Clinical Quality Measure Reporting in Practice Fusion

Presented By:Emily Richmond, MPHSenior Manager, Health Care Quality

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+Clinical quality measures, also called CQMs, are tools that help us measure and monitor the quality of healthcare and the contribution of those healthcare services towards improved health outcomes.

Clinical Quality Measures & Quality Improvement

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"If you cannot measure it, you cannot improve it."

Lord Kelvin (1824-1907)

CQM Terminology• The population of patients or encounters for which

the measure applies. Denominator

• The population of patients from the denominator who meet the measure specified clinical requirements or the population of encounters from the denominator where the measure specific requirement has been performed.

Numerator

• Specifications that would remove a patient from the denominator of a specific quality measure.

• Includes certain diagnoses that make it clinically unnecessary for the patient to receive the numerator clinical action and/or provider or patient determined reasons for refusing certain clinical actions.

Exclusions & Exceptions

• This refers to the time frame for which the CQMs will be calculated (usually one year). Measurement period

Quality Measurement Development Process

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Groups of Value Sets make up the criteria for the denominator and

numerator

Coded values that make up Value Sets

Value sets are used to create measure logic

+ Manual reporting during attestation Provider will type in values from the CQM report exactly as they

appear in the EHR at the end of your 90-day reporting period Zero values (0/0) are acceptable and will not prevent you from

achieving Meaningful Use

+ Electronic reporting at the end of the calendar year Reporting period will be a full calendar year (January 1, 2014 –

December 31, 2014) Practice Fusion will report data in January 2015 on your behalf for

providers who request this. Your MU attestation payment will be delayed until after your CQM values are reported to CMS.

May qualify for PQRS reporting as well if all measures meet PQRS reporting requirements.

Reporting CQMs for Meaningful Use

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Requirement: Report at least 9 measures covering at least 3 of the NQS domains.

+ Practice Fusion will act as an EHR Data Submission Vendor, which means we will submit PQRS measures to CMS on behalf of our providers who wish to participate in PQRS via the EHR reporting mechanism.

+ PQRS reporting for the EHR reporting mechanism will occur between January-February 2015 since the PQRS measurement period runs from January 1, 2014-December 31, 2014.

Practice Fusion and PQRS EHR Reporting

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• In order to use the EHR reporting option for PQRS, a provider must report on at least 1 measure for which there is Medicare patient data.

• The PQRS measurement period length is a full calendar year, so for 2014 it would run from January 1, 2014 through December 31, 2014.

• Providers who submit CQMs via Meaningful Use attestation can still use Practice Fusion for the purposes of 2014 PQRS reporting in January 2015.

• PF will begin accepting requests for QRDA electronic submission of CQM data for both PQRS and Meaningful Use in the Fall of 2014.

Reporting for PQRS using the EHR Reporting

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Requirement: Report at least 9 measures covering at least 3 of the NQS domains. EHR CQMs must be the most recent measure versions available from CMS.

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+ Practice Fusion currently has 13 certified MU/PQRS electronic clinical quality measures (eCQMs) in the EHR.

+ Later this summer, we will be certifying an additional set up 10-12 eCQMs that will give PF providers more options when choosing the 9 measures to report for MU/PQRS.

Practice Fusion CQMs

Measure # TitleCMS165v2 Controlling High Blood PressureCMS156v2 Use of High-Risk Medications in the ElderlyCMS138v2 Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCMS130v2 Colorectal Cancer ScreeningCMS166v3 Use of Imaging Studies for Low Back PainCMS131v2 Diabetes: Eye ExamCMS123v2 Diabetes: Foot ExamCMS122v2 Diabetes: Hemoglobin A1c Poor Control

CMS2v3 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

CMS68v3 Documentation of Current Medications in the Medical RecordCMS69v2 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpCMS50v2 Closing the referral loop: receipt of specialist reportCMS90v3 Functional status assessment for complex chronic conditions

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+ To support future CQM additions and the entry of structured patient data in the EHR, Practice Fusion recently added over 4500 new data elements to the Screenings/Interventions/Assessments section of the new chart note.

New Data Elements in Practice Fusion

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+Screenings+Assessments+ Interventions+Procedures

+Diagnostic Studies+Documentation of

ordered or delivered follow-up care

What types of data can be recorded?

Specialties that new elements are most applicable to:Pediatrics

Primary careGeneral medicine/Internal medicine

OBGYNCardiologyNeurology

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+Breast cancer screenings Screening mammography Diagnostic mammography Breast mammogram screening Right mammogram screening Bilateral mammogram screening Breast mammogram spot Breast mammogram grid

Screenings

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+ Falls risk assessment+ Assessment and interpretation of higher cerebral function,

cognitive testing+ Psychologic cognitive testing and assessment + Other cognitive assessments

BIMS summary score SLUMS, IQCODE, AD8, MoCA, BOMC

+ Pain assessments Wong-Baker FACES Visual analog scale Numeric severity scale General pain severity assessment

Assessments

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+Ordered, completed, or current palliative care+Ordered, completed, or current hospice care+Coronary artery bypass graft interventions+Percutaneous coronary interventions+OBGYN specific procedures

Cesarean delivery, vaginal delivery, etc. Routine obstetric care Mastectomy

Interventions & Procedures

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+X-rays (all areas of the body)+MRI angiograms (w/ and w/o contracts)+EKG Study+Left ventricular Ejection fraction

By US, US 2D, MRI, 2D echo and cardiac angiogram

+Gestational age+Fetal measurements

Heart, head, limb, etc.

Diagnostic studies

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+Alcohol abuse prevention education+Counseling about alcohol consumption+Referral to community drug & alcohol team and

alcoholism rehabilitation+Lifestyle education about hypertension+Weight and nutrition counseling and follow-up

care Exercise education, obesity diet education Prescribed exercise therapy Referral to physical activity program Recommendation to change food and drink intake

Follow-up care & Lifestyle interventions

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+Recording structured data in the EHR when possible allows that data to be used to improve patient care and to monitor quality improvement. Structured data is easier to share using health

information exchange and can be incorporated into other EHR systems

eCQMs use structured data to report on quality improvement metrics for you to monitor and to use for quality reporting programs like Meaningful Use and PQRS

Using the EHR for Quality Improvement

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For more slide presentations, videos, and resources on clinical quality measures and Practice Fusion go to:

http://www.practicefusion.com/blog/resources-and-faqs-on-cqms-and-pqrs-2014

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To sign up for a FREE EHR go to:www.practicefusion.com/signup

Resources