CCO Incentive Metrics: Requirements for Reporting on EHR- Based Measures in 2015 GUIDANCE DOCUMENTATION

Transcription

1 CCO Incentive Metrics: Requirements for Reporting on EHR- Based Measures in 2015 GUIDANCE DOCUMENTATION Oregon Health Authority Page 1 of 22

2 Contents Section 1: Executive Summary Objective Background Vision Changes in Year Three... 5 Section 2: Components Data Proposal Submission Process & Deadline Review Process Data Submission Submission Process & Deadline Review Process Review Notifications & Communication... 8 Section 3: Specifications... 8 Section 4: Parameters Initial Population Definition and Required Threshold Selection Calculation Report Type Payer Type Measurement Period Aggregation Level Summary of Required Reporting Parameters Section 5: Projected Reporting Requirements in Future Years Population Threshold Report Type, Submission Format, and Aggregation Level Payer Type Measurement Period Frequency Section 6: Contacts Oregon Health Authority Page 2 of 22

3 Appendix A: Meaningful Use and QRDA Appendix B: Year Three (2015) Data Proposal Template Appendix C: Data Proposal Review Form Appendix D: Reporting Parameters by Program Year Oregon Health Authority Page 3 of 22

4 Section 1: Executive Summary 1.1 Objective The purpose of this document is to provide coordinated care organizations (CCOs) with guidance on reporting requirements for the Electronic Health Record (EHR)-based measures in measurement year three (2015). These measures include: Controlling High Blood Pressure Hypertension Diabetes HbA1c Poor Control, and Screening for Clinical Depression and Follow-up Plan Additionally, in 2015 CCOs will have the option to test the collection and submission of tobacco prevalence data in order to prepare for potential future reporting requirements of this data as an EHR-based measure. Final details regarding 2015 guidance for the reporting of tobacco prevalence data will be published no later than October 1 st, Background The Metrics and Scoring Committee originally selected three CCO incentive measures that require clinical (EHR-based) data in addition to administrative (claims-based) data: Controlling High Blood Pressure Hypertension, Diabetes HbA1c Poor Control, and Screening for Clinical Depression and Follow-up Plan. Unlike data reported solely from claims, clinical data can provide information on clinical outcomes. For example, while claims data may demonstrate that a patient with diabetes had a HbA1c test performed, clinical data can demonstrate the resulting value of the test and whether the patient s diabetes is well-controlled. In 2013, OHA held discussions with stakeholders regarding the feasibility of CCOs collecting clinical data, and received extensive feedback from CCOs about their health information technology (HIT) and health information exchange (HIE) infrastructure. Based on these findings, OHA has proposed an incremental reporting approach for measurement years Each year will see increasing expectations for reporting requirements, building to regular electronic submissions of patient-level clinical measure data. Please see Section 5 for details on the projected reporting requirements for 2016 and Vision OHA s vision is that future requirements for clinical quality measure reporting will occur through regular electronic submissions to a Clinical Quality Metrics Registry (CQMR). The CQMR will have the ability to receive and display clinical quality data for the Medicaid program and inform benchmarks and other quality improvement reporting. The registry will be utilized to calculate eligibility for paying quality incentives to CCOs for the EHR-based measures. OHA s intention is to leverage the ability of 2014 certified EHRs to export clinical quality measure data in a standard format, known as Quality Reporting Data Architecture (QRDA), to the CQMR. Provider practices within a CCO network that have upgraded to 2014 certified EHR technology (CEHRT) should be able to export data as QRDA Category III (individual patient data aggregated at the provider level) and QRDA Category I (individual patient-level data). Please see Appendix A for more information about the Meaningful Use program requirements and QRDA. OHA s goal is that Oregon providers meet Meaningful Use requirements and that Oregon Health Authority Page 4 of 22

5 CCOs take action to move their networked providers towards adopting certified health information technology, such as certified EHR technology. Oregon has a unique opportunity to invest in the infrastructure that will move our state toward the vision for electronic reporting of clinical quality data. 1.4 Changes in Year Three The following is a summary of changes to the 2015 requirements from prior measurement years: The minimum population threshold for Screening for Clinical Depression and Follow-up Plan has increased to 50%. A Data Proposal is required prior to the Data Submission (no Technology Plan); the Data Proposal is due on or before December 31 st, Data should be reported at the practice level (unless submitting provider-level QRDA Category III). One measurement period will be accepted: calendar year 2015, with exceptions considered for practices that were not on a single EHR product for the full calendar year. Another significant change in 2015 is related to the payment methodology, as incentive payment eligibility for the EHR-based measures will fully transition from pay-for-reporting to pay-forperformance. Additional information can be found in the 2015 Benchmarks documentation, currently available on the CCO Incentive Metrics webpage, as well as the 2015 Quality Pool Methodology which will be posted to the webpage no later than December 1 st, Section 2: Components There are two components required to report on the EHR-based measures in 2015: a Data Proposal and a Data Submission. A description of these items, as well as the required process and due dates are outlined below. 2.1 Data Proposal In 2013 and 2014, CCOs were required to submit a narrative document, known as the Technology Plan, prior to submitting the EHR-based measure data. The completed Technology Plan outlined the CCO s first steps towards building on-going capacity for EHR-based measure reporting. The Year One Technology Plan required an extensive overview of the CCO s technological capacity, including EHR adoption, health information exchange, and other HIT initiatives. The initial Technology Plan was foundational in design, and the extensive information provided by each CCO describing their unique HIT environment was invaluable to the OHA. In Year Two, the scope of the Technology Plan was pared down in order to emphasize the requirements for reporting on EHR-based measures. In both years, an advance distribution of the CCO s final quality pool payment was paid upon approval of the Technology Plan in order to support the additional infrastructure necessary to report the EHR-based measures. In 2015, OHA is modifying the previous years requirement for a Technology Plan. Instead of a general overview of the CCO s HIT environment, OHA will require CCOs to submit an overview only of the CCO s proposed Data Submission. The Data Proposal is intended to fulfill two specific objectives related to reporting the EHR-based measures in 2015: Oregon Health Authority Page 5 of 22

6 1. Demonstrate that the proposed Data Submission will meet the necessary requirements (e.g., minimum population threshold). 2. Improve validity of the data to ensure that measures are being reported according to the required specifications Submission Process & Deadline The Data Proposal must be submitted utilizing the Year Three (2015) Data Proposal Template, included in Appendix B and available on the CCO Incentive Metrics webpage. The template must be submitted to OHA no later than 5:00 p.m. Pacific Time on December 31 st, 2015 and should be submitted to [email protected] Review Process In 2015 there is no advanced distribution of the CCO s final quality pool payment associated with the submission of the Data Proposal. This is in line with expectations that requirements for the EHR-based measures will fully transition to a pay-for-performance methodology. Although there is no advance distribution, the Data Proposal is a required reporting component and the Data Proposal will be subject to a review process. Once received, OHA will review the Data Proposal and notify the CCO of the results no later than January 29 th, The review criteria is outlined in the Data Proposal Review Form, included in Appendix C. If additional information is requested by OHA, the CCO will have 10 business days to respond and/or resubmit the Data Proposal as needed. OHA will then review the resubmitted Data Proposal and notify the CCO of the results within 10 business days. As necessary, the review process will be iterative as OHA and the CCO work collaboratively to identify and address issues identified in the Data Proposal. Although not anticipated, the review process may extend until the deadline for approval of the Data Proposal, which is 5:00 p.m. Pacific Time on March 31 st, OHA approval of the Data Proposal is required prior to the Data Submission. 2.2 Data Submission Table 1: Submission Format & Report Type If the practice is utilizing this report type: QRDA Custom Query Meaningful Use Attestation Report The Data Submission is a report/data file from the CCOs that contains the required measure data for the EHR-based measures. In 2015, CCOs are required to submit data to OHA for the three EHR-based measures. Additionally, CCOs will have the option to test the collection and submission of tobacco prevalence data in order to prepare for potential future reporting requirements of this data as an EHR-based measure. Specific guidance for reporting tobacco prevalence data in 2015 will be published no later than October 1 st, The Year Three Data Submission is intended to build upon the capacity and infrastructure created through the Year One and Year Two reporting processes. In 2015, OHA will accept data in two submission formats: 1. XLS file (i.e., Excel template provided by OHA) 2. XML file (i.e., QRDA) The appropriate submission format is:.xml file.xls file.xls file Oregon Health Authority Page 6 of 22

7 The report type (see Section 4.2 Report Type) utilized for reporting data will determine the appropriate submission format; an overview of these details is included in Table 1. OHA will publish the 2015 CCO Data Submission Template to the CCO Incentive Metrics webpage no later than October 1 st, The template will be an Excel spreadsheet in a similar format to Year One and Year Two, however, there may be additional expectations for data format and meta-data fields Submission Process & Deadline In 2015, due to the fact that OHA is not accepting patient-level data (see Section 4.5 Aggregation Level), the Data Submission Template may be sent via secure to [email protected]; the template must be submitted to OHA no later than 5:00 p.m. Pacific Time on April 1 st, Review Process Once received, OHA will begin the initial review of the Data Submission. The objective of the initial review is to confirm completeness of the Data Submission. The CCO will be notified of the results of the initial review within 10 business days of the date the Data Submission was received. If additional information is requested during the initial review, the CCO will have 10 business days to respond and/or resubmit the Data Submission as needed. Once the initial review is complete, OHA will begin the secondary review. The objective of the secondary review is an evaluation of the content of the Data Submission. The CCO will be notified of the results of the secondary review within 30 business days of the date the Table 2: Expected Data Submission Review Criteria Initial Review Was submission received by the deadline? Was the data submitted utilizing the required process and correctly labeled so submission could be identified? Was data received in the appropriate format? Does the Data Submission match information provided in the data proposal? Is the Data Submission missing data for any required fields for any practice? Secondary Review secondary review was initiated. If additional information is requested during the secondary review process, the CCO will have 10 business days to respond and/or resubmit the Data Submission as needed. As necessary, both the initial and secondary review processes will be iterative, as OHA and the CCO work collaboratively to identify and address issues identified in the Data Submission. Although not anticipated, the review process may extend until the deadline for approval of the Are requirements for data parameters met? Are data elements understood for each measure? If custom queries were utilized, are they aligned with the CMS July 2014 Update for the 2015 Reporting Year? Are there any perceived issues with data validity? Issues may include the following: o Zero denominators o Low denominators o Exclusions higher than expected o Zero numerator o Incorrect rate calculations (i.e., greater than 100%) Oregon Health Authority Page 7 of 22

8 Data Submission, which is 5:00 p.m. Pacific Time on May 31 st, The final review criteria for both the initial and secondary reviews will be published as Review Forms and will be posted to the CCO Incentive Metrics webpage, along with the 2015 CCO Data Submission Template, no later than October 1 st, OHA s expectation is that the review criteria will be similar to that noted in Table Review Notifications & Communication notifications will be sent to the individuals included on the Data Submission distribution list at the conclusion of the initial review and the secondary review. The CCO s Innovator Agent will be copied to ensure communications reach the appropriate individuals at the CCO. CCOs may submit questions about the Data Proposal or Data Submission at any point during this process. Innovator Agents should be copied on all communication regarding the Data Proposal and Data Submission. Section 3: Specifications OHA requires data for the three EHR-based measures to be aligned with the specifications utilized for the EHR Incentive Program (Meaningful Use). These measures are endorsed by the National Quality Forum (NQF) and are often referenced according to their NQF ID (i.e., NQF 0018, NQF 0059, and NQF 0418); however, the specifications utilized are specific to the Meaningful Use program and have a corresponding CMS ID as noted in Table 3. Table 3: Measure IDs Measure Name Controlling High Blood Pressure Hypertension Diabetes HbA1c Poor Control NQF ID NQF 0018 NQF 0059 CMS ID CMS165v3 CMS122v3 This is an important distinction as some technology products may Screening for Clinical Depression and Follow-up Plan NQF 0418 CMS2v4 report these measures for other quality programs that utilize claims based reporting and therefore may not be aligned with OHA s required specifications. For example, in 2014 the Physician Quality Reporting Program (PQRS) specifications for NQF 0418 included the use of G-codes for numerator completion; however, the use of G-codes for numerator completion do not align with EHR-based reporting specifications utilized by OHA or the EHR Incentive Program. OHA s specifications for the 2015 CCO incentive measures, as well as the required benchmarks, can be found on the CCO Incentive Measures webpage. These specifications utilize the 2014 ecqm Specifications for Eligible Professionals Update July which can be found in the CMS ecqm Library. In addition to the specifications, the CMS ecqm Library includes a number of other resources related to the ecqm development such as logic flows, logic guidance and release notes, and a QRDA Implementation Guide. The OHA and CMS ecqm specifications reference Value Sets for the numerator, denominator, denominator exclusion, and denominator exception criteria. Value Sets are specific code sets 1 The 2014 ecqm Specifications for Eligible Professionals Update July 2014 include ICD-10 criteria. Oregon Health Authority Page 8 of 22

9 to capture clinical concepts and patient data in the EHR and provide definitions of the codes necessary to calculate the ecqm. The Value Sets for each measure are stored by The National Library of Medicine Value Set Authority Center (VSAC). VSAC is provided by the National Library of Medicine (NLM), in collaboration with the Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services. Through the VSAC, providers, implementers, and developers can access the Value Sets for each ecqm for the EHR Incentive program. Access to the VSAC website requires a free license, due to usage restrictions on some of the codes included in the value sets. A license may be requested by navigating to the VSAC website and clicking sign in. If a user does not have the necessary license, the option to request one will be provided at that time. Another resource for detailed ecqm information is the United States Health Information Knowledgebase (USHIK). USHIK is a publicly accessible registry and repository of healthcarerelated metadata, specifications, and standards. USHIK is funded and directed by the Agency for Healthcare Research and Quality (AHRQ) with management support and engagement from numerous public and private partners. Access to the USHIK requires the same license/account required to access the VSAC. Any CCOs or practices within the CCO s network that report measure data via a custom query will need to access the VSAC or USHIK for the level of detail necessary to ensure the measure logic utilized for reporting is aligned with the required specifications. OHA reserves the right to request additional detail for any data that is submitted via a custom query. Section 4: Parameters In addition to utilizing the specifications as outlined in Section 3 of this document, OHA requires data to be submitted according to specified parameters. The parameters specified include a required population threshold, report type, payer type, measurement year, and aggregation level; requirements for each of the parameters are presented below. 4.1 Initial Population Definition and Required Threshold The EHR-based measures require that a specified minimum percentage of the CCO membership with physical health benefits are identified as the Initial Population for reporting. The Initial Population is the pool of individuals that may be included in the denominator count, provided that certain inclusion criteria are met. The requirement to identify a minimum percentage of the membership as the initial population is referred to as the population threshold. The required population threshold is not condition specific (e.g., CCOs do not need to include 50% of their members with diabetes) but it does apply to each measure. For example, the CCO cannot submit data that includes 10% of the population for the Screening for Clinical Depression and Follow-up Plan measure and 40% of the population for the Diabetes HbA1c Poor Control measure. OHA has adopted an incremental approach with increasing expectations each year for the population threshold associated with each measure. This approach is intended to account for the fact that for many CCOs, the development of capacity to support an EHR-based reporting methodology is on-going. In 2015, OHA s required population threshold for all EHR-based Oregon Health Authority Page 9 of 22

10 measures is 50% of the CCO membership with physical health benefits. This is an increase of 25% from the 2014 population threshold for NQF 0418 Screening for Clinical Depression and Follow-up Plan. There is no increase from the 2014 population threshold for NQF 0018 Controlling High Blood Pressure Hypertension or NQF 0059 Diabetes HbA1c Poor Control. The expected population threshold requirement for the tobacco prevalence data is also 50%, however, final requirements will be published as an addendum to this document no later than October 1st, Please see Section 5 of this document for more details about OHA s projections for increases in the required population threshold in future program years. Table 4: Required Population Threshold Measure Required Population Threshold in 2015 Controlling High Blood Pressure Hypertension 50% No Diabetes HbA1c Poor Control 50% No Increase from 2014? Screening for Clinical Depression and Follow-up Plan 50% Yes (25% in 2014) Selection Due to the fact that EHR-based reporting capacity is typically supported at the organization or practice level, selection of the Initial Population occurs at the organization/practice level. For the purposes of this document, organization refers to a health system (e.g., Acme Health System) while practice refers to multiple clinic locations within an organization (e.g., Acme Health West Town, Acme Health East Town, etc.). The Initial Population is the count of CCO members empaneled at the selected organizations/practices at the end of the measurement period and is inclusive of adults and children with physical health benefits (i.e., CCO-A and CCO-B). It is not a requirement to include all practices that comprise an organization within the data submission, provided that population counts can be provided for each individual practice. It is a requirement, however, that data for all MDs, DOs, NPs, and PAs at a selected organization/practice are included in the Data Submission. OHA s expectation is that the CCO will build upon the practice set utilized for reporting in prior program years. For any practices that have been included in a prior year, but are not included in the current year, OHA will require exclusion rationale to be included within the Data Proposal (see: Additional Information table within the Year Three Data Submission Template). Additionally, increases in the expected population threshold may require that additional organizations/practices are added to the practice set. Organizations/practices that meet one or more of the following criterion should be prioritized for inclusion: Primary care practices Practices that have implemented the required Health Information Technology (e.g., EHR certified for use in the EHR Incentive Program) Practices that see a high volume of Medicaid beneficiaries Practices where a high prevalence of the measure conditions exist Oregon Health Authority Page 10 of 22

11 Practices where any tailored efforts are underway to reach members with depression or to improve network capacity to address depression OHA reserves the right to require CCOs to reevaluate an approach that omits organizations/practices that meet one or more of these criteria Calculation As noted in Section 4.1.1, the Initial Population is the count of CCO members assigned at the selected organizations/practices that will be included in the Data Submission. The Initial Population count is provided by the CCO in the Data Proposal Template (see Appendix B of this document) and should be: Representative of patients assigned to the selected organization/practice for primary care purposes Inclusive of adults and children Inclusive of members with physical health benefits (i.e., CCO-A and CCO-B members) Accurate as of the end of the measurement period (i.e., a date sometime within December 2015) In order to identify the Total CCO Physical Health Membership, OHA staff will utilize the count provided in the December 2015 Physical Health Service Delivery by County report found on OHA s OHP Data and Reports webpage. OHA will utilize the following calculation to determine whether the required minimum population threshold is met: Oregon Health Authority Page 11 of 22

12 4.2 Report Type In future years, EHR-based measure data will be submitted electronically to OHA s Clinical Quality Metrics Registry. In order to facilitate electronic submission, OHA will leverage the requirements in place for EHRs certified for use in the EHR Incentive Program to support the electronic submission of Clinical Quality Measure (CQM) data as outlined in the 2014 Standards and Certification Criteria (S&CC), the federal rule for EHRs certified for use in the Meaningful Use program. These criteria, published by The Office of the National Coordinator (ONC) for Health Information Technology in September 2012, require a certified EHR to have the ability to export CQM data from the EHR in a specified format, the HL7 Quality Reporting Data Architecture (QRDA). Two categories of the QRDA were adopted: Category I to support the submission of patient-level data and Category III to support the submission of aggregate level data. The use of the QRDA Category I and Category III standards are expected to remain required functionality of HIT certified for use in the EHR Incentive Program. At the time this document was published, proposed rules for Stage 3 of the program have been released by CMS. The proposed rule includes a requirement that, beginning in 2018, all CQM reporting for the Medicare EHR Incentive Program must occur through electronic submission. As OHA continues to develop the CQMR, a statewide technology solution capable of receiving electronic data files, the criticality of a common standard for electronic reporting is evident. The use of a common standard will assist in OHA s efforts toward alignment of quality reporting requirements and the feasibility of utilizing the CQMR to support a report once strategy. While the availability of the QRDA is increasing, it is expected that some practices may not be able to submit data to OHA utilizing the QRDA format. This fact, in addition to OHA s intention to allow an interim strategy to practices that are still building this capacity, were taken into account when identifying the report types that OHA will accept for reporting of EHR-based measure data in For the 2015 program year, OHA will accept data from the following report types: 1) QRDA Category III files 2) EHR vendor-provided Meaningful Use attestation reports 3) Custom Queries Please see Section 5 of this document for more details about the report types OHA expects to accept in future program years. 4.3 Payer Type The payer type is the payer associated with patients included in the measure data. OHA s preference is that the CCO submits data for CCO Medicaid beneficiaries only, and this will be a requirement for future patient-level data submissions. However, OHA acknowledges that the functionality to parse data by payer (i.e., filter out non-medicaid beneficiaries from the Data Submission) is still largely unavailable when utilizing vendor provided reports. Therefore, for data submitted in aggregate as QRDA or from a Meaningful Use attestation report, OHA will accept data that includes beneficiaries of all payers. Data reported via a custom query must include CCO Medicaid beneficiaries only. Please see Table 5 for the required payer types in Oregon Health Authority Page 12 of 22

13 Table 5: Payer Type Required in 2015, by Report Type If the practice is utilizing this Report Type: QRDA Category III The appropriate Payer Type is: CCO Medicaid only (preferred) All Payers Custom Query CCO Medicaid only Meaningful Use Attestation Report CCO Medicaid only (preferred) All Payers Please see Section 5 of this document for more details about the payer types OHA expects to require in future program years. 4.4 Measurement Period In 2015, OHA requires a full calendar year of data: January 1 st, 2015 to December 31 st, An exception may be granted if a practice did not have an EHR implemented for the full calendar year (e.g., a practice adopted an EHR for the first time, a practice replaced an EHR during the measurement year). Upon OHA approval, these practices will be allowed to report a modified measurement period; exceptions must be requested at the time the Data Proposal is submitted (see: Additional Information table within the Year Three Data Submission Template) on or before December 31 st, Please see Section 5 of this document for more details about the measurement period OHA expects to require in future program years. 4.5 Aggregation Level The data aggregation level is the level in the network s hierarchical structure at which data is sliced and submitted to OHA. For the purposes of this document, organization refers to a health system (e.g., Acme Health System) while practice refers to multiple clinic locations within an organization (e.g., Acme Health West Town, Acme Health East Town, etc.). Depending on the reporting need, data for individual patients might be aggregated and reported at the practice, organization, or CCO level. The majority of reports for Meaningful Use, both those in QRDA format as well as attestation reports, will aggregate the data at the provider level. Due to requirements from other quality reporting Table 6: Data Aggregation Level Required in 2015, by Report Type If the practice is utilizing this Report Type: QRDA Category III Custom Query Meaningful Use Attestation Report The appropriate Data Aggregation Level is: programs (e.g., the Comprehensive Primary Care Initiative), practices may have the ability to report data from Meaningful Use reports at the practice level. Where available, OHA s preference is to receive data at the practice level, but provider level data will be accepted for practices that utilize the QRDA Category III or Meaningful Use attestation reports. Provider level data should not be submitted for data reported via a custom query. Please see Table 6 for the required appropriate aggregation level, depending on report type. Please see Section 5 of this document for more details about the data aggregation level OHA expects to require in future program years. Oregon Health Authority Page 13 of 22 Practice (preferred) Provider Practice (preferred) Organization Practice (preferred) Provider

14 4.6 Summary of Required Reporting Parameters As noted in Sections , the reporting parameters for submission format, payer type, and aggregation level are, to some extent, dependent on the report type utilized by each practice. Please see Table 7 for a review of the reporting parameters that correspond with each report type. Table 7: Required Reporting Parameters Report Type QRDA Category III Meaningful Use Attestation Report Custom Query Submission Format Payer Type.XML files CCO Medicaid Only (preferred) All Payers.XLS file CCO Medicaid (OHA Only (preferred) Template) All Payers.XLS file CCO Medicaid (OHA Only Template) Measurement Year Calendar Year 2015 Calendar Year 2015 Calendar Year 2015 Aggregation Level Practice (preferred) Provider Practice (preferred) Provider Practice Organization Section 5: Projected Reporting Requirements in Future Years OHA s vision is that reporting on the EHR-based measures in future years will occur through regular electronic submissions of patient-level data to the Clinical Quality Metrics Registry (CQMR). The go-live date for the CQMR is to be determined, but OHA projects that this solution will be in place in Q1/Q2 of 2017, in advance of the Year Four (2016) Data Submission deadline. OHA acknowledges that achieving this vision requires development of additional capacity at the CCO practice and state level, and has adopted an approach with incremental increases to reporting requirements each year. Projected reporting requirements for Year Four (2016) and Year Five (2017) are outlined below; please see Appendix D for a visual depiction of the incremental increases throughout Years One through Five ( ). This information is being provided to allow CCOs additional time to plan for future reporting years; however, at the time of this document s publication, this information represents draft requirements only. OHA reserves the right to modify the requirements as outlined in this section and in Appendix D. Final requirements for Year Four (2016) will be published in Q1 of Population Threshold Due to the fact that implementation of an EHR is a dependency to report on these measures, OHA does not have an expectation that 100% of the CCO s primary care network will be able to report data. However, there is an expectation that the population threshold associated with each measure will increase in future years. In 2016, the draft requirement for the population threshold is 65%. In 2017, the draft requirement for the population threshold is 75%. These percentages were chosen to align with the selected benchmark and progress made on the Electronic Health Record Adoption measure. In the 2014 Health Systems Transformation Report, it was noted that 67.7% of eligible providers had adopted certified EHRs. At the time of this document s publication, OHA does not anticipate the population threshold rising above 75% in future years. Oregon Health Authority Page 14 of 22

15 5.2 Report Type, Submission Format, and Aggregation Level OHA s intention for EHR-based measure reporting includes leveraging functionality in 2014 CEHRT to enable electronic submission of clinical quality measure data. OHA plans to phase out the ability to use Meaningful Use attestation reports in 2016 due to the fact that the CCOs use of EHR vendor-provided Meaningful Use attestation reports does not demonstrate capacitybuilding towards electronic reporting. The ability to use these reports in 2013, 2014, and 2015 was intended to serve as an interim solution while EHR vendors continue to build out the availability of quality measure data as QRDA. As EHR vendors continue to develop support for the QRDA format, movement from aggregate QRDA Category III measure data to patient-level QRDA Category I measure is expected. OHA s vision for electronic reporting of EHR-based measure data is that future years will require the reporting of patient-level data, in QRDA Category I. In 2016, OHA draft requirements include aggregated data submitted as QRDA Category III or in OHA s Custom Template. In addition, there will be expectations for a test submission of patientlevel data. In 2017, OHA s draft requirements include patient-level data submitted as QRDA Category I or in OHA s Custom Template. OHA anticipates that to some extent, custom queries and a custom reporting template will continue to be necessary, and will work with the CQMR vendor and CCO stakeholders to further refine this process. 5.3 Payer Type OHA s preference is that any data submitted for the CCO Incentive Measures includes CCO Medicaid beneficiaries only. However, as OHA s intention is to leverage existing Meaningful Use reports (i.e., EHR vendor-provided attestation reports in and QRDA on an ongoing basis), this has required flexibility in allowing aggregated data to be submitted for all payer types as many Meaningful Use reports do not have the ability to parse the data by payer. Many CCOs have chosen to utilize custom queries for measure reporting, with consideration to this current lack in functionality. While the final federal rule for the 2017 Standards & Certification Criteria for HIT not yet been released, the current draft requires additional requirements to increase flexibility of reporting quality measure data as QRDA. Once the CQMR is operational (projected in Q1/Q2 of 2017), OHA expects the solution to be able to parse patient-level data by payer to meet appropriate program needs. This functionality is intended to help enable the possibility of leveraging the CQMR for entities participating in multiple quality reporting programs to report once and submit data for additional payer types in a single submission. 5.4 Measurement Period OHA expects that a full calendar year will remain the required measurement period for reporting in future years. Exceptions may continue to be considered for practices in the CCO s network that did not have an EHR implemented for the full calendar year (e.g., a practice adopted an EHR for the first time or a practice replaced an EHR during the measurement year). 5.6 Frequency OHA expects that an annual submission will continue to be the required reporting frequency in 2016 and Once the CQMR is operational (projected in Q1/Q2 of 2017), OHA may consider increasing reporting requirements for more frequent submission. Oregon Health Authority Page 15 of 22

16 Section 6: Contacts For questions related to the content of this document, or the CCO Incentive Measure Program, please contact For questions related to the Medicaid EHR Incentive program, please contact Oregon s Medicaid EHR Incentive Program at or [email protected]. For questions related to the Medicare EHR Incentive Program, please contact: CMS at (primary number) or (TTY number). Oregon Health Authority Page 16 of 22

17 Appendix A: Meaningful Use and QRDA The Office of the National Coordinator for Health Information Technology (ONC) is the entity through which an Electronic Health Record (EHR) product receives certification for use within the EHR Incentive Program (Meaningful Use). The 2014 Edition Standards & Certification Criteria (S & CC) can be found at and includes certification criteria for clinical quality measures focused on data capture, calculation, and export to enable electronic submission of clinical quality measure (CQM) data. The Certified Health IT Product List (CHPL) for the 2014 Edition S&CC can be found at One criterion of the 2014 S&CC is the capability for EHRs to export clinical quality measure in a standard HL7 format: Quality Reporting Data Architecture (QRDA). QRDA is a Clinical Document Architecture (CDA) based standard for reporting health care quality measurement data. 2 There are three QRDA categories: QRDA Category I (single-patient report) o An individual patient-level report containing quality data for one patient for one or more quality measures. o QRDA I reports will be generated for all patients within the health information system who meet the quality measure(s), regardless of payer type. QRDA Category II (patient list report) o A multi-patient report across a defined population that may or may not identify individual patient data within the summary. QRDA Category III (calculated report) o An aggregate report containing calculated summary data for one or more measures for a given population over a specific period of time. o No individual patient data is included. o XML document. For more information about QRDA: Educational Webinar: Overview of QRDA Category I and III Reports (April 2013) Guidance/Legislation/EHRIncentivePrograms/Downloads/VendorWorkgroupCall_April16.pdf 2 Information in this section adapted from a June 2013 Office of the National Coordinator for Health IT (ONC) presentation by Gaye Dolin and Russ Ott: Quality Reporting Document Architecture (QRDA) Overview. Oregon Health Authority Page 17 of 22

18 Appendix B: Year Three (2015) Data Proposal Template CCO Name: Click here to enter text. The Data Proposal is the narrative required prior to submission of EHR-based measure data and is intended to fulfill two specific objectives related to reporting the EHR-based measures in 2015: 1. Demonstrate that the proposed Data Submission will meet the necessary requirements. 2. Improve validity of the data by ensuring that measure data is aligned with the required specifications. Please complete the tables below, rows may be added or deleted as necessary. The completed Data Proposal is due to OHA no later than 5:00 p.m. Pacific Time on December 31 st, 2015; please submit to and copy the CCO s Innovator Agent. Organizations/Practices in the Year Three Data Submission Please complete this table with the information requested for each organization/practice included in the Year Three Data Submission. If all practices (i.e., physical sites) in an organization (i.e., health system) will be included in the Data Submission, a single row may be completed for the entire organization. Please note that the parameters chosen for the level of data aggregation and payer type should align with the expectations for each report type, as outlined in Table 4 of the Year Three Guidance Documentation. The option N/A may be chosen for any measures for which the organization/practice will not be submitting data. Organization & Practice Name **EXAMPLE** Acme Health System East Town EHR Product Name and Version Number Centricity 9.8 # of Primary Care Providers # of CCO Members 8 Adult: 783 Child: 274 Adult: Child: Adult: Child: Report Type: Screening for Clinical Depression and Follow-up Plan: NQF 0418 N/A Report Type: Controlling High Blood Pressure Hypertension: NQF 0018 Custom Query Report Type: Diabetes HbA1c Poor Control: NQF 0059 Custom Query Level of Data Aggregation Practice Payer Type CCO Medicaid Only Oregon Health Authority Page 18 of 22

19 Adult: Child: Adult: Child: Adult: Child: Adult: Child: Additional Information Comments The # of CCO Members provided in the table above is current as of: Will all practices in the data submission submit data for the entire calendar year of 2015? Are all practices from the Year One and Year Two Data Submissions included? Are all primary care providers at each organization/practice included in the data submission? Click here to enter a date. Yes No Yes No Yes No The date provided must be within December If no, please provide exclusion rationale in the comments column If no, please provide exclusion rationale in the comments column. If no, please provide exclusion rationale in the comments column. Specifications Specifications for the 2015 CCO Incentive Measures can be found on the CCO Incentive Measures webpage. OHA s specifications align with the CMS specifications released in July 2014 for the 2015 Meaningful Use Reporting Year which can be found in the CMS ecqm Library. Oregon Health Authority Page 19 of 22

20 For each practice in the Data Submission that is submitting data for NQF 0418 Screening for Clinical Depression and Follow-up Plan via a custom query, please provide the information requested in the table below. If common specifications for NQF 0418 were utilized at each practice that reported via a custom query, this can be indicated by noting All in the Organization & Practice Name column. During the review process, OHA may request additional detail for any measures submitted via custom query. Organization & Practice Name Which data elements were utilized to report on the follow-up component of NQF Screening for Clinical Depression and Follow-up Plan? Please select all that apply: Additional evaluation for depression Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression Please select all that apply: Additional evaluation for depression Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression Is this practice able to report exclusions? Yes No Yes No Is this practice able to report exceptions? Yes No Yes No Comments Oregon Health Authority Page 20 of 22

21 Appendix C: Data Proposal Review Form CCO Year Three Data Proposal: Review Form CCO Name. Review completed on: Click here to enter date. Review completed by: Click here to enter text. Technology Plan Required Elements Review Criteria Approved Reviewer Notes Organizations/Practices in the Year Three Data Submission Identification of Organizations/Practices Are all practices from prior Click here to enter text. years data submissions included? Reporting Parameters Will the submission meet the Click here to enter text. required population threshold? Are reporting parameters appropriate? Overall comments Click here to enter text. Specifications Follow-up component for NQF 0418 Screening for Clinical Depression and Follow-up Plan Do the data elements utilized align with the required specifications? Click here to enter text. Overall comments Click here to enter text. Oregon Health Authority Page 21 of 22

22 Appendix D: Reporting Parameters by Program Year Oregon Health Authority Page 22 of 22