PROGRAM OVERVIEW. Your Local Contact: Enter your org Information here

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1 General eligibility The H3 consortium invites small practice providers in SE Wisconsin, NE Illinois and Northern Indiana (including Indianapolis). Clinics are eligible to participate if they: Have 10 providers Are focused on adult primary care Have a certified electronic health record system Do not currently receive significant quality improvement support PROGRAM OVERVIEW What is H3? A federally funded research program that will work with small practice clinics in the Midwest to implement and evaluate quality improvement strategies for cardiovascular care. How does it work? Small practices receive one year of hands-on coaching, tools and strategies to provide point-of-care support for Million Hearts cardiovascular measures aspirin therapy, blood pressure control, cholesterol management and smoking cessation. Half of the practices will also receive support to engage in population health management. What is the purpose of the research? The research will evaluate different implementation strategies and determine the best ways to support small practices with quality improvement work. How do I get more information? Registration is beginning now. Please contact your local H3 partner if you or a provider you know might be interested in participating in this important work. Your Local Contact: Enter your org Information here Part of the Agency for Healthcare Research and Quality s EvidenceNOW Grant Initiative Logo H3 highlights Practices get access to expert coaching that will support physicians as they optimize their EHR clinical decision support functionality, implement and modify office-based protocols, engage in community efforts and team-based approaches, and collect and analyze cardiovascular quality measures. Education aligns leading quality programs, payer models and financial incentive programs. Resources will be available for providers to learn about and prepare for these programs. Practices will be reimbursed for time used to extract data. H3 PARTNERS Northwestern University, CHITREC, Purdue University, PurdueREC, Northern Illinois University, IL-HITREC, local and State Departments of Public Health, American Medical Association, Alliance of Chicago, University of Chicago, Telligen and MetaStar Principal Investigator: Abel Kho, MD MS IRB# STU , AHRQ# HS Northwestern University Center for Health Information Partnerships Phone:

2 The Healthy Hearts in the Heartland (H3) program is part of EvidenceNOW, a national initiative of the Agency for Healthcare Research and Quality to transform healthcare delivery. Specifically, EvidenceNOW seeks to identify the best practices, tools and supports needed for small clinic settings to improve heart health of their patients. This type of work is becoming commonplace in large health systems; your clinic has the opportunity to pioneer how this quality improvement work can be done effectively in a small primary care setting.. Individualized coaching at the center of H3 H3 PROGRAM DETAILS H3 will help you to implement tools and strategies that can help you monitor your patients cardiovascular care. For one year, expert facilitators will support small practice clinics as they: Optimize electronic health record (EHR) clinical decision support functionality. For example, studies have shown increases in aspirin prescribing between % when using clinical reminders at the point of care. Implement and modify office-based protocols. Coaching will incorporate best practices advocated by the Million Hearts campaign. Engage in community efforts to encourage team-based approaches. For example, studies have shown that providing care in collaboration with pharmacists has greatly reduced systolic blood pressure in hypertensive patients. Collect and analyze clinical quality measures. This approach aligns with many pay-for-performance models, which can reduce reporting burden and helps providers to target patient populations. The strategies your facilitator will present to you are all evidence based and have been proven to improve cardiovascular quality of care in other primary care settings. The research will test point of care strategies alone versus point of care plus population health management strategies. Heart Health Measures that Matter The quality measures that will be the center of this program are known as ABCS aspirin when appropriate, blood pressure control, cholesterol management and smoking cessation. These measures are the focus of the Million Hearts federal initiative and are also centerpieces of many other popular quality and incentive programs, including Meaningful Use, PQRS, VBPM, the ACO Share Savings Programs and many others. Experts partnering to deliver quality support H3 has leveraged 10 leading organizations in the region including four health IT regional extension centers, two quality improvement organizations and the American Medical Association to work with primary care practices on implementing evidence-based strategies to address heart health issues. H3 facilitators come from a variety of clinical and technical backgrounds; and educational opportunities will include the latest knowledge about clinical best practices, as well as emerging quality and pay-for-performance programs.

3 Onboarding (Fall '15, Winter '16 or Spring 2016) PARTICIPATION TIMELINE Facilitation (Months 0-12) Monitoring Months Consent - Software installation - Baseline survey - Training and technical support to use QI tools - Monthly reports and up to weekly coaching sessions - Educational resources and opportunities (e.g., webinars, peer groups, CME credits) - Support to participate in quality and payer programs related to the ABCS EXPECTATIONS - Data collection - Access to tools & resources - Exit survey at 18 months If you choose to take part in the H3 consortium, we hope you will engage in the quality improvement work as fully as possible. You will also be responsible for a small handful of tasks, such as taking surveys and helping to arrange for data collection. In turn, facilitators are committed to providing high-value support and resources. And most importantly, as researchers we take seriously our duty to protect your clinical data. Expectations for H3: Tools, processes and conduct will follow HIPAA guidelines when collecting and analyzing clinical data. Facilitators will provide high-quality, timely support. Coaching will be sensitive to the needs of your practice and your patients. Education will reflect up-to-date, evidence-based information about quality and pay-for-performance programs related to cardiovascular outcomes. Education will be made available both in real time (events) and, whenever possible, posted online for viewing and reference. Expectations for participating practices: Providers and relevant clinical staff will complete surveys at baseline, 12 months and 18 months. The baseline meeting will take 1 hour, and surveys will take approximately 30 minutes to complete. Practices will allow time for coaching.. Providers will work with H3 to establish a safe, secure method for collecting data (e.g. the pophealth tool). Practices may be asked to consider new strategies and tools for quality improvement, which may require some organizational change. When possible, providers and staff will participate in educational events (e.g., webinars). RISKS AND DATA SECURITY Our #1 priority at H3 is the safety of your patients data. We are using HIPAA-compliant software (pophealth and HealtheRx) in this study, and any data that is sent to us for analysis is being stored at Northwestern University using HIPAA-compliant systems. Efforts will be made to limit the use and disclosure of your personal information. We may publish the results of this research. However, we will keep you and your clinic s name and other identifying information confidential. Patient-level data will only be presented in aggregate form. In addition to trained H3 staff, organizations that may audit, inspect and/or copy your information include Northwestern University s Institutional Review Board; other representatives of Northwestern University; H3 partner organizations; and the study sponsor, the Agency for Healthcare Research and Quality.

4 ALIGNMENT WITH OTHER PROGRAMS Education, coaching, webinars, and other tools are chosen with quality improvement and financial incentive programs in mind. Our experienced facilitators and quality improvement experts are equipped to support physicians who are participating or thinking of participating in a wide range of popular provider programs related to the ABCS. Aligned program, initiative, financial incentive or resource ABCS Quality Measures included (Aspirin regimen Blood pressure control, cholesterol management, smoking cessation) Resources available through H3 Chronic Care Management (CPT Code 99490) All X CMS-directed Quality Improvement Organizations (QIOs) All X Healthcare Effectiveness Data and Information Set (HEDIS) All X Medicare Accountable Care Organizations (ACOs) All X Medicare and Medicaid EHR Incentive Programs (Clinical Quality Measures, Clinical Decision Support) All X Merit-Based Incentive Payment System (proposed for 2017) All X Million Hearts All X Patient-Centered Medical Home (PCMH) All X Physician Quality Reporting System (PQRS) All X Value-Based Payment Modifier Program All X CDC State-Based Tobacco Control Programs Smoking only X Regional private insurer quality improvement programs All X A sample of how various programs can incentivize or penalize primary care providers: Chronic Care Management. Providers can now receive approximately $40 per month for each Medicare patient they see with two or more chronic health conditions. To receive the reimbursement, the clinic must provide a patient with non-face-toface services for 20 minutes per month. Medicare and Medicaid EHR Incentive Programs. These EHR Incentive Programs provide payments to eligible professionals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. Meaningful use aims to improve quality, safety, efficiency and reduce racial disparities; engage patients and families; improve care coordination, and population and public health; and maintain privacy and security of patient information. Providers not attesting to meaningful use are now being penalized on Medicare Part B claims. Merit-Based Incentive Payment System (MIPS). This proposed program will incentivize or penalize Medicare providers based on four performance categories: Meaningful use, PQRS, Value-Based Payment Modifiers and clinical practice improvement. PCMH. This model shifts how care is organized and delivered. A team of healthcare providers is accountable for meeting a large majority of the patient s physical and mental health needs, and focuses on five key areas: comprehensive care, patientcentered, coordinated care, accessible services, and quality and safety. PCMH certification may become a way to receive Medicare and possibly Medicaid incentives. PQRS. This quality reporting program encourages individual eligible professionals and group practices to report information on the quality of care to Medicare. Those who report satisfactorily will avoid future penalties on Medicare Part B claims. Value-Based Payment Modifier. The Value Modifier provides payment to a physician or group of physicians under the Medicare Physician Fee Schedule based upon the quality of care furnished compared to the cost of care during a performance period.

5 H3 TECHNOLOGY TOOLS pophealth The pophealth software is a clinical quality measure reporting tool developed by the Office of the National Coordinator for Health IT (ONC) to support providers and EHR vendors in achieving and reporting Meaningful Use of health IT. The H3 program will use the PopHealth tool in three ways: Creating Targeted Support. The tool will create aggregate reports that facilitators will use to provide you targeted coaching to better address your patients needs when they come for a visit. We can also use the data to help determine other types of offerings, such as webinars, that address issues that many of the participating practices are facing. Extracting Data. The software gives us an easy way to extract your data for the research portions of the program. Without pophealth, the study could require laborious chart reviews and time spent by your staff and our researchers to analyze your practice s performance on these cardiovascular measures. pophealth makes the process much faster and safer. Engaging in Population Health Management. For half of the providers in the study, they will also be using the pophealth software to apply a system-based approach to care management. This means they can look at dashboards and reports to make decisions about strategies to best address the needs of their population of patients with cardiovascular conditions. HealtheRx HealtheRx is a new kind of health and wellness prescription. The software matches health information from a patient s electronic medical record with a list of places and programs that meet the patient s health needs and are near his or her home. The recommendations are printed automatically at the end of a health care visit and are also available online. The system is a secure, HIPAAprotected technology that protects patients privacy. For the practices in our study randomized to implement population health management strategies, HealtheRx will be installed to provide connections to community resources for patients with cardiovascular conditions. H3 is partnering with major pharmacies to make sure that up-to-date resources and programs can be subscribed throughout SE Wisconsin, NE Illinois and Northern Indiana.