 57 Correctly Documente d 55 Other 119 Cessation Intervention Given No 121 Incorrectly Documente None given d 58 2 Yes 21 Numerator Loss Patient Refused 63 Smart Form 1055 Correctly Documente d 2 Other 1083 No 98 Incorrectly Documente d 19 None given 65 Patient Refused 33 Chart 1. 1 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 11
“The Quality World is Flat” • For the past 3 years, no statistically significant increase in quality measures: • 57% Commercially insured • 64% Medicaid insured • 86% Medicare insured Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 12
Pay for Performance Design Considerations: Avoiding Unintended Consequences Barriers in Payment Strategies Re-alignment with Clinical Goals Treat patients that are easily compliant Pay more for harder to treat patients Too many indicators and requests for patient information Focus on with the largest impact on lives and costs Rewards typically go to “Top Performers” only Reward all efforts Unclear what is being paid for Transparent and easy to understand payment methods Reward amounts not commensurate with effort Incentive amount must be meaningful Table 1. 2 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 13
Pay for Performance Design Considerations: What Should a Program Pay For? Increasing Difficulty in Achievement Examples Pros Cons Participation Data submission Data reporting Data collection Attestation Encourages all to participate; provides a good starting point Does not distinguish the best from the average or low performers Achievement of a specific goal or benchmark 80% of hypertensive patients have blood pressure measured <140/90 Clear standard for passing, drives improvement Threshold can be too high, making achievement seem impossible for some providers or practices Top tier Score or performance is in the top 10 th percentile among peers or comparison providers Creates competition to be the best Rewards fewer participants and only those that have exceptional achievement “zero defects” meet multiple goals; patient achieves all recommended clinical guidelines Patient with diabetes have met all goals: eye exam, foot exam, nephropathy test, LDL test &control, BP control, smoking cessation intervention, and A 1 c test &control Assurance of meeting a very high standard, drives improvement Can be discouraging to providers as achievement is difficult and potentially not feasible for a large proportion of patient population Table 1. 3 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 14
NYC Health e. Hearts Rewards • Payment that rewards disease prevention and effective chronic disease management • $6 M Grant from Robin Hood Fund • Aggregated data from EHR serves as basis for rewards and recognition • Prevention as a top priority – Focus on an area with maximum potential for saving lives (cardiovascular health) • Reduce disparities • Incentive amounts are meaningful – Pay on ALL eligible patients – Higher rewards for harder to treat patients Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 15
Quality Measures for Rewards – The “ABCS” Aspirin Therapy Ages 18 years or older with Ischemic Vascular Disease or ages 40 years or older with Diabetes on aspirin or another anti-thrombotic therapy Patients 18 -75 years of age with Hypertension, without Ischemic Vascular Disease or Diabetes who have a BP < 140/90 Blood Pressure Control Cholesterol Control Smoking Cessation Patients 18 -75 years of age with a diagnosis of Diabetes AND Hypertension with the most recent BP below 130 systolic and 80 diastolic Patients 18 -75 years of age with a diagnosis of Ischemic Vascular Disease AND Hypertension without Diabetes with a BP below 140 systolic and 90 diastolic Male patients >= 35 years of age and female patients >=45 years of age without Ischemic Vascular Disease or Diabetes who have a total cholesterol < 240 or LDL < 160 measured in the past 5 years Patients 18 -75 years of age with a diagnosis of Ischemic Vascular Disease or Diabetes and Lipoid disorder who had a LDL < 100 in the past 12 months Patients ages 18 years or older identified as current smokers who received cessation interventions or counseling Table 1. 4 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 16
Health e. Hearts Payment Per Patient Measures ( ABCS ) Medicaid or Un-Insured Commercial, Medicare, or Other Insurance Antithrombotic Therapy $20 BP Control General Population $40 $20 BP Control High Risk Population $80 $40 Cholesterol Control Gen Pop $40 $20 Cholesterol Control High Risk $80 $40 Smoking Cessation Intervention $20 Table 1. 5 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 17
Sample Provider Quality Reports From Health e. Hearts (NYCDOH, 2010. ) Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 18
Health e. Hearts Year 1 Results • Practices with incentives showed improved quality measure scores over 1 year on 2 of the 4 measures – (Aspirin Therapy and Blood Pressure Control) • Practices earned an average of $12, 000 in 1 year • Providers requested comparisons to citywide quality performance averages • Providers requested additional instructions on how to identify patients that did not meet targets Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 19
Health e. Hearts Year 2 Results • After receiving financial rewards in year 1, will staff and providers will be more attuned to meeting quality measures? • A new cohort of providers was recruited-half randomized to financial incentives • Same program design of quarterly report cards and payment schedule Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 20
Measures in Achieve Meaningful Use 2011 Measures (July 2010 Final HITECH) Maintain active medication list for more than 80% of patients that have at least one entry recorded as structured data Maintain active medication allergy list for more than 80% of patients that have at least one entry recorded as structured data Record smoking status for patients 13 years of age or older for more than 50% of patients 13 years of age or older that have smoking status recorded as structured data Diabetics Hgb A 1 c <8% Hypertension: Blood pressure measurement Ischemic Vascular Disease Patients with LDL under control Adult Weight Screening and Follow-up Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention Colorectal cancer screenings Breast cancer screenings Ischemic Vascular Disease Patients on aspirin prophylaxis Preventive Care and Screening: Influenza Immunization for patients 50 years old or older Pneumonia Vaccination for older adults. Table 1. 6 Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 21
Quality Reporting Summary • Important characteristics and componets of health care quality measurement systems • Measures to achieve meaningful use • e. Hearts payment systems example • “ABC” of quality measures for rewards Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 22
Quality Reporting References: 1. Brown, L. , Franco, L. M. , Rafeh, N. Quality assurance of health care in developing countries. Retrieved on October 1 st, 2010 from http: //pdf. usaid. gov/pdf_docs/Pnabq 044. pdf 2. Donabedian, A. Evaluating the Quality of Medical. 1966 (reprinted in Milbank Quarterly, 2005, visit: http: //www. milbank. org/quarterly/830416 donabedian. pdf) 3. Retrieved on October 1 st, 2010 from What is evidence based medicine? http: //www. cebm. net/index. aspx? o=1914 4. Desirable Attributes of HEDIS. Retrieved on October 1 st, 2010 from Desirable http: //www. ncqa. org/tabid/415/Default. aspx 5. NQF Measures Evaluation Criteria. Retrieved on October 1 st, 2010 from Desirable http: //www. qualityforum. org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria. aspx 6. Lee TH. (2007). Eulogy for a Quality Measure. N Engl J Med 357: 1175 -1177 7. Retrieved on October 1 st, 2010 from http: //www. ncqa. org. 8. Retrieved on October 1 st, 2010 from http: //www. nqf. org. 9. Retrieved on October 1 st, 2010 from http: //www. aqaalliance. org. 10. Retrieved on October 1 st, 2010 from http: //www. cms. gov/EHRIncentive. Programs/Downloads/EHR_Incentive_Program_Agency_Training_v 8 -20. pdf 11. Retrieved on October 1 st, 2010 from http: //www. mnmc. org. 12. Retrieved on October 1 st, 2010 from http: //www. iha. org. 13. Retrieved on October 1 st, 2010 from http: //www. mhqp. org. 14. AHRQ Resources on Pay for Performance (P 4 P): A Decision Guide for Purchasers, by R. Adams Dudley and Meredith B. Rosenthal. (Final Contract Report) Rockville, MD: Agency for health care Research and Quality, 2006. AHRQ Pub. No. 06 -0047. Retrieved on October 1 st, 2010 from http: //www. ahrq. gov/qual/p 4 pguide. htm 15. Retrieved on October 1 st, 2010 from PCIP http: //www. nyc. gov/html/doh/html/pcip. shtml Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 23
Quality Reporting References Charts, Tables, Figures: 1. 1 Table: Shih, S. (2010). Health care quality measurement in use by the health care industry. Primary Care Information Center, New York Department of Health and Mental Hygiene. 1. 1 Chart: Shih, S. (2010). Distribution of documentation smoking cessation status & cessation intervention. Primary Care Information Center, New York Department of Health and Mental Hygiene. 1. 2 Table: Shih, S. (2010). Pay for performance design considerations: avoiding unintended consequences. Primary Care Information Center, New York Department of Health and Mental Hygiene. 1. 3 Table: Shih, S. (2010). Pay for performance design considerations: What Should a Program Pay For? Primary Care Information Center, New York Department of Health and Mental Hygiene. 1. 4 Table: Shih, S. (2010). Quality measures for rewards “The ABC’s”. Primary Care Information Center, New York Department of Health and Mental Hygiene. 1. 5 Table: Retrieved on October 1 st, 2010 from http: //www. cms. gov/EHRIncentive. Programs/Downloads/EHR_Incentive_Program_Agency_Training_v 8 -20. pdf 1. 6 Table: NQF Measures Evaluation Criteria. Retrieved on October 1 st, 2010 from http: //www. qualityforum. org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria Images: Slide 8 : Shih, S. (2010). Using EHRs for automated quality reporting. Primary Care Information Center, New York Department of Health and Mental Hygiene. Slide 9: Shih, S. (2010). Quality measures in data warehouse. Primary Care Information Center, New York Department of Health and Mental Hygiene. Slide 18: Shih, S. (2010). Sample provider quality reports from health e. Hearts. Primary Care Information Center, New York Department of Health and Mental Hygiene. Health IT Workforce Curriculum Version 3. 0/Spring 2012 Public Health IT Quality Reporting 24
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