Aligning Meaningful Use CQM and PQRS Reporting for 2015 August 19, - - PowerPoint PPT Presentation

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Aligning Meaningful Use CQM and PQRS Reporting for 2015 August 19, - - PowerPoint PPT Presentation

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Aligning Meaningful Use CQM and PQRS Reporting for 2015 August 19, 2015 Introductions Marni Anderson Laura Sawyer Project specialist, MetaStar Clinical application coordinator, MPRO manderso@metastar.com lsawyer@mpro.org 608-441-8253

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Aligning Meaningful Use CQM and PQRS Reporting for 2015

August 19, 2015

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Introductions

Laura Sawyer Clinical application coordinator, MPRO lsawyer@mpro.org 248-465-7384 Candy Hanson Program manager, Stratis Health chanson@stratishealth.org 952-853-8524 Marni Anderson Project specialist, MetaStar manderso@metastar.com 608-441-8253 Ben West CTO, Health eFilings Bwest@Healthefilings.com 608-841-1381

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Agenda

  • Participating with Lake Superior Quality

Innovation Network (QIN)

  • Review reporting requirements for Electronic

Health Record (EHR) Incentive Program clinical quality measures (CQMs) and Physician Quality Reporting System (PQRS)

  • Review payment adjustments and potential

incentives

  • How to report quality measures once for both

programs directly from your certified EHR

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Lake Superior QIN

Three quality improvement organizations:

  • Stratis Health in Minnesota
  • MPRO in Michigan
  • MetaStar in Wisconsin

Collaboration to improve health care for Medicare beneficiaries, share best practices and maximize efficiencies

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Quality Improvement Initiatives

Lake Superior QIN will focus on health care quality improvement initiatives that include:

  • Improving cardiac health and reducing cardiac health care disparities
  • Reducing disparities in diabetes care
  • Improving prevention coordination through health information

technology

  • Reducing health care associated infections in hospitals
  • Reducing health care acquired conditions in nursing homes
  • Improving the coordination of care between health care settings
  • Improving quality through performance-based incentives and reporting

systems

  • Improving identification of depression and alcohol use disorder in

primary care for behavioral health conditions

  • Improving adult immunizations and reducing immunization disparities
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Introduction to Health eFilings

Health eFilings is a data submission vendor that works with any EHR. 100 percent of their customers’ files were accepted by Medicare last year. Ben West, CTO, is on the HL7 workgroup which created the Quality Reporting Document Architecture (QRDA) standard and advises Medicare and ONC on quality reporting standards.

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Review of EHR Incentive Program CQM Requirements

  • Eligible professionals
  • Doctors of medicine or osteopathy
  • Doctors of dental surgery or dental medicine
  • Doctors of podiatry
  • Doctors of optometry
  • Chiropractors
  • Certified EHR Technology (CEHRT)
  • Electronic CQMs
  • Technical specifications for EHR reporting
  • The Centers for Medicare & Medicaid Services

(CMS) guidance

  • Recommended adult and pediatric core set
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Review of PQRS Reporting Requirements

  • Eligible professionals
  • Medicare physicians, practitioners and therapists billing

Medicare Physician Fee Schedule (MPFS) Part B or critical access hospital (CAH) Method II

  • Reporting methods
  • Claims
  • Registry
  • Qualified Clinical Data Registry (QCDR)
  • Direct EHR
  • Data submission vendor
  • PQRS data analyzed by CMS and contributes

to value based modifier

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Why Electronic Reporting?

2015 is the performance year for 2017 payment adjustments.

  • EHR incentive program
  • PQRS and Value-Based Modifier (VBM)

2017 is the first performance year for Merit-Based Incentive Payment System (MIPS).

  • Incentives based on performance in EHR Incentive

Program and PQRS/VBM

Electronic reporting may be more efficient and satisfy multiple program reporting requirements.

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2017 Payment Adjustments

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How to Report Once

To reduce the burden, CMS has aligned reporting requirements for those reporting electronically using their CEHRT.

  • The electronic clinical quality measures (eCQMs)

specifications are used for electronic reporting option for PQRS as well as the Medicare EHR Incentive Program

  • Satisfactory reporting of eCQMs for PQRS will allow group

practices to qualify for the CQM component of meaningful use

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How to Report Once: Individual

Report nine measures across three domains covering a full year of data. Submit this data in one of three ways:

  • Direct EHR
  • Data submission vendor
  • QCDR
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How to Report Once: Group

Direct EHR or Data Submission Vendor:

  • Submit a full year of data with nine measures
  • OR submit a full year of data with six

measures, plus Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Using web interface (25+ EP’s only):

  • Submit a full year of data with all web interface

measures

  • 100+ EP groups are required to additionally do

CAHPS

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How to Report Once: ACO

Both Pioneer and the Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) are required to use the web interface with a full year of data.

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Electronic Reporting Workflow (Not Using a DSV)

  • 1. Create an Enterprise Identity Management

system (EIDM) account

  • 2. Work with your EHR vendor to extract QRDA

files

  • Track and resolve any errors in your EHR
  • Track and ensure that files are created for every provider +

taxpayer identification number (TIN)

  • 3. Log in to QualityNet and upload your files

from #2

  • 4. Resolve any errors
  • 5. Repeat 2-4 until all providers are submitted
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Electronic Reporting Workflow (Using a DSV)

1. Create an EIDM account 2. Work with your EHR vendor to extract QRDA files

  • Track and resolve any errors in your EHR
  • Track and ensure that files are created for every provider + TIN

3. Login to QualityNet and upload your files from #2 4. Resolve any errors 5. Repeat 2-4 until all providers are submitted

  • 1. Sign contract with a data submission vendor

(DSV)

  • 2. Some DSVs may make you do step number 2

above

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Getting Started

  • Decide if you want to use a DSV
  • Determine available measures
  • Review eCQMs available in your CEHRT
  • Work with your CEHRT vendor to understand

how to properly document patient care

  • Understand how an eCQM is different/similar

to measures used in registry or claims reporting

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Example eCQM: Controlling High Blood Pressure

Domain: Clinical Process/ Effectiveness Measure description:

  • Percentage of patients 18-85 years of age who

had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

  • CMS165v3; NQF# 0018 - PQRS # 236 - GPRO

HTN-2

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Technical Details

  • Quality Reporting Data Architecture (QRDA)
  • Category I and III
  • History of development and how they are

created

  • PQRS portal
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Common Error Messages

  • “SHALL contain exactly one [1..1]

effectiveTime (CONF:26933).”

  • Meaning: a time is missing
  • “This id SHALL contain exactly one [1..1]

@extension, which SHALL be selected from ValueSet CMS Program Name 2.16.840.1.113883.3.249.14.101 STATIC (CONF:711162).”

  • Meaning: program is incorrect (e.g. you didn’t declare that it was

for PQRS)

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Common Error Messages

  • Even if you don’t get an error message, that

doesn’t mean the submission was valid!

  • If you don’t use a DSV, you will need to work

with your EHR vendor to resolve these.

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Example Feedback Report

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Data Submission Vendor

  • EIDM account not required
  • Testing and error checking files submissions
  • Who is a data submission vendor?
  • EHR vendor
  • QCDR
  • Dedicated DSV (e.g. Health eFilings)
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Things to Ask a DSV/EHR

  • Are you on the HL7 Clinical Quality

Informatics workgroup?

  • This workgroup manages the standards, so

entities on that group will be more familiar with them

  • Do you participate in the CMS quality

reporting kaizens?

  • Medicare invites leaders in quality reporting to

advise them on their quality programs. Participation indicates that the DSV is thought highly of and participates in making policy.

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Resources

2015 How to Report Once for Medicare Quality Reporting Programs http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2015HowtoReportOnce.pdf 2015 PQRS EHR Reporting Made Simple http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2015_PQRS_EHR_Made_Simple.pdf 2015 Guide for Group Practices Reporting via PQRS GPRO Using an EHR http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2015_GPRO_EHR_Reporting_forGroups.pdf Electronic Reporting Using an Electronic Health Record (EHR) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Electronic- Health-Record-Reporting.html eCQM Library https://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

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Resources

Payment Adjustment Information https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Payment-Adjustment-Information.html Intro to EHR Incentive program http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/downloads/Beginners_Guide.pdf PQRS Eligible Professionals http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/Downloads/2015_PQRSList_of_Eligible_Professionals.pdf CMS Enterprise Portal http://portal.cms.gov CMS Enterprise Identity Management (EIDM) User Guide https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information- Technology/IACS/Downloads/IACS-EIDM-Migration-User-Guide.pdf

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Webinar slides will be posted at:

https://www.youtube.com/user/LSQIN

Upcoming events:

Visit our listings at https://www.lsqin.org/events/ Follow Lake Superior QIN on social media

@LakeSuperiorQIN

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How Do I Sign Up?

If you are interested in signing up or to learn more about the initiatives, please contact:

Michigan: Laura Sawyer lsawyer@mpro.org 248-465-7384 Minnesota: Candy Hanson chanson@stratishealth.org 952-853-8524 Wisconsin: Marni Anderson manderso@metastar.com 608-441-8253

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QUESTIONS?

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30 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-D1-15-41 081015

Follow us online @LakeSuperiorQIN

The Lake Superior Quality Innovation Network represents the states of Michigan, Minnesota and Wisconsin.

Thank You!

We look forward to partnering with you!