Helen Macfie, Pharm.D., FABC

For IHI Leading Population Heath Transformation – February, 2017

Integrating Data Systems to Support PIManaging the Measurement

Madness

Alignment?

THE PROBLEM• Seen one ACO, seen one

– Over 100 unique metrics– Multiple definitions for “similar

indicators”

• Moving from designated to add attributed populations

• Original “P4P” measures we knew well, these are different

– Quality gates and shared savings thresholds vary

• Impact on the front line providers

• What about overdiagnosis?

H. Gilbert “Gil” Welch, M.D.

Author of “Overdiagnosed”

Metric mania

Here’s just one example for Depression Screening “NQF 0711, 0712”:• Boeing – get credit for >18yo with dx of

depression/dysthymia if have PHQ9 within 1 month of PCP visit AND, if score >9, meet the % target for depression remission to <5 within 6 months

• NextGen ACO – get credit if hit a different target for the % screened and then % in remission at 12 months

• Integrated Healthcare Association for CA Medical Groups/IPAs – 2017 measure under discussion for % assessed within defined 4 month measurement period, no target yet

Inclusions? Exclusions?*&^%$#!

SO FAR, SO GOOD…but a caution– We achieved 100% of Quality Gate scoring for Anthem ACO in

year 1 and 2…and 100% in Vivity for both MG & hospital scores

– Both the Next Gen & Boeing ACOs are “pay for reporting” in Year 1, then it gets tougher … both in metrics and thresholds

The easy stuff

Started with a gap analysis

Type Indicator (Bold Goal) CMS IQR/VBP IHA P4P Medicare

5-StarVivity

Anthem Q-HIPAnthem ACO Aetna ACO

NG ACO (partial/33 total) *

DTE 2017 BPCICMS Core Quality

Collab 2016 (Proposed)

Measure Overlap

Notes

CLAvoidance of Abx in Adults w/Acute Bronchitis X X X 3 NQF 0058

CLACEI or ARB Tx in CAD, diabetes or LVSD (LVEF<40%) X 1 ACO-33

CL

Aspirin or other antithrombotic use in Ischemic Vascular Dz (IVD)

X X 2 NQF 0068/ACO-30

CL Blood Pressure control in HTN X X X X X 5 NQF 0018/ACO-28

CLPersistence of beta-blocker treatment after heart atack X 1 NQF 0071

CL

Beta blocker Tx for left ventricular systolic dysfxn (LVSD) in Heart Failure (HF)

X 1 ACO-31 Legend

CL Diabetes LDL X 1 Bold Goal BG

CL ODC ODC - Diabetes Care Combo X 1 Prevention PV

CL ODC Diabetes: HbA1c < 8 (BG) X (<8) X (<8) 2 Clinical CL

CL ODC Diabetes: BP < 140/90 X x 2 NQF 0061 Patient Experience PE

CL ODC Diabetes: HbA1c testing X (2 per yr) X X ( 1 per yr) 3 NQF 0057 Patient Safety PS

CL ODCDiabetes: Nephropathy Tx

and monitor'gX X X X X 5 NQF 0062 Efficiency /Resource

Use RU

CLDiabetes: HbA1c Poor control (>9)

X X X X X 5 NQF 0059/ACO-27

CL Diabetes: Retinal Eye Exam X x X 3 NQF 0055/ACO-41

CL Diabetes Care: Foot Exam X 1 NQF 0056

CLDiabetes: Nephropathy Tx and monitor'g

X X X X X 5 NQF 0062

CLAnnual Monitoring Persist ACE ARB

X X 2

CLAnnual Monitoring Persist Diuretics

X X 2

Getting granular

TOOLS TO DO THE JOB• EHR rebuild – screens, documentation

Making it easier (not easy)

Measure Definition Impact Tgt CurrentMetric

Assessment Notes

EHR Build Notes

Falls: Screening for Future Fall Risk (ACO-13) (GPRO CARE 2)

• % of patients 65 years of age and older who were screened for future fall risk during the measurement period

• Exclusions: none • Notes - may be done

with a formal screening tool, information can come from patient or other caregiver/rep

• Clarification: documentation must include an assessment for history of fall, any fall with injury, or no falls

Report only for Year 1 (2016)then P4P

82.3% TBD • Currently capturing today when patient has wellness visit.

• NextGen ACO is already built out. No customization is needed.

• Need PCPs on board be champions, as before each practice choseown PI priorities

• Epic: Need to confirm if includes ALL inpatient stays for fall risk. Build health maintenance alert.

• NextGen: no build needed

TOOLS TO DO THE JOB• Leveraging new “sit-on-top” tools - snapshots

Making it easier (not easy)

TOOLS TO DO THE JOB• Leveraging new “sit-on-top” tools – physician panel dashboards

Making it easier (not easy)

TOOLS TO DO THE JOB• Leveraging new “sit-on-top” tools– patient level drilldown

Making it easier (not easy)

TOOLS TO DO THE JOB• Understanding measure sampling and abstraction flow

Making it easier (not easy)

Creating sanity at the front line

LEVERAGING LEAN• Purpose – create an

organizational plan to develop, execute and manage the processes for improving quality measure results

• Assumption – data is valid, timely and accessible

• Pre-work: had already done the gap analysis on measures; EHR changes for documentation

Guiding Principles• Systemic thinking• Visibility of progress/

process• Single piece flow (avoiding

batches and silos)

Lean team created focus

BOUNDARIES• Process trigger –

identification of patient due to quality measure care gaps

• Ending point – patient care gaps are satisfied

• Segment – P4P Commercial and 5 Star Medicare (to start with)

Select MeasuresCommercial Value Based P4P measures:1. Diabetes Care: Medical Attention for

Nephropathy2. Breast Cancer Screening: Ages 50-743. Chlamydia Screening in Women: Ages 16-244. Childhood Immunization Status: Combo 10

(DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV Influenza)

5. Colorectal Cancer Screening: Ages 50-756. Adolescent immunizations

Medicare Stars Measures1. Diabetes Care: Medical Attention for

Nephropathy2. Breast Cancer Screening: Ages 50-743. Colorectal Cancer Screening: Ages 50-75

Voice of the customer

SURVEY SAYS• Silos and inconsistency in practice

office workflow, missed opportunities• Numerous IT platforms on which

process measure display, confusing to staff, redundant messages to patient

• Inconsistent processes for communication between centralized and decentralized teams - misses

• Some providers who don’t choose to address care gaps during visit

• Staff don’t always see value of preventative screenings

• Patient understanding/”compliance”• Access to services (ex. colonoscopy)

Vision

SHARED FUTURE STATE• Process measure care gaps are addressed every time there is a

patient touchpoint• There is clear and consistent two-way communication between

care team and patient collaborative culture of prevention• Improvement doesn’t exclusively rely on dedicated PCP time• The care gap plan is communicated to care team members

within PCP offices, specialist offices and ancillary services• Continuous and consistent patient outreach to address

preventative screening proactively throughout the year• The patient and his/her care team member understand process

care gaps, have visibility on their care plan, see the value and actively participate in following through

• Care gap services are scheduled conveniently and easily by patients

Key Change!

Redesign plan

TEAMWORKIssue OutcomeConsistent process

• Standard work developed for to address care gaps at every visit

• Improved workflows for screening needs

Follow-up • Developed role of Quality Champions – clinic staff

Staff awareness • Created Tip Sheets for front office (scheduling) and practice staff

• Education and implementation plan

Patient activation • Screening fact sheets for patients• Colorectal screening tool for patients• Developed workflows for “noncompliant” patients

Visibility • Developed consistent reporting standards• Created template and guidelines for Visibility Board

for each practice/office site, easy to update• Communication paths between centralized and

decentralized teams

Accountability • Developed tiered accountability for metrics not met

Check-ins • Quarterly meetings with PI Team and Quality Champions

Recognition • Process for reward and recognition for high performing and most improved office

Making it visible

SURVEY SAYS• Developed a template for

visibility boards that gets updated regularly

• For all clinics (MCMG) and practice sites (IPA) so they can easily track their performance on process measures

• The template includes compliance information on the measure by physician with comparison to the group/practice and the 90th

%ile benchmark

Transparency & celebration

RECOGNITION• Awards are good!

Joy at work

ENTIRE CARE TEAM