3Q18 Core Measures 1Q19 MBQIP Data Promoting Interoperability Stage 3

May 17, 2019

Revised: May 22, 2019

Joshua Salander, MBA, PMP

Consultant

Conflict of Interest / Disclaimer

• Conflict of Interest: I, Joshua Salander, am employed by Scheurer Hospital. Any content or opinion in this presentation shall not be construed as an opinion or representation of Scheurer Hospital.

• Disclaimer: This presentation is informational only. You should review requirements to determine specific impacts to your hospital. Persevion, LLC is not liable for the accuracy of this information or how it pertains to your hospital.

• Disclaimer: Any information included in this presentation or the Reports Appendix is intended for quality improvement and benchmarking purposes only.

2

Reports delivery

• 3Q18 reports were sent via email on May 12, 2019

• Quarterly Reports

• Quarterly Trend Charts

3

MICAHQN Reports Schedule

4

Qtr CMS Data Deadline* Data Provided By*

1st Qtr August 15 August 31

2nd Qtr November 15 November 30

3rd Qtr February 15 February 28

4th Qtr May 15 May 31

Summary of 3Q18 MICAHQN Core Measures Performance

5

Measure # Hospitals Denominator Current Rate/Value

Top Performer(s)

OP-1 12/40 23 27 Aspirus Ontonagon Hospital

OP-2 12/40 23 69.6% Helen Newberry Joy Hospital Baraga County Memorial Hospital Aspirus Ontonagon Hospital Scheurer Hospital Harbor Beach Community Hospital, Inc. Aspirus Grand View

OP-3a 19/40 52 82.5 Carson City Hospital

OP-3b 13/40 39 109 Carson City Hospital

OP-3c 11/40 13 71 Bell Hospital

OP-4a 35/40 585 96.8% See next slide

OP-4b 33/40 221 95.5%

OP-4c 34/40 364 97.5%

OP-5a 40/40 749 6 Aspirus Iron River Hospital and Clinics

OP-5b 38/40 286 7 Kalkaska Memorial Health Center Aspirus Ontonagon Hospital Aspirus Iron River Hospital and Clinics

OP-5c 39/40 463 6 Munson Healthcare Manistee McKenzie Health System

3Q18 - OP-4a: Aspirin at Arrival (100%)

6

Hospitals

Allegan General Hospital Hills & Dales General Hospital

Aspirus Iron River Hospital and Clinics Kalkaska Memorial Health Center

Aspirus Keweenaw Hospital Mackinac Straits Health System, Inc.

Aspirus Ontonagon Hospital Marlette Regional Hospital

Baraga County Memorial Hospital Munising Memorial Hospital

Borgess - Lee Memorial Hospital Paul Oliver Memorial Hospital

Caro Community Hospital Schoolcraft Memorial Hospital

Charlevoix Area Hospital Sheridan Community Hospital

Deckerville Community Hospital Sparrow Clinton Hospital

Harbor Beach Community Hospital, Inc. Sparrow Ionia Hospital

Hayes Green Beach Memorial Hospital Spectrum Health Gerber Memorial

Helen Newberry Joy Hospital Spectrum Health Reed City Hospital

7

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Rat

e

OP4a - Aspirin at Arrival - Overall Rate

MICAHQN Overall UCL LCL

Summary of 3Q18 MICAHQN Core Measures Performance

8

Measure # Hospitals Denominator Current Rate/Value

Top Performer(s)

OP-18a 40/40 4259 132 Carson City Hospital St. Mary’s of Michigan Standish Hospital

OP-18b 40/40 3742 121 Mercy Health Lakeshore Campus

OP-18c 38/40 163 203 McKenzie Health System

OP-18d 39/40 379 232 Paul Oliver Memorial Hospital

OP-20 33/40 3366 13.5 Munising Memorial Hospital

ED-1a 35/40 2730 239 Harbor Beach Community Hospital, Inc.

ED-1b 35/40 2692 239 Harbor Beach Community Hospital, Inc.

ED-1c 19/40 38 236 Scheurer Hospital

ED-2a 35/40 2654 64 Deckerville Community Hospital

ED-2b 35/40 2617 64 Deckerville Community Hospital

ED-2c 18/40 37 66 Eaton Rapids Medical Center

9

95

100

105

110

115

120

125

Me

dia

n T

ime

OP18b - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Reporting Measure

MICAHQN Overall UCL LCL

100

120

140

160

180

200

220

240

Me

dia

n T

ime

OP18c - Median Time from ED Arrival to ED Departure for Discharged ED Patients - Psychiatric/Mental Health Patients

MICAHQN Overall UCL LCL

10

205.0

210.0

215.0

220.0

225.0

230.0

235.0

240.0

245.0

250.0

Me

dia

n T

ime

ED-1b - Median Time from ED Arrival to ED Departure for Admitted ED Patients - Reporting Measure

MICAHQN Overall UCL LCL

11

48.0

50.0

52.0

54.0

56.0

58.0

60.0

62.0

64.0

66.0

Me

dia

n T

ime

ED-2b - Admit Decision Time to ED Departure Time for Admitted Patients - Reporting Measure

MICAHQN Overall UCL LCL

40.0

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Me

dia

n T

ime

ED-2c - Admit Decision Time to ED Departure Time for Admitted Patients - Psychiatric/Mental Health Patients

MICAHQN Overall UCL LCL

Summary of 1Q19 MBQIP Performance

12

Measure # Hospitals Current Rate/Value

Notes

EDTC-1 36/36 97% 22 @ 100%

EDTC-2 36/36 97% 25 @ 100%

EDTC-3 36/36 98% 24 @ 100%

EDTC-4 36/36 97% 24 @ 100%

EDTC-5 36/36 97% 24 @ 100%

EDTC-6 36/36 95% 16 @ 100%

EDTC-7 36/36 98% 26 @ 100%

EDTC-Overall 36/36 89% 12 @ 100%

13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Me

dia

n T

ime

All EDTC Measure

MICAHQN Overall

1Q19 - EDTC-Overall (100%)

14

Hospitals

Bronson LakeView Hospital

Caro Community Hospital

Eaton Rapids Medical Center

Harbor Beach Community Hospital Inc.

Hills and Dales General Hospital

Mackinac Straits Health System, Inc.

McKenzie Health System

Mercy Health Lakeshore Campus

Sparrow Clinton Hospital

Sparrow Ionia Hospital

Spectrum Health Gerber Memorial

Spectrum Health Reed City Hospital

Promoting Interoperability Stage 3: Health Information Exchange Objective

Promoting Interoperability Stage 3: Health Information Exchange Objective

Objectives Description

Electronic Prescribing Generate and transmit permissible discharge prescriptions electronically

Health Information Exchange Encourage and leverage interoperability on a broader scale and promote health IT-based care coordination

Provider to Patient Exchange Provide patients electronic access to their health information

Public Health & Clinical Data Exchange • Syndromic Surveillance • Immunization Registry • Electronic Case Reporting • Public Health Registry • Clinical Data Registry • Electronic Reportable Laboratory Result Reporting

Measures that an eligible hospital or CAH attests yes to being in active engagement with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using certified electronic health record technology (CEHRT) for two measures within the objective.

16 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EH_Medicare_2019.pdf

Promoting Interoperability Stage 3: Health Information Exchange Objective

Measure Points

Electronic Prescribing 10

Query of Prescription Drug Monitoring Program (PDMP) (optional) 5 bonus

Verify Opioid Treatment Agreement (optional) 5 bonus

Support Electronic Referral Loops by Sending Health Information

20

Support Electronic Referral Loops by Receiving and Incorporating Health Information

20

Provide Patients Electronic Access to their Health Information 40

Public Health & Clinical Data Exchange (attest to two measures) 10

17 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

IT & Quality Collaboration

18

Definition of Terms

19 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf

Support Electronic Referral Loops by Sending Health Information

• Denominator: Number of transitions of care and referrals during the EHR reporting period for which the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) was the transitioning or referring provider.

• Numerator: Number of transitions of care and referrals in the denominator where a summary of care record was created and exchanged electronically using CEHRT.

• Exclusion: No exclusions for this measure in 2019.

20 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf

Support Electronic Referral Loops by Receiving and Incorporating Health Information

• Denominator: Number of electronic summary of care records received using CEHRT for patient encounters during the EHR reporting period for which an eligible hospital or CAH was the receiving party of a transition of care or referral, and for patient encounters during the EHR reporting period in which the eligible hospital or CAH has never before encountered the patient.

• Numerator: Number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT for the following three clinical information sets: (1) Medication – Review of the patient’s medication, including the name, dosage, frequency, and route of each medication; (2) Medication Allergy – Review of the patient’s known medication allergies; Current Problem List – Review of the patient’s current and active diagnoses.

• Exclusion: An exclusion is available for eligible hospitals and CAHs that could not implement this measure for an EHR reporting period in CY 2019 • If you claim the exclusion, points are redistributed to “Support Electronic

Referral Loops by Sending Health Information” 21

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf

Additional Information Excerpts

• Referring provider must have reasonable certainty of receipt by the receiving provider (acknowledgement)

• Apart from required information (problems, medications, allergies), where there is no information available because hospital/CAH does not record or not available to record, may leave blank and meet objective

• Laboratory test results – Must have ability to send results, can limit to most appropriate results for transition/referral • Send full results upon request

• In cases where access is shared to EHR, transition or referral may still count toward measure if referring provider creates summary of care document and sends electronically • If you include such transitions, must do so universally for all patient and all transitions or

referrals

22

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf

Additional Information Excerpts

• Must comply with HIPAA

• In Stage 3, no longer include third parties converting transmission to fax in numerator. Must be C-CDA format.

• Cannot incorporate if discarded without reconciliation of clinical information or stored in manner not accessible for provider use within EHR

• “Unavailable” clarification – exclude from denominator (special notes – query HIE, no access to HIE, not operational)

• Non-medical staff may conduct reconciliation under direction so long as provider or credentialed medical staff is responsible and accountable for review/assessment/action

23

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicareEH_2019_Obj2-.pdf

Thank you!

Joshua Salander, MBA, PMP

Consultant

jsalander@persevion.com

(989) 666-7033