Do more than just celebrate national health observances this April. Use them as opportunities for quality improvement and to directly impact patient health.

April is National Minority Health Month, dedicated to improving the health of racial and ethnic minority populations by raising awareness of health disparities. The theme of this year’s observance is “Advance Health Equity Now: Uniting our Communities to Bring Health Care Coverage to All”. See this downloadable poster: http://minorityhealth.hhs.gov/actnow/templates/Materials.aspx

April 7 is also World Health Day, which marks the anniversary of the founding of the World Health Organization (WHO) in 1948. The theme for 2013 is high blood pressure with the goal to reduce heart attacks and strokes worldwide.

Here are some tips for how these can apply directly to quality improvement:

Make controlling blood pressure (BP) a priority in your practice.  Get every staff member on board and decide how each will contribute to controlling BP in your patient population.

Measure your performance on controlling high blood pressure in your patient population. For patients with diagnosed hypertension, use PQRS #236 (NQF 18) to measure.  For patients without diagnosed hypertension, use PQRS #317.

Segment your population by race, ethnicity, sex and payer. Determine the rate of uncontrolled BP for each segment to see if disparities exist. Decide which solutions may be effective with various population segments.  If race/ethnicity isn’t consistently captured, use this brochure to educate staff and patients about the importance of collecting this data:  http://www.cdc.gov/minorityhealth/brochures/OMHD.pdf

Identify patients with uncontrolled BP and discuss possible causes.  Develop a plan of care with the patient, set goals and actions the patient accepts.  Consider potential causes such as access to care, smoking, patient understanding, cultural food preferences, financial, provider/staff commitment to controlling BP, nutrition, not taking medications, and others.

Raise patient awareness of the causes and consequences of high blood pressure and healthy lifestyle.  Here’s a good handout: “Know the Facts about High Blood Pressure” http://www.cdc.gov/bloodpressure/docs/ConsumerEd_HBP.pdf

Make BP measurement affordable.

• Missouri has one of 23 CDC-funded WISE WOMAN programs that provide standard preventive services including blood pressure and cholesterol testing. http://www.cdc.gov/wisewoman/locations/index.htm.
• Understand Medicare benefits for Cardiovascular Behavioral Therapy: http://www.medicare.gov/coverage/cardiovascular-disease-behavioral-therapy.html  and Cardiovascular Screening http://www.medicare.gov/coverage/cardiovascular-disease-screenings.html .

Join the Million Hearts Campaign and do your part to prevent 1 million heart attacks and strokes over the next five years: http://millionhearts.hhs.gov/

The Centers for Medicare & Medicaid Services (CMS) has selected the Physician Quality Reporting System (PQRS) as the method for providers to report quality measures for all CMS programs.

As we near the end of 2012, providers may want to assess the status of their 2012 PQRS submissions.  If you haven’t yet participated using Claims, it’s probably too late to start.  But there are three other mechanisms that may be worth trying, even at this late date.  Incentives are 0.5% of the Medicare Part B Physician Fee Schedule allowable charges.

• Qualified Registry.  Registries submit data to CMS after the end of the year.  Depending on the specific registry, you may still be able to participate for 2012.  A listing of qualified registries for 2012 PQRS can be found here.  Most registries charge a fee per provider, but some may be free.  Contact information is provided in the link above.
• Qualified EHR—Direct Submission.  Twenty EHRs are qualified to report PQRS data directly to CMS in 2012. Data is pulled from your EHR using vendor software and submitted to CMS after the end of the year.  This is a great option for providers who want to get the most value out of their EHR.  Qualified EHRs can be found here.
• Qualified EHR Data Submission Vendor. New in 2012 are qualified Data Submission Vendors (DSVs) which obtain data from the EHR and submit PQRS to CMS.  Some EHR vendors offer this option instead of Direct Submission, and some specialty registries obtain the data through an interface.  A listing of DSVs can be found here.

The final rules and regulations for 2013 and 2014 PQRS reporting were published Nov. 1.  Primaris and MSMA are co-hosting a webinar on Dec. 20 to cover this important topic in detail (Register here). Here are a few highlights of the final rule:

• 2013 PQRS data will be used for many purposes, including:
  • Determining PQRS incentives for 2013
  • Assessing PQRS payment penalties in 2015
  • Determining the Value-based Modifier for eligible providers in groups of 100 or more to be applied in 2015 (and all providers by 2017)
  • Piloting reporting of Meaningful Use Clinical Quality Measures (CQMs) in 2013 (and electronic reporting of CQMs in 2014 and beyond)
  • Reporting quality measures for Accountable Care Organizations and Medicare Shared Savings Programs in 2013
  • Public Reporting for large groups in 2014 (and for individual providers thereafter)
• Measures included in the above programs are being aligned in 2013, and full alignment will be completed by 2014.
• There are new options for reporting PQRS to earn incentives and avoid payment adjustments.  Requirements for participation are very lenient for 2013, but will become more strict in the future.

Please join us for this learning opportunity.  You must register in advance.

PQRS is a dynamic system that utilizes quality measures developed and vetted by professionals, and should be an integral part of every provider’s Quality Improvement Plan!

Electronic Health Records (EHRs) offer many different tools to support clinical decisions. These include Rules, Reminders, Lists, Alerts, Order Sets, and Performance Measures to help manage patients and improve care.  All serve slightly different purposes, but can complement each other. Here are some suggestions for how to use some common tools.

Rules:  Rules are applied to your entire panel of patients to determine their status on selected care management issues (e.g., “All patients Age 50-75 will receive [appropriate] colorectal cancer screening”).

• Rules can be set up to run automatically (e.g., nightly) or on demand.
• Results are usually displayed in the patient chart summary view when a chart is opened.
• Rules help avoid missed opportunities to address overdue care for a patient during a visit.

Reminders:  Reminders are automatically generated messages to patients or providers between visits.

• Reminders may be sent automatically to patients that are due for care, such as colorectal cancer screening. This can be repeated at regular intervals until the patient responds.
• Reminders can be run based on Rules, or they can be set for individual patients.
• Reminders may be sent via an automated letter, voice message, or patient portal.

Lists:  Lists can be generated at will to identify patients with common characteristics. Use them for population management and practice analysis.

• Lists can help you understand patient population needs, common diagnoses or age groups.  You can then plan for new services, then establish workflows and templates to provide those services consistently and efficiently.
• EHRs can generate a list or report at an established interval (e.g., monthly) based on a Rule. For example, you can list all patients that do not meet the Rule for colorectal cancer screening.   Lists allow you to identify care needs that may otherwise be overlooked for patients that do not come in routinely.

Alerts:  Set alerts to emphasize important data that requires immediate attention during an encounter.

• Alerts are patient-specific and appear as soon as a patient chart is opened or an action is taken.
• Alerts may be for administrative reasons (e.g., a patient account is overdue) or for safety (medication allergy or drug interactions).
•  Limit the use of alerts to critical issues. Excessive use leads to “alert fatigue” and may cause providers to disregard the content.

Order Sets:  Order sets are an under-used, but powerful decision support tool.

• Providers agree to a set of orders for a subset of patients.  Coded templates are designed and linked to the order set (such as diabetics, or patients with ischemic vascular disease, or prevention services).
• When applicable patients are seen, the order set is pulled into the note and the linked templates allow quick documentation in structured, reportable format.
• Order sets empower team members to assist in patient care.

Clinical Quality Measures – These are evidence-based measures of performance, supported by clinical research and practice.

• Measures may be related to structure (e.g., a patient portal is in place), process (e.g., mammogram performed every 2 years for women age 40-69) or outcome (blood pressure in control).
• Clinical Quality Measures are designed and maintained by professional groups (such as the AMA).
• Many measures are being re-engineered to be compatible with EHR-based data collection and measurement.

Use clinical decisions support tools to improve disease and population management and make the most of each patient visit.  Effective use leads to more streamlined workflow, improves safety and supports prevention.

Providers have until September 4 to help shape the Center for Medicare & Medicaid Services (CMS) proposed rules to quality reporting initiatives affecting Medicare Physician Fee Schedule payments on or after Jan. 1, 2013. Programs affected include Physician Quality Reporting System (PQRS), E-prescribe, and the Value-Based Modifier (VBM).

Providers must report PQRS in 2013 and beyond or face penalties to Medicare Part B PFS payments. Any provider that successfully earns an incentive in 2013/2014 will also avoid PQRS payment penalties in 2015/2016.

Eligible Providers (EPs) include physicians (MD, DO, dentist, chiropractor, podiatrists, optometrist), practitioners (NP, PA, CNA, midwife) and therapists (PT, OT, audiologist, dietitian) that bill Medicare Part B PFS.

Key take-away points from proposed rules:

• Providers may report individually or as a group. The advantage to group reporting is that as long as the reporting thresholds are met, incentives will be earned for the entire group.
• PQRS incentives and penalties will apply to both individuals and groups.
• Options for reporting PQRS to earn an incentive have been expanded:
  • Individual EPs may report three individual measures or one Measures Group. Reporting thresholds are 50% of patients if reporting via Claims, and 80% via a Qualified Registry or electronic health record (EHR). Twenty patients must be reported for a Measures Group (down from 30 in 2012)
  • Groups of 2-99 EPs (under the same TIN) may report three individual measures using Claims (50% reporting threshold), a Qualified Registry or EHR (80% threshold for both), or 18 measures that are part of the Group Practice Reporting Option (GPRO) web-based interface
  • Groups of 100 or more EPs must report the 18 measures using the GPRO web-based interface.
• In addition to the above options, two new options for reporting have been added by which providers can avoid a PQRS penalty:
  • Individuals and groups may elect to report using a new Administrative Claims option. CMS will calculate performance on 19 measures based on Part B claims submitted for the year. EPs do not have to submit any additional quality codes
  • Individuals and Groups that simply report one measure or measure group during 2013/2014 via Claims, Registry or EHR will avoid payment penalties in 2015/2016. This option is meant to encourage providers who have never reported to learn how to participate in PQRS.
• Value-based purchasing is also scheduled to go into effect in 2015 (based on 2013 reporting). A Value-Based Modifier (VBM) will be applied against all Medicare Part B charges to either increase or decrease payments based on quality and cost. The rule proposes that the VBM affect only groups of 25 or more EPs that bill under the same TIN in 2015/2016–all other providers have until 2017. The quality component of the VBM is heavily reliant on PQRS.
  • Providers can position themselves to be “high quality” providers by reporting traditional PQRS measures on which they perform very high. High quality/low cost providers will receive bonuses under the VBM
  • Even though providers in groups of 25+ EPs can avoid PQRS payment adjustments by reporting individually, they can NOT avoid VBM payment adjustments by reporting PQRS individually. They must report as a Group in 2013/2014
  • Successful PQRS reporters may elect to either set the VBM at 0.0% (thereby having no impact on payment) or may elect to have CMS calculate a VBM. If they elect to have CMS calculate a VBM, their payment may increase or decrease in 2015/2016, depending on their relative quality and cost.
• Two new hardship exemptions are proposed for EPs achieving or intending to achieve meaningful use for the first time in 2013/2014.

Don’t miss your chance to leave comments to help shape these proposed rules. Please submit comments by Sept. 4, 2012 to http://www.regulations.gov.

Understanding the specifications of the quality measures you select will help you determine if calculated performance rates are accurate.

Denominators identify the patients that should have had the quality action performed.

• The patient must have had at least one eligible visit with the provider during the reporting period to be included in the denominator. Only certain encounter codes constitute “eligible” visits.
• The PQRS reporting period is always the calendar year (e.g., 01/01/2012 – 12/31/2012).
• For measures that are diagnosis-specific, applicable diagnosis codes must be in the patient’s problem list or captured in the chart through a template. For example, “Hypertension” must be in the patient’s problem list or visit note for PQRS Measure #236: “Hypertension: Controlling High Blood Pressure” to apply. This measure won’t include patients that simply had high blood pressure readings without a diagnosis of hypertension.
• Some measures also look at procedures to determine if the patient will be part of the denominator. For example, Measure #6 “CAD: Antiplatelet Therapy,” looks for either a diagnosis code or prior cardiac surgery.

Numerators indicate which patients actually had the desired process (service) or outcome.

• For most measures, it doesn’t matter which provider performed the service, as long as the patient received the service. For example, if Dr. A gave a flu shot to a patient, all providers reporting on that patient will get credit for the flu shot–as long as the information is captured appropriately in the provider’s EHR.
• Some measures look outside the reporting period for services (e.g., colonoscopy within 10 years).

If your numerators are low resulting in poor performance rates, consider the following common documentation remedies:

• Make certain your labs, immunizations, preventive services and medications been correctly mapped to standard master codes (such as CPT, LOINC, RxNorm, SNOMED or CVX codes). Lab linking is an ongoing maintenance requirement.
• Run updates and fixes in a timely manner as they are released by your vendor.
• Verify where your particular EHR looks for data for each measure (e.g., in the notes? Billing module? Flowsheet? Past medical history?)
• Identify which date is being associated with an actionby your EHR. This may be the date the test was done, the date you recorded it in your EHR, the date the result came in, the date you ordered it, or the date captured in a template.
• If you’ve customized templates, make certain the fields are correctly linked to updated standard codes.

Clinical quality measures have been carefully designed by experts in healthcare and engineered for electronic application. Effective use can help you improve the health of your patient population and lead to high provider and patient satisfaction.

PQRS EHR-based measure specifications can be found here: “Accept” the CPT User Agreement. Questions may be directed to Sandy Pogones, Program Manager Physician Services, spogones@primaris.org.

Many providers continue to report PQRS through Claims because there are no EHR vendor fees. Claims reporting is primarily a manual process and requires diligence to identify eligible PQRS cases and to report all applicable Quality Data Codes (QDCs) daily on each eligible claim.

To Report PQRS through Claims

1. Decide if you will report Individual Measures or a Measures Group:

a. Individual Measures. There are over 200 individual measures, so select those that are important to your practice. You must report a minimum of 3 measures for at least 50% of eligible instances. While there is no minimum number of cases, it is risky to begin reporting this late in the year, as it may be difficult to meet the 50% reporting threshold. The AMA has designed and published worksheets free of charge to make data collection easier. [Go to http://www.ama-assn.org/ and search for “PQRS”.]
b. Measures Group. A Measures Group contains four to ten related measures. There are 12 measures groups that can be reported through Claims. All applicable measures within the group must be reported at least once for each of 30 patients, but plan to report more to allow for any potential errors.

2. Download the Implementation Guide from the CMS website and read it thoroughly. There are different guides for reporting individual measures vs. measures groups.
3. Download the Measure Specifications. Measures group specifications are different from those of the individual measures that form the group, so make certain you are using the correct specification for the current year.
4. Identify eligible instances for the measures selected. Only Medicare Part B Fee-for Service claims (including Medicare as secondary and Railroad Retirement) are eligible for PQRS. PQRS does NOT include Medicare Advantage (i.e., Medicare Part C).

a. An instance is eligible if it meets all the denominator requirements in the specs.
b. Consider implementing an edit on the billing software that will flag each claim every time the combination of codes listed in a measure’s denominator is billed.

5. Enter the quality-data codes (QDCs)—which supply the numerator– on each eligible claim.

a. To initiate reporting a measures group, you must submit a “group-specific intent G-code” on the first claim indicating your intention to begin reporting a measures group. (No initiation code is required for individual measures.)
b. Measures with a 0% performance rate and measures groups containing a measure with a 0% performance rate will not be counted.
c. You cannot submit a Claim solely for the purpose of reporting or correcting QDCs codes.

6. Track your Remittance Advise/Explanation of Benefits for the denial code N365, which indicates the PQRS codes were received and passed on for review. N365 does not guarantee reporting was correct, only that the codes were received and not stripped by the billing software.

Someone in the United States has a stroke every 40 seconds.  In 2008, more than 133,000 Americans died from stroke— one person every four minutes— making strokes the fourth leading cause of death in the United States and a significant cause of disability.

In 2011, the Department of Health and Human Services launched the Million Hearts initiative to prevent 1 million heart attacks and strokes by 2017. Providers can do their part by monitoring their patient population to see how well they perform on the ”ABCS” (see below) of cardiac health and stroke prevention, then take action to improve performance.

There are several clinical quality measures that are built-in to most EHRs to help you track the cardiac health of your patient population.  Use either the PQRS number or the National Quality Forum (NQF) number to locate the measures in your specific EHR.

Appropriate Aspirin therapy:

• PQRS Measure #204(NQF #0068):  Ischemic Vascular Disease (IVD):  Use of Aspirin or another Antithrombotic, Age 18+.  This measure looks for evidence of antithrombotic use in patients that have had a prior MI, CABG, or PTCA, or a current diagnosis of IVD.

Blood pressure control

• PQRS Measure #236 (NQF #0018):  Hypertension:  Controlling High BP, Age 18-85.  BP control is considered <140/90.
• PQRS Measure #317(NQF—TBD):  Preventive Care & Screening,  Screening for High BP, Age 18+.  This is a new measure for 2012 and looks for appropriate screening for patients without known hypertension.

Cholesterol management

• PQRS Measure #241 (NQF #0075): Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL-C Control, Age 18+.  This measure looks for LDL-C performed and in control in patients that have had a prior MI, CABG, or PTCA or a current diagnosis of IVD.
• PQRS Measure #2 (NQF #0064):  Diabetes Mellitus, LDL-C Control.  This measure looks for control of LDL-C in patients that have diabetes and have had their LDL measured during the measurement period.
• PQRS Measure #316 (NQF—TBD):  Preventive Care & Screening, Cholesterol – Fasting LDL-C test Performed AND Risk-stratified Fasting LDL for patients Age 20-79.  This is a new measure for 2012 and looks at patients that have had a fasting LDL performed and whose risk-stratified fasting LDL is at or below the recommended LDL goal.

Smoking Cessation

• PQRS Measure #226 (NQF #0028):  Preventive Care & Screening:  Tobacco Use, Screening and Cessation Intervention, Age 18+. This measure looks for screening for tobacco use for patients and cessation counseling for tobacco users.

Providers that wish to participate in 2012 PQRS reporting via Claims or a Registry, but have not yet started, could still earn incentives by reporting the Cardiovascular Measures Group for at least 30 unique Medicare Part B PFS patients.  This measures group includes all the above measures (except #316).  Each measure needs to be reported for each patient in the sample.  Refer to the CMS website for specific instructions for reporting Measures Groups, or contact Primaris for more information.

Cardiac and preventive care quality measures are the focus of the final regulations covering Physician Fees Schedule changes that will be used to determine the Medicare Value-Based Modifier (VBM).
By monitoring measures related to these areas now, you can improve performance rates and positively impact the VBM.

• Using your Meaningful Use reporting software, run performance reports for each provider on the core measures.
• Compare documentation practices between patients who MET the measure and those who DID NOT meet the measure. Provide correct documentation requirements to all care team members, including providers, nurses, and support staff.
• If services weren’t provided, determine a process and workflow to help prevent oversights in the future. This may involve such things as using reminders, scheduling Medicare Annual Wellness Visits, upgrading history and/or visit templates to include cardiac and preventive services, or assigning specific care team members’ responsibility for rendering services at visits.
• Continue to monitor and improve performance by running reports at least quarterly.
• Submit PQRS to CMS and collect incentives. Visit the CMS website for complete information on PQRS reporting http://www.cms.gov/pqri.

Primaris can get you on the right track for quality reporting under both Meaningful Use and PQRS. Contact Primaris NOW for free assistance! (E-mail: spogones@primaris.org; Phone: 573-673-4531).

If you are in your second year of Meaningful Use or plan to participate in PQRS using the EHR mechanism in 2012, now is the time to prepare, as a full 12-month reporting period is required for both!

• Select measures that will satisfy both programs. In 2012, you may report the same quality measures for Meaningful Use as you do for PQRS (e.g., 3 core, 3 Alternate Core as needed, and 3 Menu)
• Identify built-in EHR performance reports for each measure and run reports for each provider in January to obtain a baseline. Share reports with entire staff.
• Determine the root cause of poor performance through team discussions. Assign responsibility for action steps.
• Test small changes to address deficiencies, re-measure, and determine if improvement took place.
• Use Clinical Decision Support (CDS) capabilities of your EHR to set alerts and send reminders related to the selected measures.
• Share and implement successful strategies practice-wide.
• Re-run the reports at least quarterly (preferably monthly) and chart progress.

Primaris can get you on the right track for quality reporting under both Meaningful Use and PQRS. Contact Primaris NOW for free assistance! (spogones@primaris.org; Phone: 573-673-4531).