Comprehensive Primary Care (CPC) Assessment

Comprehensive Primary Care (CPC) Assessment

Meaningful Use: The Building Block for CPC By Denise Anderson, Ph.D. NJ-HITEC February, 2013 The Centers for Medicare and Medicaid Services (CMS) jump-started the Health Information Technology evolution through its Electronic Health Record (EHR) Incentive Programs. Furthermore, for those who believe that Health IT is a passing fad, the statistics state the opposite Health IT is here to stay. According to a study published in the 2013 January/February issue of the Annals of Family Medicine, EHR adoption by family physicians has doubled since 2005, with researchers estimating that the adoption rate will exceed 80 percent by the end of 2013. (Healthcare IT News, January 15, 2013.) Moreover, CMS has already distributed billions of dollars in federal incentives and that amount grows daily. The term Meaningful Use has become synonymous with EHR technology, and achieving Meaningful Use of an EHR system is the building block for additional programs that utilize Health IT as their foundation. Two such programs are the Comprehensive Primary Care (CPC) and the Patient-Centered Medical Home (PCMH) initiatives. The CMS CPC is a multi-payer initiative fostering collaboration between public and private healthcare payers to strengthen primary care. Medicare is working with commercial and State health insurance plans and offers bonus payments to primary care providers (PCPs) who better coordinate care for their patients. The 500 primary care practices that were selected to participate in this initiative are given resources and guidance to better coordinate primary care for their Medicare patients. In August 2012, CMS announced the practices chosen to participate in this initiative. These practices represent over 2,100 providers serving an estimated 313,000 Medicare beneficiaries across the country and include the following markets: the State of Arkansas, the State of Colorado, the State of Oregon, New York s Capital District-Hudson Valley Region, Ohio and Kentucky s Cincinnati-Dayton Region, Oklahoma s Greater Tulsa Region, and the State of New Jersey. In New Jersey, CMS selected 71 primary care practices that include 272 providers to benefit over 41,000 Medicare beneficiaries. The payees along with CMS include Amerigroup, AmeriHealth NJ, Horizon Blue Cross Blue Shield of NJ, Teamsters Multi-Employer Taft Hartley Funds and UnitedHealthcare. The organizations collaborating to assist the practices through this process are TransforMED, New Jersey Academy of Family Physicians (NJAFP), and the New Jersey Health Information Technology Extension Center (NJ- HITEC). TransforMED is assisting in the overall project coordination, NJAFP is providing the in-house support for practice transformation, and NJ-HITEC, deemed by CMS as the faculty expert, is providing the education and training. NJ-HITEC s North Jersey Services Provider Coordinator, Dena Ragusa, explains, NJ-HITEC s role in this project is to function as "expert faculty" to the New Jersey CPC partners. This initiative is testing the idea that by supporting primary care, we have the opportunity for better health, better care, and decreased

healthcare system costs. NJ-HITEC is proud to be part of this initiative and contribute to the efforts of healthcare reform as well as practice transformation." It is fitting that NJ-HITEC provides the tools and education necessary for the primary care practice transform process because the Meaningful Use requirements tie into the reporting milestones for CPC. Ragusa, the lead on this initiative for NJ-HITEC, adds, There are nine milestones which primary care practices have to meet for CPC. The fifth milestone - Use Data to Guide Improvement to Care at the Provider/Care Team Level relates to the Clinical Quality Measures that a provider s EHR system should be reporting to achieve Meaningful Use. Ragusa further explains, NJ-HITEC has developed a tool that will assist the providers in understanding how to utilize their EHR system to meet the CPC milestones. The tool emphasizes how Meaningful Use measures are incorporated in the CPC milestones and how a provider can use a certified EHR system to meet those milestones. By comparing these measures, we are able to guide providers on other possible system functionality that may be necessary for this initiative. The tool is rolling out in New Jersey and Arkansas first and then we anticipate this tool to be used nationally. NJ-HITEC will also be providing numerous webinars on topics such as Meaningful Use Stage 2 and Stage 1 Updates; Clinical Quality Reporting; Public Health Agencies (Registries); Utilizing EHRs for Data Collection and Data Reporting; and more. NJ-HITEC Executive Director Bill O Byrne adds, We have established ourselves as Meaningful Use subject matter experts as well as national leaders in Health IT. We earned this reputation because of our knowledge and dedication to assisting physicians reach Meaningful Use Stage 1, Year 1. Approximately 90 percent of the practices selected to participate in New Jersey s CPC initiative are NJ-HITEC members and have achieved Stage 1 Meaningful Use. This confirms that our outreach efforts are successful. We welcome the opportunity to share our expertise with the PCPs selected as well as NJAFP and TransforMED. The selected CPC practices will be tracked through 2013 to determine if the initiative milestones, once met, result in cost savings for CMS and the insurers as well as improve the quality of healthcare delivery to patients. It is expected that if the results are positive, this program will continue.

Comprehensive Primary Care (CPC) Cross-Walk Meaningful Use retrieve a patient s problem list for longitudinal care. Stage 1 Core Objective 5 Applying Meaningful Use CMS Initiatives Measures Milestone 1: Complete an Annual Budget or Forecast Accountable Care Organization Milestone 2: Provide Care Management for High Risk Patients Stage 1 Core Objective 3 Accountable Care Maintain Up-to-Date Problem List record a diagnosis in a Organization structured format to identify high risk CMS Data Registry patients. Maintain Active Medication List Reduce medication errors, assist with risk stratifying patients, and communication of medications to patient and other health care providers to aid in medication reconciliation. Stage 1 Core Objective 9 Stage 2 Core Objective 5 Record Smoking Status retrieve the smoking status of a patient. Stage 1 Core Objective 10 Stage 2 Clinical Quality Measures Electronically calculate six (6) Clinical Quality Measures (CQMs) Stage 1 Menu Objective 3 Stage 2 Core Objective 11 Generate Patient Lists Electronically select, sort, retrieve, and generate lists of patients according to the data elements included in: Problem list, Medication list, Demographics; and Laboratory test results. identify patients on medications with potential adverse side effects, assisting in patient stratification and identify high risk patients. identify patients of higher risk of pulmonary and cardiac disorders which can be incorporated during risk stratification. Utilize an EHR to monitor one or more quality measures by developing priorities, support needs, and track improvements through data. Utilize the reporting function in an EHR to run patients lists sorted by care conditions, race or ethnicity. Diabetes Mellitus (DM) Measures Group Chronic Kidney Disease (CKD) Measures Group Preventative Care Measures Group Coronary Artery Bypass Graft(CABG) Measures Group Heart Failure (HF) Measures Group Coronary Artery Disease (CAD) Measures Group HIV/AIDS Measures Group Chronic Obstructive Pulmonary Disease (COPD) Measures Group Hypertension (HTN) Measures Group Oncology Measures Group Patient-Centered Medical Home Standard 2: Identify and Manage Patient Populations Standard 3: Plan and Manage Care Standard 4: Provide Self-Care Support and Community Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance Considerations Utilize CPC Budget Tool Use the CPC Budget tool to complete a practice assessment and forecast a budget. Custom Templates It may be necessary to work with an EHR vendor to create custom templates to structure data and create reportable information. Custom Templates can be used to track risk stratification and care plans.

Stage 1 Core Objective 14 Stage 2 Core Objective 9 Protect Electronic Health Information Access Control: Assign a unique name and/or number. Emergency Access: Permit authorized user s health information during an emergency. retrieve a patient s problem list for longitudinal care. Stage 1 Core Objective 7 Stage 2 Core Objective 3 Milestone 3: Ensure 24/7 Patient Access Guided by Medical Records Portal vs. Web Page 24/7 access to Protected Health Information (PHI) must conform to the standards in Meaningful Use of protecting PHI. Utilize a privacy and security risk assessment and analysis. Patient-Centered Medical Home Standard 1: Enhance Access and Continuity Standard 4: Provide Self-Care Support and Community Standard 6: Measure and Improve Performance Milestone 4: Assess and Improve Patient Experience of Care Stage 1 Core Objective 3 Maintain Up-to-Date Problem List record a diagnosis in a structured format to identify high risk patients. Record Patient Demographics retrieve patient demographic data including preferred language, gender, race, ethnicity, and date of birth. Stage 1 Core Objective 12 Stage 2 Core Objective 7 Provide Patients with an Electronic Copy of their Health Information Stage 1 Core Objective 13 Stage 2 Core Objective 8 Provide Clinical Summaries for Patients for Each Office Visit Provide an after-visit summary with relevant information and instructions, as well as an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit. Stage 1 Menu Objective 3 Stage 2 Core Objective 11 Generate Patient List Electronically select, sort, retrieve, Recording patient demographics such Date of Birth, Gender, Ethnicity and Language Preference will assist in the identification and assessment of the patient population. Utilize the reporting function in an EHR to run patients lists sorted by care conditions, race or ethnicity. Patient-Centered Medical Home Standard 1: Enhance Access and Continuity Standard 4: Provide Self-Care Support and Community Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance The type of EHR in your practice will determine realtime remote access to patient data. Web-based products are accessible from workstations, whereas remote access to clientserver models needs to have workstations pre-configured with a Virtual Private Network (VPN). Both access types can be are accessed remotely through an encrypted Internet connection.

and generate lists of patients according to the data elements included in: Problem list, Medication list, Demographics; and Laboratory test results. Stage 1 Menu Objective 4 Stage 2 Core Objective 12 Send Reminders to Patients Send reminders to patients per patient preference for preventive/follow-up care Stage 1 Menu Objective 5 Stage 2 Core Objective 17 Access to Health Information Provide patients with an electronic copy of their health information including diagnostics test results, problem lists, medication lists, and medication allergies upon request. Stage 1 Menu Objective 6 Stage 2 Core Objective 13 Use Certified EHR Technology to Identify Patient-Specific Education Electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient s: problem list; medication list; and laboratory test results; as well as provide such resources to the patient. generate reports of patients that have received specific patient education materials and resources. Milestone 5: Use Data to Guide Improvement in Care at the Provider/Care Team Level Accountable Care Organizations CMS Data Registry All Measures Groups Registries Stage 1 Core Objective 10 Stage 2 Clinical Quality Measures (CQM) Electronically calculate six (6) Clinical Quality Measures (CQMs) Utilize an EHR to monitor one or more quality measures by developing priorities, support needs, and track improvements through data. Patient-Centered Medical Home Standard 2: Identify and Manage Patient Populations Standard 3: Plan and Manage Care Standard 4: Provide Self-Care Support and Community Standard 5: Track and Coordinate Care Use an EHR to extract a list of patients with a specific disease to track in the registry. Registries can use the structured data to create charts, making data easier to view and monitor progress. Capturing CQMs within an EHR simplifies reporting and measures improvements. Standard 6: Measure and Improve Performance

Stage 1 Menu Objective 7 Stage 2 Core Objective 14 Medication Reconciliation Electronically compare two or more medication lists. Stage 1 Menu Objective 8 Stage 2 Core Objective 15 Summary Care Record for Each Transition of Care Transition a patient to another setting of care or provider of care and include the following information: diagnostic test results, problem list, medication list, and medication allergy list. Stage 2 Menu Objective 2 Electronic Notes Enter at least one electronic progress note created, edited and signed. The text of the electronic note must be text searchable and may contain drawings and other content. Milestone 6: Demonstrate Active Engagement and Care Coordination Performing medication reconciliation will allow practices to report numerators and denominators which will contribute to satisfying this milestone when used in conjunction to dates of hospital Patient-Centered Medical discharge. Home Utilizing a summary of care will assist in the transition of patients to a new care setting, easing the transition and aiding in care coordination. Recording patient information in searchable electronic text fields enables a provider to review a patient s record or recent actions. Standard 1: Enhance Access and Continuity Standard 2: Identify and Manage Patient Populations Standard 3: Plan and Manage Care Standard 4: Provide Self-Care Support and Community Standard 5: Track and Coordinate Care Standard 6: Measure and Improve Performance Milestone 7: Improve Patient Shared Decision-Making Capacity Stage 1 Core Objective 5 Maintain Active Medication List identify patients on medications with a high CMS Data Registry All Measures Groups prevalence of adverse Patient-Centered Medical side effects or patients retrieve a patient s active Home taking multiple medication list as well as medications to identify medication history for longitudinal Standard 3: Plan and Manage over use. care. Care Stage 1 Core Objective 3 Maintain Up-to-Date Problem List retrieve a patient s problem list for longitudinal care. Stage 1 Core Objective 6 Maintain Active Medication Allergy List retrieve a patient s active capture data on chronic illnesses, diseases, or conditions that may be used to identify a target population to receive directed patient education materials. capture data on patients with allergies that may require additional or focused patient education materials. Standard 4: Provide Self-Care Support and Community Custom Templates Define the care coordination area most relevant to the practice; choose specific structured fields inside the EHR to enter data for traceable and reportable information. This may be done in the EHR by using an existing field and redefining it for a specific measure. This creates reportable data which can be utilized to extract totals and compile numerators and denominators for the measures required. Health Information Exchange (HIE) Connecting to the HIE will give allow the opportunity to improve the flow of information across various platforms. Active participation of all care providers in an HIE will allow providers to share patient information electronically. Provider & Patient Portals Portals serve as additional tools to connect patients and providers. Information inside the portal includes: alerts/reminders of appointments or prescription refills. Portals allow patients to enter and update information to track progress and it provides the ability to share the information with necessary family members or whomever else they wish to assist in their care, allowing the electronic health information to be accessible anywhere at any time.

medication allergy list as well as medication allergy history for longitudinal care. Stage 1 Core Objective 9 Stage 2 Core Objective 5 Record Smoking Status retrieve the smoking status of a patient. Stage 1 Core Objective 8 Stage 2 Core Objective 4 Record and Chart Vital Signs retrieve a patient s vital signs including, at a minimum, height, weight, and blood pressure. Stage 1 Menu Objective 3 Stage 2 Core Objective 11 Generate Patient Lists Electronically select, sort, retrieve, and generate lists of patients according to, at a minimum, the data elements included in problem lists. identify a patient population that are considered high-risk for pulmonary and cardiac disorders and may be targeted for focused patient education material as well as shared care decision making. identify and group patients according to a specific height, weight and blood pressure that will help identify the patients that require patient education material and are eligible for shared decisionmaking. generate reports on patients by specific care conditions to find priority and high risk conditions. Stage 1 Menu Objective 6 Stage 2 Core Objective 13 Use Certified EHR Technology to Identify Patient Specific Education Electronically identify and provide patient-specific education resources according to, at a minimum, the data elements included in the patient s: problem list; medication list; and laboratory test results; as well as provide such resources to the patient. generate reports of patients that have received specific patient education materials and resources. Milestone 8: Participate in the Market-Based Learning Community Milestone 9: Attest to the Requirements for Stage 1 of Meaningful Use for the EHR

Comprehensive Primary Care (CPC) and Meaningful Use Stage 1 and Stage 2 Meaningful Use Cross-Walk CPC Milestones Meaningful Use Measure Stage 1 Meaningful Use Measure Stage 2 Milestone 1 Milestone 2 Milestone 3 Milestone 4 Milestone 5 Milestone 6 Core Objective 3 Maintain Up-to-Date Problem Lists of Current and Active Diagnoses Core Objective 5 Maintain Active Medication List Core Objective 9 Record Smoking Status Core Objective 10 Clinical Quality Measures Menu Objective 3 Generate Patient Lists Core Objective 14 Protect Electronic Health Information Core Objective 3 Maintain Up-to-Date Problem List of Current and Active Diagnoses Core Objective 7 Record Patient Demographics Core Objective 12 Provide Patients with an Electronic Copy of their Health Information Core Objective 13 Provide Clinical Summaries for Patients for Each Office Visit Menu Objective 3 Generate Patient Lists Menu Objective 4 Send Reminders to Patients Menu Objective 5 Provide Patients with Timely Electronic Access to their Health Information Menu Objective 6 Use Certified EHR Technology to Identify Patient-Specific Education Core Objective 10 Clinical Quality Measures Menu Objective 7 Medication Reconciliation Core Objective 8 Provide Summary or Care Record for Each Referral or Transition Core Objective 5 Record Smoking Status Clinical Quality Measures Core Objective 11 Generate Patient Lists Core Objective 9 Protect Electronic Health Information Core Objective 3 Record Patient Demographics Core Objective 7 Provide Patients the Ability to View Online, Download, or Transmit their Health Information Core Objective 8 Provide Clinical Summaries for Patients for Each Office Visit Core Objective 11 Generate Patient Lists Core Objective 12 Send Reminders to Patients Core Objective 17 Secure Electronic Messaging to Communicate with Patients Core Objective 13 Use Certified EHR Technology to Identify Patient -Specific Education Clinical Quality Measures Core Objective 14 Medication Reconciliation Core Objective 15 Provide Summary of Care Record for Each Referral or Transition

Milestone 7 Milestone 8 Milestone 9 Core Objective 5 Maintain Active Medication List Core Objective 3 Maintain Up-to-Date Problem List Core Objective 6 Maintain Active Allergy List Core Objective 9 Record Smoking Status Core Objective 8 Record and Chart Vital Signs Menu Objective 3 Generate Patient List Menu Objective 6 Use Certified EHR Technology to Identify Patient-Specific Education 14 Core Objectives 5 out of 10 Menu Objectives 6 Clinical Quality Measures (CQM) Menu Objective 2 Electronic Notes Core Objective 5 Record Smoking Status Core Objective 4 Record and Chart Vital Signs Core Objective 11 Generate Patient List Core Objective 13 Use Certified EHR Technology to Identify Patient-Specific Education 17 Core Objectives 3 out of 6 Menu Objectives 9 Clinical Quality Measures (CQM)

Comprehensive Primary Care (CPC) and Clinical Quality Measures (CQMs) The below Meaningful Use Stage 1 Clinical Quality Measures (CQMs) are aligned across payers participating in the Comprehensive Primary Care (CPC) initiative. National Quality Forum (NQF) Number (NQF# 0041) (NQF# 0028) (NQF# 0034) (NQF# 0031) (NQF# 0059) (NQF# 0061) (NQF# 0018) (NQF# 0075) (NQF# 0083) (NQF# 0043) (NQF# 0575) (NQF# 0036) Clinical Quality Measure Preventive Care and Screening: Influenza Immunization for Patients >= 50 years old. Preventive Care and Screening: Measure Pair a. Tobacco Use Assessment b. Tobacco Cessation Intervention Colorectal Cancer Screening. Breast Cancer Screening. Diabetes: Hemoglobin A1c Poor Control. Diabetes: Blood Pressure Management. Diabetes: Low Density Lipoprotein (LDL) Management and Controlling High Blood Pressure. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control. Heart Failure (HF): Beta Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD). Pneumonia Vaccination Status for Older Adults. HbA1c Control (<8.0%). Use of Appropriate Medications for Asthma.

Comprehensive Primary Care (CPC) Best Practices: By Measure Milestone 1: Complete an Annual Budget or Forecast Determine how much it will cost to have unlimited secure and remote access to your EHR. If you are planning on reporting to a registry, determine if your EHR has reporting capabilities. If not, you will need to identify a new vendor capable of reporting and calculate additional costs. o NJ-HITEC is a 2013 CMS Certified Data Registry, reporting to this registry comes at no additional cost to members. Determine if your EHR vendor offers a Patient Portal. Identify how much it will cost to implement, customize and if there are additional training costs involved. Be aware of the new 2014 CEHRT requirements, make sure your EHR vendor qualifies and discuss if there are costs associated with the upgrades. Be sure to your EHR is capable of reporting for Stage 2 of Meaningful Use. Milestone 2: Provide Care Management of High Risk Patients Create and use customized templates inside your EHR to structure data appropriately to identify and track high risk patients through reports. Talk to your EHR vendor to learn how to use your EHR to track high risk stratification. Report collected data to appropriate registries. Use your EHR to monitor one or more Clinical Quality Measures (CQMs) and Utilization Measures. Milestone 3: Ensure 24/7 Access to Medical Record Information Ensure all providers have the ability to access the EHR remotely. If you are using a nurse call line after-hours, be sure they have secure remote access to the EHR. Determine all possible resources that your practice might need to achieve remote and secure access to the EHR. If you are planning on sharing coverage responsibilities, make sure all parties have unlimited and secure remote access. Explore expanded hours (moving beyond the answering machine after 5 P.M.). Milestone 4: Assess and Improve Patient Experience of Care Implement Patient Surveys o Utilize a CG-CAHPS patient survey then report at least two quarters of focused survey data based on at least one patient survey domain that best suits your practice. o Register of all patients for CG-CAHPS survey. o Identify domain(s) of concern. o Understand data and results and use it to guide changes in your practice. Implement a Patient Advisory Council o Provide evidence of guidance from a patient advisory council that meets at least once every quarter. Report a specific discussion of how feedback from the patient advisory council was used to change practice workflow or policy. o Create a roster of all patients. o Meet with your staff to identify possible participants of the council and organize meetings. o Establish a time and place that can support a patient advisory council meeting. o Discuss the results of the meeting with your staff and implement suggestions accordingly.

Milestone 5: Use Data to Guide Improvement in Care at the Provider / Care Team Level Take advantage of your EHRs capability to generate reports on quality measures and use this data accordingly. Use custom templates or structured data fields in your EHR to capture data considered to be of high-value for example; labs reports, immunization records and test results. Using checklists or patient status sheets can provide data for all the measures that require care for chronic illnesses for every patient visit. Milestone 6: Demonstrate Active Engagement and Care Coordination In the event a patient visits the Emergency Room, be sure to complete the following: Ensure that you are able to send/receive a notification of an ER visit in timely fashion. Complete a medication reconciliation process within hours of hospital discharge. Ensure a notification of admission and discharge are received in an appropriate manner and that clinical information and care transition is received on both occurrences. Exchange information between other primary care and specialty care providers when a referral is required. Milestone 7: Improve Patient Shared Decision-Making Capacity Use your EHR to accurately track patients within your practice that have a specific priority condition or chronic illness. Structure data fields to document or check if a patient was given appropriate decision aids. A report from your EHR must be generated to show the number of patients (numerators and denominators) who received decision aids in order to meet the requirements for this measure. Milestone 8: Participate in Local Learning Community Create a small workgroup of other CPC providers to stay informed of upcoming events, and as a resource for creating materials for the CPC collaboration site. Milestone 9:Attest to the Requirements for Meaningful Use Become a member of your local Regional Extension Center, such as NJ-HITEC. RECs have the resources necessary to simplify the Meaningful Use attestation process, reducing the burden placed on you and your office staff.