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FLEXIBLE INTELLIGENT SECURE
Clinical Quality Measures:Now and Future
MUSE InternationalGaylord National Harbor
May 28, 2013 Zahid Butt MD, FACG
© 2011 Medisolv, Inc. All Rights Reserved
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Conflict of Interest Disclosure
• Medisolv CEO – Healthcare Business Intelligence & Clinical Quality Reporting Software Vendor
• Represent myself as an Individual in this presentation
• No financial compensation
© 2011 Medisolv, Inc. All Rights Reserved
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eCQM / eMeasures Definitions
• CQM - Clinical Quality Measures
• eCQM - Electronic Clinical Quality Measures (aka..eMeasures)
• eSpecs - Electronic Specifications
• QDM - Quality Data Model
• HQMF - Health Quality Measure Format
• QRDA - Quality Reporting Data Architecture
Change is Here…………….
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The Change Agent !
“Transform this program
(Medicare) as we said time and
time again from being nothing
more than a passive payer to an
active purchaser of high quality
healthcare for Medicare
beneficiaries. We call this Value
Based Purchasing.”
Herb Kuhn
Deputy Administrator CMS
Circa 2006
Exhibit 4. Projected U.S. National Health Expenditures (NHE) by Source, 2013–2023
28% 26%26%
26%25%
24%18%
18%
18%
28%
31%
32%
0
1000
2000
3000
4000
5000
6000
2013 2018 2023
Federal government
State and localgovernment
Private employers(including "otherprivate revenue")
Households
$2.9 trillion
$4.0 trillion
$5.5 trillion
Note: GDP = gross domestic product.
Source: Estimates by Actuarial Research Corporation for The Commonwealth Fund.
NHE in $ billions
% GDP: 17.9% 18.7% 20.5%
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Quantify Value ?
Page 6
Quality
Value =
Cost (Revenue)
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Measurement Drives Triple Aim
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Quality Measures Growth
Page 9
CMS Quality Reporting Programs
Hospital Quality PhysicianQuality
“Payment Model” Quality
“Population”Quality *
IQR / OQR
ASC
Inpatient Psychiatric & PPS-Exempt Cancer
PQRS Medicare Shared Savings Program
Medicaid Adult& CHIPRA Quality Reporting
HAC / Readmission eRx Quality Reporting
Hospital Value based Purchasing (VBP)
Health Information Exchange Reporting
EHR Incentive Program - EH/CAH
EHR Incentive Program - EP
MedicarePart C & D
* Future
CMS Quality Reporting AlignmentRoadmap
2013 2014 2015 and beyond
EH/CAH - Align HVBP & IQR on Hospital Compare
- Implement EHR Reporting Pilot
- Introduce eCQM Reporting in IQR
- Transition to fully eCQM reporting in IQR and other reporting programs
EP-Individuals - Implement PQRS-EHR Incentive Pilot
- Align PQRS EHR reporting options with Stage II rules
EP- Groups - Align PQRS GPRO web interface with ACO &VBM GPRO Measure Sets
GPRO Reporting for ACO&VBM using CEHRT fulfills MU eCQM reporting
2012 Medicare EH/CAH Pilot: Participation
• 4 Hospitals submitted successfully!
• All 15 CQMs finalized in Stage 1 ruleo ED Throughput
o Stroke
o VTE
• Submission Vendor: Medisolv
2012-13 Medicare EH/CAH Pilot: Key Points
• Voluntary participation
• May continue to attest
• Requirements1. Submit 15 Stage 1 CQMs: ED, Stroke, VTE
o In 2013 CMS will accept 2014 e-Specifications
2. Patient level data
3. Medicare patients only
4. 1 full year reporting period
o Federal fiscal year (FFY) – October 1 – September 30
o Same reporting period regardless of program year participation
5. Transmission format: QRDA Category-I
6. CMS portal for data submission: QualityNet
eCQM Reporting in Meaningful UseEH & CAH
CEHRT 2011 Edition CEHRT 2014 Edition
MU Requirement One of the Core ObjectivesStage I
Incorporated in MU definitionStages I & II
Time Frame FY 2011 - 2013 From FY 2014 (October 1 2013)
Number 15 out of 15 16 out of 29. 3 NQS Domains
Specifications HITSP 1.1 and 1.2 2014 Edition eCQM (April 2013)
Certification Minimal Testing. Measure Algorithm & Logic Testing Excluded
2 Base EHR Criteria1 Criteria to Test Measure Logic in Quality Module
Method Attestation (Aggregate) Attestation (Aggregate) orEHR Incentive Pilot (QRDA)
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National Quality Strategy Domains
• Patient and Family Engagement
• Patient Safety
• Care Coordination
• Population and Public Health
• Efficient Use of Healthcare Resources
• Clinical Processes/Effectiveness
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Meaningful Use; Means to an End !
16
Data capturing
and sharing
Advanced clinical
processes
Improved outcomes
Stage 1
Stage 2
Stage 3
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MEDITECH MU eCQM Reporting Options
• MEDITECH Best Practices
• MEDITECH DR SQL Queries- IMO Integration Required for 2014 edition
• MEDITECH Alliance Partners- Medisolv (DR Supported)
- IHM
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Quality Measurement Lifecycle
Evidence
Specifications
Data Collection
Calculation
Reporting
Page 18
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VTE 1 – VTE Prophylaxis
• This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
Page 19
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VTE 1 – VTE Prophylaxis
• Patient Population Criteria- All Patients
• Denominator Data Elements- Comfort Measures- Clinical Trial - Denominator Exclusions
• Numerator Data Elements- Mechanical or Pharmacologic Prophylaxis- Contraindications- End of Surgery Date/time
Page 20
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VTE 1: Manual Abstraction Specification
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VTE 1: Manual Abstraction Specification
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VTE 1: Abstraction Worksheet Example
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VTE 1: Human Readable eSpecification
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VTE 1: Human Readable eSpecification
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VTE 1: HQMF eSpecification
VTE 1: Data Capture/CDS Workflow
Physician Admission Orders
Contraindication
Physician Order
Mechanical Prophylaxis
Pharmacologic Prophylaxis
VTE Prophylaxis
Nursing Documentation
EMAR/BMV
RXNORMSNOMED
SNOMED
Clinical Trial / Comfort Measures
SNOMED
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eCQM Future – Stage 3 and beyond
• Better “Retooled” Measures
• Develop “de novo” eCQM (CMS TEPs)- Outcomes Measures; Including Patient Reported
Outcomes
- Fill NQS Gaps; E.g. Care Coordination
- eMeasures Risk Adjustment
• Leverage CDS linked to eCQM for CQI
• ? Creation of eMeasures Incubator
• Streamline eMeasures Development Process
eMeasures Development “Ecosystem”
VSAC
cEHRT
eCQMsQDM MATNQF MAPRules
CypressPopHealth
SEVT(reportingto CMS)
CDARIM
HQMF
QRDA
STANDARDS
vMR HeD
CDS
USHIK
Page 30
31
HHS Post Kaizen Event – Notional Future State Clinical Quality Measure Testing Process Flow
Title
5.
Imple
me
nta
tion
Fie
ld T
esting
4. D
ata
Ele
ment
QA
and e
-Sp
ec
3.
Measure
Concept
Researc
h
2.
Exte
rnal
Sta
keho
lders
1. H
HS
Contr
acts
6. R
elia
bili
ty &
Va
lidity F
ield
Testing
Identify Measure
Concept
Submit IRB
Application
Vet Prospective
Testing Entities
Approved Test Bed
Vendors Hosps Beacons HIEs EPs
National
IRB/HIPAA
Waiver
Testing Templates
(Plan, SOW, DUA)National
Test Tools
National
Test Bed
Criteria
Proposed National Testing Development Efforts
Add Task Cross-
Stakeholder
Innovation
Measure Related Contract Modifications
Incorporate
Agile/Lean
Modify
Deliverables
Schedule
Allocate
New Task
Funding
Potential Testing Entities
Vendors Hosps Beacons HIEs EPs
SOW/DUA
Paperwork
Select SME
Panel
HL7/Standards Organizations
Clinicians
Methodologists
EHR Data
Experts
Standards
Experts
Preliminary Data Element
Assess (see sub-flow 1)Review Materials
Preliminary Face
Validity Assess
Data Element
Repo
National
Fail Early?
1 Measure
NarrativeN
Update National
Templates
Allocate
Test Bed
Funding
Draft HQMF MAT Entry VSAC /
NLM
VS Repo
National Draft Measure
Require. Tool
Measure
Developer
Create Test Cases
Vetting Process
Cypress &
Bonnie ETL
Answer
Key Test Cases
Simulated
Modifications
Updated HQMF
Fail Early?N
2
Update AMA National
Template Data Element
Table Tool (DET) ®
Update National
Template Query
Vendor
Review Fail Early?
Completed
DET
Data Warehouse
Vendor Query
CountsFeasibility
Analysis
Vendor
Implementation
3
N
ETL
Measure Calc
Performance
Report
Answer Key
Comparison
Fail Early?4
N
Data Collection
Form (DCF)
Binomial
Analysis Code
Approved IRB/
HIPAA WaiverExecuted
Contract/DUA
Determine R&V Testing
Approach
Does DB Volume/Struct.
Support Binomial Analysis?
Perform Binomial
R&V Analysis
Binomial R&V
Analysis Results
Perform On-Site
Validity Against
Gold Standard
R&V Compare
ResultsEHR System
Production
N
Fail Early?
5a
Fail Early?
5b
Y
B o o z | A l l e n | H a m i l t o n F e b r u a r y 2 4 , 2 0 1 3P o s t - K a i z e n M e a s u r e T e s t i n g a n d C e r t i f i c a t i o n W o r k g r o u p P a g e 1
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"Americans can always be counted on to do the right thing......after they have exhausted all other possibilities."
-- Winston Churchill
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eMeasures Implementation:Key Success Factors
• Organizational Leadership
• Teamwork is Essential- IT/Quality/Clinicians/Vendors/SME’s
• Smart Data Capture / Clinical Workflow Design/Re-design
• Standards & Terminology Capability
• Integrate CDS & CQM in CQI
• Create a Learning Health System
Page 33
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Data Capture/Workflow Principles
Reduce data capture burden for quality reporting only; Avoid “Death by a thousand clicks”
Make clinical data capture sharable;
Routine patient care / Clinical decision support/ eMeasures
Anticipate & Incorporate “downstream needs” for standardized data early during data capture screen/form builds
Develop working knowledge of Key Standards SNOMED / RxNorm / LOINC
Involve Clinicians early; Find Champions
Dedicate resources for education in quality measurement
Communicate often & Celebrate successes
Leverage MEDITECH “Best Practices” where possible
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Handle with Care!!
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If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.
If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.
— Code of Hammurabi, c. 1750 B.C.
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Thank you !!
Page 37
Zahid Butt MD,FACG
443-539-0505 Ext 223
410-925-7005 (cell)
Twitter:@zbytes
