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1 EHR Systems Promote Quality Improvement and Practice Efficiencies Andrew Miller, MD, MPH In 2004, the US Department of Health and Human Services (DHHS) released an outline for a 10-year plan to transform the delivery of health care by building a new health information infrastructure, including electronic health records (EHRs) and a network to link health records nationwide. At that time, DHHS Secretary Tommy Thompson emphasized that America needs to move much faster to adopt information technology (IT) in our healthcare system. Electronic health information will provide a quantum leap in patient power, doctor power, and effective health care. We can t wait any longer. 1 The Centers for Medicare and Medicaid (CMS) is fully supporting this effort. The CMS Pilot Program CMS started a pilot program called the Doctor s Office Quality Information Technology (DOQ-IT) Project in 2004 and included it as part of its national quality initiative for the 8th Statement of Work (SOW) a 3-year contract running from August 2005 through July The 53 Medicare Quality Improvement Organizations (QIOs) that cover all US states, territories, and the District of Columbia were responsible for implementing DOQ-IT in each of their coverage areas. CMS created 2 roadmaps for addressing the components of the DOQ-IT Project: 1. An EHR roadmap for adopting an EHR system 2. A care management roadmap for improving the functional and clinical outcomes in patients with chronic disease after an EHR system has been implemented Both of these roadmaps provide step-by-step directions for choosing the best EHR system to run a more efficient practice and utilize the capabilities of an EHR system to implement care management. QIO consultants are providing assistance to DOQ-IT physicians in following these guidelines. However, all physicians interested in implementing and using EHR systems for care management can benefit from the materials available with these roadmaps. Materials can be obtained by going to the CMS MedQIC Web site at and clicking on Physician Offices. Adopting an EHR System The recruitment phase of the DOQIT Project, which identified a specific number of primary care physicians (PCPs) who were interested in acquiring EHR systems in each state or jurisdiction, is completed. QIO consultants work with these practices to assist in selection and implementation of an EHR system. The EHR roadmap provides phases for adopting EHRs in a systematic way (Table 1). This approach separates EHR implementation into individual components, with each step building on the previous. By using this approach, important details have not been overlooked and practices have moved forward successfully. Applying Care Management Strategies The goal of the DOQ-IT Project is to improve the quality of care patients receive by helping physicians monitor and improve the healthcare services they provide. Care management improves functional and clinical outcomes in patients with chronic disease and reduces the need for additional medical services that result from disease complications. It also supports prevention, early detection, and early treatment of disease to yield the best outcomes. As with the EHR adoption strategy, this CMS roadmap assists physicians with implementing care management into routine clinical practice (Table 2). When the EHR systems have been implemented and evaluated and the DOQ-IT physician prac- 20 Medicare Patient Management

2 Table 1. tices understand system capabilities, QIO consultants will begin working with the physician practices on implementing care management for continued quality improvement. CMS has identified topics that it will use to measure performance by having physicians transmit data from their EHRs to a CMS data warehouse. The identified topics are shown in Table 3. CMS maintains a list of EHR system vendors that have declared their support for the DOQ-IT Project. The vendors have signed a DOQ-IT letter of intent, declaring their pledge to meet program expectations of capturing and sending clinical quality data that meet CMS requirements. Currently, a limited number of DOQ-IT physicians are able to transmit this data to a CMS clinical warehouse because only a few EHR vendors have products that can perform this function. Physician Quality Reporting Initiative CMS is taking additional steps to support the federal government s 10-year plan to transform the delivery of health care with IT by introducing a program for physicians to voluntarily and confidentially report data about designated quality measures. The 2006 Physician Voluntary Reporting Program (PVRP) has been discontinued and has been replaced by the Physician Quality Reporting Initiative (PQRI). PQRI is designed to find the most effective methods of using CMS-identified measures in routine practice to improve quality of care. By participating in PQRI, physicians will have hands-on experience with CMS s data collection process and receive confidential feedback reports with Roadmap for Adopting an EHR Phase Assessment Planning Selection Implementation Evaluation Improvement Table 2. Action Individual needs of the practice are identified. Project plan is established. An EHR vendor is selected. A go-live date is established. Physicians and staff are trained on the new system. Data interfaces are completed and tested. Effectiveness of the EHR system is measured. Workflow processes are continuously improved and care management begins. Roadmap for Implementing Care Management 1. Define the subpopulation of patients in need of care management. 2. Choose a physician performance measurement set of quality measures. 3. Use a clinical information system to track quality measures. 4. Establish patient goals for quality improvement. 5. Analyze the current workflow processes to identify areas for improvement. 6. Implement a change in the workflow process. 7. Measure and analyze results. 8. Repeat actions 6 and 7 until goals are reached. 9. Sustain the improvement. Table 3. CMS Topics and Measures for Care Management Chronic Disease Management Coronary artery disease Diabetes End-stage renal disease (ESRD) Heart failure Hypertension Preventive Care Adult immunization (influenza and pneumococcal) Blood pressure measurement Breast cancer screening Colorectal cancer screening Low-density lipoprotein (LDL) cholesterol level Tobacco use March/April

3 2006 Physician Voluntary Reporting Program (PVRP) 2007 Physician Quality Reporting Initiative (PQRI) information on their reported performance rates compared with others on a national level. Why Physicians Should Participate When PVRP was introduced, it was not associated with a financial incentive. This, however, changed with the passage of the Tax Relief and Health Care Act of 2006 (HR 6111) in late The law includes a 1.5% bonus payment (pay-for-reporting) for physicians who report data on quality measures via CMS s PQRI beginning in July Additional reasons for participating include: PQRI provides physicians with confidential reports they can use to benchmark their performance compared to other physicians. CMS has stated that this information is not intended to be shared with the public. However, at the de-identified aggregate level, CMS may release information as part of lessons learned in this program. PQRI participation will give physicians the opportunity to ensure that their claims processor and office software can support a CMS reporting process. How to Participate For 2007, eligible professionals need not enroll or file an intent to participate. Physicians can participate by reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor. In order to satisfactorily meet the requirements of the program and receive the bonus payment, certain reporting thresholds must be met. When no more than three CMS launched the Physician Voluntary Reporting Program (PVRP) in 2006 to better analyze the quality of care provided to Medicare beneficiaries by using a set of codes established by Medicare. PVRP-specific G-codes and CPT Category IIs could be reported voluntarily by using the existing administrative system for physician claims. The 2006 PVRP ended December 31, Participating physicians may continue to access a confidential feedback report (regarding their practice's performance in 2006) via QualityNet Exchange. The PVRP was replaced by the 2007 Physician Quality Reporting Initiative (PQRI), as authorized by the Tax Relief and Health Care Act of Under the 2007 PQRI, eligible professionals who successfully report specified measures will earn a payment bonus, subject to a cap. The reporting period for the PQRI will be July 1 through December 31, There is no need to enroll to participate in the PQRI. Details about the 2007 PQRI are available on the CMS website: quality measures are applicable to services provided by a physician, each such measure must be reported in at least 80% of the cases in which the measure is reportable. When four or more measures are applicable to the services provided by an eligible professional, the 80% threshold must be met on at least three of the measures reported. Physicians should select and report measures that are applicable to their practice. While reporting for the 2007 PQRI begins with claims for dates of service as of July 1, 2007, eligible professionals should become familiar with the 2007 PQRI measures before the reporting period begins. The 2007 PVRP quality measures were posted on December 5, 2006 under the title "2007 Physician Voluntary Reporting Program (PVRP) Quality Measures." This December 5, 2006 document identifying sixtysix quality measures is accessible on the "Transition From Physician Voluntary Reporting Program" PQRI page. On January 22, 2007 the AQA Alliance, through its consensus-based process, adopted eight other measures. These eight additional measures are now included in the PQRI measures for How to Submit Quality Measure Information The usual source of clinical data for quality measures is retrospective chart abstraction, but data collection through chart abstraction can be burdensome. Consequently, the PQRI focuses on ways to obtain valid quality measure data as efficiently as possible. CMS is collecting quality information on services provided to the Medicare population by using the administrative claims system. CMS has defined a set of HCPCS (healthcare common procedure coding system) codes, known as G- codes and CPT Category II codes, to report data for the calculation of the physician quality measures. These codes supplement the usual claims data with clinical data that can be used to measure the services rendered to beneficiaries. Each measure has an appropriate G-code or CPT Category II code, which is submitted on the Medicare claim form generated after a covered service has been performed. Physicians simply add the appropriate codes to their claims and submit their claims in the routine fashion. CMS has worksheets to will assist in the submission process. 22 Medicare Patient Management

4 2007 PQRI Physician Quality Measures 1. Hemoglobin A1c control in type 1 or 2 diabetes mellitus 2. Low-density lipoprotein control in type 1 or 2 diabetes mellitus 3. High blood pressure control in type 1 or 2 diabetes mellitus 4. Falls: Screening for fall risk 5. Heart failure: angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD) 6. Antiplatelet therapy prescribed for patient with coronary artery disease 7. Beta-blocker therapy for patient with prior myocardial infarction 8. Beta-blocker therapy for LVSD 9. Antidepressant medication during acute phase for patient with new episode of major depression 10. Stroke and stroke rehabilitation: computed tomography (CT) or magnetic resonance imaging (MRI) reports 11. Stroke and stroke rehabilitation: carotid imaging reports 12. Primary open-angle glaucoma: optic nerve evaluation 13. Age-related macular degeneration: antioxidant supplement prescribed/recommended 14. Age-related macular degeneration: dilated macular examination 15. Cataracts: assessment of visual functional status 16. Cataracts: documentation of presurgical axial length, corneal power measurement, and method of intraocular lens power calculation 17. Cataracts: presurgical dilated fundus evaluation 18. Diabetic retinopathy: documentation of presence or absence of macular edema and level of severity of retinopathy 19. Diabetic retinopathy: communication with the physician managing ongoing diabetes care 20. Perioperative care: timing of antibiotic prophylaxis: ordering physician 21. Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin 22. Perioperative care: discontinuation of prophylactic antibiotics (noncardiac procedures) 23. Perioperative care: venous thromboembolism (VTE) prophylaxis (when indicated, in all patients) 24. Osteoporosis: communication with the physician managing ongoing care postfracture 25. Melanoma: patient medical history 26. Melanoma: complete physical skin examination 27. Melanoma: counseling on self-examination 28. Aspirin at arrival for acute myocardial infarction (AMI) 29. Beta-blocker at time of arrival for AMI 30. Perioperative care: timing of prophylactic antibiotic: administering physician 31. Stroke and stroke rehabilitation: deep vein thrombosis (DVT) prophylaxis for ischemic stroke or intracranial hemorrhage 32. Stroke and stroke rehabilitation: discharged on antiplatelet therapy 33. Stroke and stroke rehabilitation: anticoagulant therapy prescribed for atrial fibrillation at discharge 34. Stroke and stroke rehabilitation: tissue plasminogen activator (tpa) considered 35. Stroke and stroke rehabilitation: screening for dysphagia 36. Stroke and stroke rehabilitation: consideration of rehabilitation services 37. Dialysis dose in ESRD patient 38. Hematocrit level in ESRD patient 39. Screening or therapy for osteoporosis for women aged 65 years 40. Osteoporosis management following fracture 41. Osteoporosis pharmacologic therapy 42. Osteoporosis: counseling for vitamin D, calcium intake, and exercise 43. Use of internal mammary artery (IMA) in coronary artery bypass graft (CABG) 44. Preoperative beta-blocker in patient with isolated CABG 45. Perioperative: discontinuation of prophylactic antibiotics (cardiac procedures) 46. Medication reconciliation 47. Advance care plan 48. Assessment of presence or absence of urinary incontinence in women aged 65 years 49. Characterization of urinary incontinence in women aged 65 years 50. Plan of care for urinary incontinence in women aged 65 years 51. COPD: spirometry evaluation 52. COPD: bronchodilator therapy 53. Asthma: pharmacologic therapy 54. ECG performed for nontraumatic chest pain 55. ECG performed for syncope 56. Vital signs for community-acquired pneumonia 57. Assessment of oxygen saturation for community-acquired pneumonia 58. Assessment of mental status for community-acquired pneumonia 59. Empiric antibiotic for communityacquired pneumonia 60. (GERD: assessment for Alarm Symptoms 61. GERD: upper endoscopy for patients with alarm symptoms 62. GERD: biopsy for barrett s esophagus 63. GERD: barium swallow- inappropriate use 64. Asthma assessment: percent of patients who were evaluated during at least 1 office visit within 12 months for the frequency of daytime and nocturnal asthma symptoms 65. Appropriate treatment for children with URI 66. Appropriate testing for children with pharyngitis 67. Myelodysplastic syndrome (MDS) and acute leukemias: baseline cytogenetic testing performed on bone marrow 68. Myelodysplastic syndrome (MDS): documentation of iron stores in patients receiving erythropoietin therapy 69. Multiple myeloma: treatment with bbisphosphonates 70. Chronic llymphocytic leukemia (CLL): baseline flow cytometry 71. Hormonal therapy for stage IC-III, ER/PR positive breast cancer 72. Chemotherapy for stage III colon cancer patients 73. Plan for chemotherapy documented before chemotherapy administered 74. Radiation therapy for invasive breast cancer patients who have undergone breast conserving surgery For details go to: Downloads/PQRIMeasuresList.pdf March/April

5 P ROVIDER ACTION Impact to You Physicians have the ability to increase their reimbursement by 1.5% from Medicare by participating in the Physician Voluntary Reporting Program (PVRP). This reporting and the improvement of these measures can be greatly improved through the use of electronic health record (EHR) systems. What You Need to Know Physicians need to know how to submit their data to the PVRP. CMS is collecting this quality data by using the administrative claims system. This is the first step in Medicare s and other insurers' move to pay-for-performance. What You Need to Do Under the 2007 PQRI, reporting specified quality improvement measures can result in a payment bonus. The reporting period is July 1 - December 31, Enrollment is not required for participation. Details available on the CMS website: PVRP Physician Quality Measures In 2007 CMS introduced 74 evidence-based, clinically valid PQRI measures that are included in numerous guidelines endorsed by physicians and medical societies. The measures are divided by physician specialty and physicians report data for only the measures within their specialties. The abbreviated list appears on page 23. Measure specifications information can be downloaded at www. cms.hhs.gov/pqri/downloads/pq RIMeasuresList.pdf Earning More Reimbursement Through Reporting IT in physician offices is becoming an integral component for practice efficiency. DOQ-IT and PVRP are supporting the government s plan to build a health information infrastructure and meet CMS s vision for the 8th SOW and beyond: the right care for every person every time. By becoming part of the plan, physicians can help improve the quality of patient care, make their practices more efficient, and get paid for reporting. MPM Andrew Miller, MD, MPH, is the Director of Physician Services at Healthcare Quality Strategies, Inc. (HQSI), the federally designated QIO for New Jersey. HQSI is an independent, nonprofit company committed to accelerating improvement in healthcare quality through a collaborative and interactive process with the healthcare community. This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare QIO for New Jersey under contract with CMS, an agency of the US DHHS. The contents presented do not necessarily reflect CMS policy. 8SOW-NJ-GEN Reference 1. US Department of Health and Human Services. Thompson launches Decade of Health Information Technology [press release]. July 21, Medicare Will Provide Beneficiaries with Physician Performance Results as Part of Its Value-driven Healthcare Initiative The Centers for Medicare & Medicaid Services (CMS) announced in February that the Delmarva Foundation for Medical Care (Delmarva), one of its quality improvement organizations, has entered into subcontracts with 4 regional collaboratives, as part of the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) Project. These regional collaboratives will combine Medicare data with data from other insurers to produce information on the performance of healthcare providers for the benefit of Medicare beneficiaries. The following regional collaboratives have signed subcontracts: Indiana Health Information Exchange (IHIE), Massachusetts Health Quality Partners (MHQP), Minnesota Community Measurement (MNCM), and Wisconsin Collaborative for Healthcare Quality (WCHQ). The results of the BQI Project will be used for two primary purposes: first, to provide performance information to physicians that will assist them in improving the quality of care they are delivering to Medicare beneficiaries; and second, to give physician performance information to Medicare beneficiaries to help them with physician selection. This is an important advancement, said CMS Acting Administrator Leslie Norwalk. The BQI project will give Medicare beneficiaries a broad overview of provider performance, resulting in better choices in meeting their health care needs. The regional collaboratives, spurred by great leadership from physicians and others in the healthcare community, will also provide critical information to physicians and Medicare on the best practices for data collection, aggregation, and reporting. The BQI Project is part of Department of Health and Human Services' Secretary Mike Leavitt s Value-driven Healthcare Initiative, which is based on the following 4 cornerstones: interoperable health information technology (health IT); transparency of price information; transparency of quality information; and the use of incentives to promote high-quality and cost-efficient health care. The Initiative directs federal agencies, to the extent permitted by law, to share information with beneficiaries on the quality of services provided by doctors, hospitals, and other healthcare providers. Additional information on each regional collaborative as well as the Secretary s Value-driven Healthcare Initiative is available at: 24 Medicare Patient Management