Oct 21, 2014CS524: Advanced Computer Networks1 LAN Addressing Advanced Computer Networks.
LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.
-
Upload
kendrick-jarry -
Category
Documents
-
view
215 -
download
0
Transcript of LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.
![Page 1: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/1.jpg)
LAN: An Introduction and Addressing of Issues With
Quality Reporting
February 29, 2012
![Page 2: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/2.jpg)
2
Presenters• Paul Kleeberg, MD, FAAFP, FHIMSS
Clinical Director
REACH – Regional Extension Assistance Center for HIT
• Phil Deering Regional Coordinator REACH – Regional Extension Assistance Center for HIT
• Connie Geyer RN, BSN
Quality Improvement Specialist
North Dakota Healthcare Review Inc.
• Jerri Hiniker, RN, BSN, CPHERProgram ManagerStratis Health
![Page 3: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/3.jpg)
3
Agenda
• Overview of the Learning and Action Network (LAN)
• Overview of Quality Reporting for Meaningful Use
• Introduction to Using Quality Reporting
![Page 4: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/4.jpg)
4
OVERVIEW OF A LEARNING AND ACTION NETWORK (LAN)
Connie Geyer and Jerri Hiniker
![Page 5: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/5.jpg)
5
What is the Learning and Action Network (LAN)?
• Partnership of REACH and the Minnesota and North Dakota Quality Improvement Organizations (QIOs)
• Part of the QIO program’s ongoing prevention work
![Page 6: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/6.jpg)
6
QIO Prevention Project
• Focus: Improve health for populations and communities
• Timeframe: August 1, 2011 – July 31, 2014• Goal:
– Provide a collaborative environment for the clinics/providers that are working with the Regional Extension Center (REC) and have achieved Milestone 2 (as part of Meaningful Use) to focus on optimization of their electronic health record (EHR) to improve population health
![Page 7: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/7.jpg)
7
Learning and Action Networks• Mechanisms for fostering large scale improvement• Encourage rapid cycle improvements regardless of
change methodology used• Consciously manage knowledge as a valuable
resource• Provide opportunities for communities to harness
knowledge, skills, and abilities of their peers• Function to support activities at the local level with
ultimate goal of spread of the knowledge gained across the country
• Promote sustainability and spread
![Page 8: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/8.jpg)
8
Strategies
• Review of educational needs of clinics and their providers
• Provide regular opportunities for collaboration and sharing of best practices via:– Conference calls– Webinars – Face-to-face meetings– Online
• Provide technical assistance as appropriate in collaboration with REC
![Page 9: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/9.jpg)
9
OVERVIEW OF QUALITY REPORTING FOR MEANINGFUL USE
Phil Deering
![Page 10: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/10.jpg)
10
CQMs – The Basics• Each EP needs to report on 3 clinical quality
measures (CQMs) from a set of “Core” or “Alternate Core” quality measures.
• Each EP needs to report on three additional CQMs from a list of 38 “Additional” quality measures.
• Numerators, denominators, and exceptions must be those generated by certified electronic health record technology.
• Link to CQM table: http://go.cms.gov/cqm_TBL
![Page 11: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/11.jpg)
11
What if Core CQMs Don’t Apply1. MU requires reporting on three Core or Alternate Core
CQMs.
2. Report on all Core that apply (denominator ≠ 0).
3. Go to Alternate Core to find additional (denominator ≠ 0) that do apply if three Core don’t apply.
4. Finally, report 0 denominators to get three Core/Alternate Core.
5. Attest to 0 denominators for all if you don’t have 3 that apply
6. Example of Pediatrician who sees no teensa. No Core apply – all for adults
b. Alt 2 and 3 apply – attest to numerator, denominator, and exclusions from EHR
c. Attest to 0 denominators for 3 Core and 1 Alt Core
![Page 12: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/12.jpg)
12
Reporting Additional CQMs
1. For most, possible to find 3 that do apply
2. If less than 3 apply, attest that none of the others apply.
3. If your certified EHR technology only gives 3 Additional measures, and none apply, then you need to report 0 denominators for all of them. “The EP is not responsible for determining the status of CQMs that their certified EHR technology is not capable of calculating”
Goal is to report six non-zeros or attest to the fact that you have only 0 denominators
![Page 13: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/13.jpg)
13
What if the CQMs Are Wrong?• Many providers are confronted with certified
technology that introduces CQM logic or implied workflow that is difficult or unreasonable to implement.
• You do not need to attest to the “accuracy” of any of the CQMs, just the numerator and denominator generated by the certified EHR technology.
• There is no threshold for low percentages.
• Put another way: Don’t change your workflow to accommodate awkward CQM technology.
![Page 14: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/14.jpg)
14
Will We Report CQMs Electronically in 2012?• Original rule stated: “CQMs by attestation in
2011, electronically in 2012”.• New guidance has emerged:
– In 2012, there will be two options for CQM reporting:
• Attestation
• Electronic Reporting Pilots
– EPs – through PQRS
– Participation in the pilot is voluntary and enables EPs, eligible hospitals, and CAHs to satisfy the Medicare EHR Incentive Program requirements for reporting CQMs for the 2012 payment year. EPs, eligible hospitals, and CAHs that choose not to participate in the pilot will be able to continue to use an attestation methodology for reporting CQMs for payment year 2012.
![Page 15: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/15.jpg)
15
Can I Report Non-certified Measures?
• This is the corollary to the guidance that you don’t have to report CQMs that your EHR is not capable of providing
• If your certified EHR can produce CQMs that aren’t certified by an ONC-ATCB, you can report those measures CMS FAQ ID #10649
Yes, the EP can submit results for CQMs in the additional set (Table 6 of the final rule) calculated by certified EHR technology, even if those CQMs were not individually tested and certified by an ONC-ATCB.
![Page 16: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/16.jpg)
16
What Does Stage 2 Hold• We are committed to aligning quality measurement and
reporting among our programs (for example: IQR, PQRS, CHIPRA, ACO programs).
• More measures to be reported
– 12 or 11 + 1• Many new measures proposed
– 81 by a rough count– Dentistry, radiology, dementia, optometry, mental health
• No required percentages in Stage 2• Guidance to align CDS rules with CQMs
– Implement CDS to improve CQM
![Page 17: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/17.jpg)
17
INTRODUCTION TO USING QUALITY REPORTING
Paul Kleeberg, MD
![Page 18: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/18.jpg)
18
If you don’t measure it, how can you improve it?
• All providers believe they provide above average care
• How can you create change without creating a need for change?
• Providers are inherently competitive and data driven
• “My patients are different…” “That data is inaccurate!” But still improvements magically happen
![Page 19: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/19.jpg)
19
Tracks all the quality measures of interest to them for their hypertensive patients comparing the organization, 3 clinics and one provider to the state statistics
![Page 20: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/20.jpg)
20
Tracks the use of depression screens (completed PHQ-9 forms) over time for three separate quarters
Notice most show gradual improvement over time demonstrating improvement in follow-up screening of depressed patients
![Page 21: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/21.jpg)
21
Patient specific report allows provider to identify patients who are in need of labs or a follow-up appointment
![Page 22: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/22.jpg)
22
Utilize Your Meaningful Use Report• Use to track
progress and troubleshoot gaps in a clinic workflow or documentation
• Track areas of clinical interest to you
• Use them to identify patients falling through the cracks
![Page 23: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/23.jpg)
23
How to Proceed:• Run the numbers a few times yourself to
see if they make sense• Run and show data for the clinic as a whole,
for all individuals – keeping the individual names anonymous but allowing providers to identify themselves
• Finally make all providers data public within the clinic
There may be denial, but there will be improvement
![Page 24: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/24.jpg)
24
DISCUSSION QUESTIONS
![Page 25: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/25.jpg)
25
• What quality reports do you currently submit from your practice?
• Do you use any of these reports for care improvement and if so, which ones?
• What issues have you encountered as a result of having to submit reports to multiple entities?
• How would you like to see this Learning and Action Network assist you in improving quality
![Page 26: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/26.jpg)
26
QUESTIONS?
![Page 27: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/27.jpg)
27
Contact Information:Connie Geyer RN, BSN
ND Healthcare Review Inc.
Phone: 701-857-9723
Jerri Hiniker, BSN, RN, CPEHR
Stratis Health
Phone: 952-853-8540
![Page 28: LAN: An Introduction and Addressing of Issues With Quality Reporting February 29, 2012.](https://reader035.fdocuments.in/reader035/viewer/2022062515/56649cae5503460f94972047/html5/thumbnails/28.jpg)
28
Thank You!
Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted
expert in facilitating improvement for people and communities.