Metrics Technical Advisory Workgroup May 25, 2017 PLEASE DO NOT - - PowerPoint PPT Presentation

Metrics Technical Advisory Workgroup

May 25, 2017

PLEASE DO NOT PUT YOUR PHONE ON HOLD – IT IS BETTER IF YOU DROP OFF THE CALL AND REJOIN IF NEEDED

Today’s Agenda

• Updates
• SBIRT EHR-based measure workgroup update
• TAG 2018 recommendations to Metrics & Scoring
• (jumping to ECU)

Effective Contraceptive Use

• Exclude same-sex partners, sterility, gender orientation

and pregnancy intentions

• This would require moving to an EHR-based measure
• Many of these visits occur with public health rather than

primary care. TAG expressed concern about public health’s ability to document these situations in an EHR.

• It would be preferable to capture these situations in

benchmark and target setting. TAG members feel that the current benchmark is too high and should be reviewed.

• TAG does not recommend modifying the measure specs in

this way, but rather adjusting the benchmark and/or target methodology.

Effective Contraceptive Use

• Add codes for unspecified contraception
• Measure whether patient is offered

contraceptives/contraceptive counseling, rather than contraceptive use

• Move from claims-based to EHR-based measure

(stop using surveillance codes)

• The TAG expressed a desire to better understand the

intent of this measure before making a recommendation on potential modifications.

The intent of this measure

• 1. Providing high quality primary care for women by improving

contraception access

• Women are fertile for about 40 years, on average they are trying to

avoid pregnancy for 35 of them

• 99% of sexually active women use contraception at some point in

their lives

• Contraception is the most commonly needed primary care service for

women (along with dental care!)

• At least 70% of women age 18-50 need contraception, only 36% of

those on Medicaid got it in 2015

• 2. Preventing unintended pregnancy
• Having an unintended pregnancy means a woman is three times more

likely to end up below the poverty line 2 years later

• Unintended pregnancies can derail education and job options,

relationships and are associated with worse maternal and infant

• utcomes

https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states https://www.ansirh.org/research/turnaway-study https://www.nap.edu/catalog/4903/the-best-intentions-unintended-pregnancy-and-the-well-being-of

Is this metric meeting our intent?

• Yes, in that it focuses on the measureable outcome of

contraception claims.

• Primary outcome for our first intent (more contraception access)
• Intermediary outcome for our second intent (unintended

pregnancy)

• Shortcomings in the specifications
• We cannot reliably exclude from the denominator women who do not need

contraception (trying to get pregnant, not having sex with men)

• We cannot count vasectomies as they are claims on someone else’s chart
• Lookback for hysterectomy and tubal is 7 years within Medicaid
• Surveillance codes required for multiyear methods
• We account for the unfixable shortcomings in specifications by lowering the

benchmark

• A “perfect score” is 70%, not 100%

Updates

CCO Metrics Dashboards

• CY 2016 dashboard released April 28
• May 10 release
• Child immunization status
• Immunization for adolescents
• Postpartum care
• May 18 release
• CAHPS – Access to care; Satisfaction with care
• Prenatal care (revised)
• Effective contraceptive use (revised)
• Colorectal cancer screening

CCO Metrics Dashboards

• Next Steps
• CCO validation questions due May 31
• Final CY 2016 results (dashboards) distributed June 22
• Public CCO Metrics Report released June 27
• Quality pool (including challenge pool) dollars

distributed by June 30

Rebase policy for EHR-based measures

• Metrics TAG asked whether OHA would rebase

improvement targets if a CCO started to report CCO Medicaid only data

• Answer: Yes, if the CCO can submit data to support the

rebase calculation and the CCO is switching all of its reporting to CCO Medicaid only

• If a CCO requested a rebase for its 2018 improvement targets,

for example, it would have to submit a rebase report of 2017 data that was limited to CCO Medicaid only

• The rebase data would be due later in the year than the CCO

data submission used for performance calculation

• A CCO could not request rebasing until all of its reporting

clinics can report CCO Medicaid only

Transformation Center Technical Assistance

• CCO needs assessment calls covering the new metric: Emergency department utilization for individuals

experiencing severe and persistent mental illness

• Tuesday, May 30, 10-11 a.m. OR Friday, June 2, noon-1 p.m.
• 866-390-1828; participant code: 4628003
• Tobacco Cessation Webinars:
• Tobacco Cessation Clinical Workflow
• When: July 18, 1-2:30 p.m.
• Register here: https://attendee.gotowebinar.com/register/1587067351965435394
• Mobile Health Behavioral Intervention Platforms for Smoking Cessation
• When: June 13, 9:30-10:30 a.m.
• Register here: https://attendee.gotowebinar.com/register/641296036523653635
• Questions? Contact Anona Gund at anona.e.gund@state.or.us.
• Effective Contraceptive Use among Women at Risk of Unintended Pregnancy
• Webinar series: Clinic-level strategies to increase effective contraceptive use
• When: May 31, June 7, June 15, June 22, June 29
• See handout for more information, including exact times and the links to register.
• Webinar - Immediate Postpartum LARCs: Billing and Coding
• When: Thursday, June 1, 1-1:45 p.m.
• Register here: https://attendee.gotowebinar.com/register/4815094952765841921
• Questions? Contact Adrienne Mullock at adrienne.p.mullock@state.or.us.

TRANSFORMATION CENTER Health Policy & Analytics Division 11

Hospital Transformation Performance Program

• Payment for Year 3 / 2016 will be distributed in June (report

to be published 13 June)

• Hospital Performance Metrics Advisory Committee will next

meet on July 31st.

Metrics & Scoring Committee

• Met last Friday, 19 May
• Heard presentations on and discussed the effective

contraceptive use measure, kindergarten readiness, and SBIRT

• Draft ‘long list’ of metrics (informal, for discussion only)

included in packets

• Next meeting is Friday, 16 June
• Hear TAG’s recommendations regarding 2018 measures
• Select 2018 measures
• Benchmarking discussions will begin in July

SBIRT Update

CCO SBIRT Measure

Metrics & Scoring Committee approved in concept, subject to pilot testing and implementation decisions Initial Patient Population (IPP) = All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period Rate 1: Screening D1 = IPP N1 = Patients who received an age-appropriate screening, using an SBIRT screening tool approved by OHA, during the measurement period, and had either a brief screen with a negative result or a full screen Rate 2: Brief intervention and referral D2 = Patients in IPP who had a positive full screen during the measurement period N2 = Patients who received a brief intervention, a referral to treatment, or both within 2 months of a positive full screen

Exclusions and Exceptions

• Numerator exclusion: SBIRT services in ED or

hospital setting

• Denominator exceptions*
• Patient refuses
• Emergent situation
• Patient functional capacity or motivation

* These are the same denominator exceptions as depression screening and follow-up measure, but intention is to allow for data capture in a queryable field, not just in SNOMED codes

Denominator Exclusions

• Active diagnosis of alcohol or drug dependency
• Engagement in treatment
• Dementia or mental degeneration
• Limited life expectancy
• Palliative care (includes comfort care and hospice)

Implementation Considerations

• Need volunteers to pilot the measure – please

email metrics.questions@state.or.us by June 9

• Questions to consider for further discussion in

June:

• Unintended consequences of shortening measurement

period for first year to start July 1, 2018?

• Feedback to Metrics & Scoring Committee about how to

approach setting a first year benchmark?

Review: TAG Measure Modification Recommendations

Bundled Measures (1-4)

• Bundled metrics generally add unnecessary

complexity and do not save work in terms of data and reporting.

• TAG does not recommend any of the proposed

bundled measures for implementation in 2018.

Adolescent Well Care Visits

• Change upper age limit to 18
• Up to age 21 is pediatric scope of practice. We don’t

want to drop a group of people (age 19-21) that need help.

• Many CCOs take a different approach to AWC for age 12-

18 vs 19-21. Members also begin to fall into different rate groups as they get older.

• The TAG does not support this modification.

Adolescent Well Care Visits

• Exclude sports physicals
• Sports physicals are a way for providers to engage and teach. If the

intent of AWC measure is to establish healthy behaviors, sports physicals accomplish that.

• HEDIS includes sports physicals. Since sports physicals alone make

up such a small percentage of AWC numerator hits, we do not want to deviate from HEDIS.

• The Transformation Center is working with OSAA to better

understand the difference in well care visits and sports physicals.

• The TAG does not support the modification to exclude sports

physicals at this time. The TAG wants to keep informed of the work

• f the Transformation Center and OSAA around this issue.

Childhood Immunization Status

• Modify numerator to include children on catch-up

schedules

• This would complicate how the measure is tracked and

could allow slippage on the immunization schedule.

• It also complicates the public health message.
• The TAG does not support this modification.

Controlling Hypertension

• In an earlier survey, a respondent suggested using

different measure treatment thresholds to follow the JNC 8 best practice guidelines (BP goal of 150/90 for ages 60-85 with no diagnosis of diabetes)

• This proposal aligns with HEDIS specs, but deviates from the

CMS specs used for Meaningful Use, MIPS, and CPC+

• The CMS 2018 specs stick with 140/80 for ages 18-85.
• Last TAG discussion raised concern that a threshold of 140/80

for people age 60+ is not good clinical practice

• One alternative would be to limit the measure to people age

59 and under until CMS catches up with the HEDIS specs. Once CMS catches up, include entire population again.

• Excluding age groups could cause problems pulling data from some

EHRs; however, this option is worth exploring in order to implement clinical best practice.

• OHA will sent a survey to CCOs to assess the feasibility of

programming this measure with HEDIS specs.

Controlling Hypertension Measure (survey responses)

• Currently, can your practice generate a report from

your EHR using the HEDIS specs for controlling high blood pressure?

Answers # of Respondents Yes 16 No 18 Unsure 6 Other 7

Effort to get to HEDIS specs

If your practice currently cannot generate a report from your EHR using HEDIS specs, how much effort would it take to be able to report to those specs?

• Widely varying estimates for staff time needed – responses included

unknown / unsure and then ranged from 1 hour all the way to 3 staff

• ver a 2-week period
• Concerns about EHR vendor support: needing vendor approval to

change report; uncertainty about how much vendor support would be needed; costs; possible workflow modifications

• Concerns about losing alignment with CMS specs and about competing

priorities with other projects

• “The qualitative answer is not a lot and yet entirely too much effort.

This requires re-tasking current staff for a measure change that doesn’t help our clinic. We are performing within expectations on this measure and so aren't actively working to improve it.”

Lead time to get to HEDIS specs

If your practice currently cannot generate a report from your EHR using HEDIS specs, how much time would it take to be ready to report to those specs? (Please give a rough estimate of time)

• Responses included unknown / unsure and ranged from

needing 1-2 weeks; 1 month; a few months; a year lead time

• “We wouldn't be able to tweak an existing report so would

have to choose building from scratch in SQL or manually editing canned output. The decision would be based on our best guess at how much the measures are likely to diverge in the future.”

• “We could most likely have it refined for measurement year
• 2018. We could have it sooner, but deviations that require

custom work across the state should be seriously considered with stakeholder feedback guiding the final decision.”

Stratifying reports by age

How much effort would it take your practice to be able to stratify an existing report from your EHR using CMS specs to limit the measure to patients aged 18-59?

• Responses reflected lots of uncertainty. Variation in estimated time from 1 hour, 1 day or less,

a few days, 1 week to 1 month. Some vendors have agreed to do this; others haven’t

• “We are unable to limit by age range. This would also be a decision made by our EHR vendor.”
• “I'm not sure if this is even realistic for the organization this year - the time involved would be

extensive and the report would be invalid after Oct. 21st. We are not sure what will be involved in requesting specialized reports out of [our EHR]”

• “The HEDIS report could be copied and the criteria then modified. The report would then

have to move through testing, change control committees, migration to production, and final

• validation. This would require a variety of staff. We could likely do this in under 10 hours.”
• “This would be a manual/excel process and would probably take ~20 minutes a quarter given
• ur vendors current reporting set-up. That set-up is changing this year but I don't anticipate

losing access to patient-level outcomes. This also allows a greater chance of human error - miskeying out a swath of patients”

• “This is relatively painless as the existing report gives date of birth and I can filter out ages

60+ pretty easily. The logic for ages 60+ and diabetes diagnosis is not possible with the existing reports.”

• “There are no existing reports currently that contain the information required to stratify. We

have relied primarily on the CMS/MU reports.”

Comments in favor of CMS specs

• We would rather not have any changes made as this will be yet another reporting burden that we suffer from.

We are not easily able to get our EHR vendor to change specs and how reports are pulled and measured.

• All of our internal QI and reporting initiatives are aligned to CMS. UDS just aligned to CMS. My feeling is that it

is best to align to CMS and then let CMS align to HEDIS as it sees fit. This keeps things simple and reduces

• errors. What is the use of having data you want to have if half of it is full of errors.
• For all of our CMS reporting we report on the CMS specs and not the HEDIS specs. When submitting the

quality metrics for Meaningful Use (previously) there was no place to enter documentation for the different age ranges. It strictly looked at the CMS spec.

• Request to continue using the specification currently set for UDS.
• We have a strong preference to remain with CMS specs.
• The applications that our organization has currently focus more on ACO/CMS specs and reporting.
• Please stick to the CMS specs. We are already required to submit data for this spec for MU and do not need

an additional measure to meet that will require custom report building.

• My only feedback is that most of the CMS CQM's are very easily done through OCHIN EPIC because of the

alignment with the UDS metrics that occurred recently. I have no experience with the HEDIS metrics.

• If CMS is not prepared to follow HEDIS, making Medicaid providers in Oregon responsible for deviating from

CMS seems out of line. The metrics and scoring committee is charged with designing and implementing a meaningful measurement system that supports health system transformation. I would rather see the benchmark change than see hundreds/thousands of practices across the state have to produce custom reports for OHA, while maintaining CMS compliant reporting for Medicaid/Medicare Meaningful Use.

• We utilize CMS specifications for all matters within the outpatient setting due to our participating in an ACO.
• CMS specs are what the BPHC is moving to. It would be most efficient to keep one set of reporting standards.

As long as goals are set keeping in mind that a portion of the population is being managed to different clinical standards, one measure for all age groups should work for quality reporting. This won’t be true if one (or a handful) of CCOs or practices has a population that differs from the rest by age. I don’t know how likely that is

• r how extreme the effect will be.

Comments in favor of HEDIS specs

• Clinically the HEDIS measure makes more sense, but creating reports not already there is a

challenge for us. But once the report is created, it is easy to maintain.

• To reduce reporting burden on organizations, it would be best suited to align with the

HEDIS measure as more organization reports this measure to HEDIS and widely recognized among the medical community.

• It is always easier if OHA aligns measures with HEDIS. Since most payers align with HEDIS

measures, communicating the targets to clinicians is better when there is one solid target, rather than a moving target based upon payer. The moving target, in the eyes of many, negates some of the clinical validity of targeting that as a benchmark, since it is not consistent.

• My providers are not happy that CMS does not keep up with the current

recommendations and that we have to report on CMS specs. They feel that they will score lower on the quality metric while still practicing quality medicine. It is nice that someone is looking to do more up to date data gathering but we are at the mercy of the EHR system/vendor that we have. My bigger frustration with EHR supplied quality reports/data is that they are tied to a calendar year for attestation purposes. Quality should be reportable on an ongoing rolling 12 month time frame. My numerator and denominator should not go back to 0/0 on January 1st. In other words there should be two reports - one for attestation on the measure year and one for ongoing assessment. I know that's a little off topic - thanks for letting me vent.

Other comments

• We can do it however it is required. Making this change would

require custom reports, however, as the standard vendor- supplied reports are in alignment with current CMS QPP specifications and not the HEDIS specs.

• Our EHR vendor has us doing a major upgrade soon to get the

new MACRA/MIPS dashboard for reporting. We have no idea how this will look or function since it has not been completed yet. Scary since we are almost half way through the year.

Controlling Hypertension – TAG recommendation

• Based on the survey results, and other discussion,

does the TAG want to recommend changing the measure specs away from CMS specs in order to follow JNC 8 best practice guidelines (BP goal of 150/90 for ages 60-85 with no diagnosis of diabetes)?

Dental Sealants

• Include sealants provided in previous years for

children in the denominator

• The current specs incentivize reapplying sealants just to

get measure credit, even if it’s not clinically necessary.

• OHA would need to reset targets if we made this type of

change.

• The TAG generally supported this modification, pending

results of OHA testing.

Dental Sealants

• Add exclusion for patients who are not clinically

indicated to need sealants (e.g., at low risk)

• There were conflicting opinions from TAG participants about

the merits of risk coding.

• OHA commissioned an analysis from Q Corp, which showed

that, while risk coding is increasing, still only 5% of kids have been coded.

• Clarification / Discussion: The proposal is to exclude children

at low risk, not to only measure children at elevated risk (very few children would be excluded based on current coding rates)

Depression Screening and Follow- Up

• Modify to accept follow-up services occurring in

different encounters or on different days than the screening encounter

• TAG asked and OHA confirmed that numerator credit is

given under current specs if the clinic screens in advance

• f the visit and the review of results occurs at the visit.
• The TAG does not support this modification.

Developmental Screening

• Modify measure to include “follow-up” component:

Referral to specialist/services

• TAG members expressed concern with availability of timely

follow up in some geographies.

• Incorporating a “follow-up” component could lead to small

denominators in some CCOs.

• This information could be difficult to extract from an EHR.
• TAG recommends putting this suggestion in the parking lot, and

as we move forward with CQM registry, this may be a measure we consider.

• OHA is interested in creating a subgroup to do a deeper dive on this

measure, and explore future inclusion of the follow-up component. If you are interested in participating in this work, please email us at metrics.questions@state.or.us

Developmental Screening

• Include screening tools returned by mail and

entered into EHR by care team

• TAG/OHA confirmed that tools returned by mail will

already count for numerator credit if the provider reviews screening results and discusses with family.

• TAG determined no reason to alter this aspect of the

measure.

Follow Up After Hospitalization for Mental Illness

• Allow longer timeline for out-of-area discharges
• Time is of the essence in these cases, so we want to be careful

about allowing longer follow up timelines.

• If longer timelines are allowed, we must carefully define “out of

area”. “Out of state” is not sufficient because the metro area CCOs should still be responsible for following up for people in Vancouver.

• Some CCOs have very small denominators for this measure, so one

person out of area makes it very difficult for them to meet the benchmark/target.

• The TAG does not support this modification. Instead, OHA and TAG

agreed that CCOs should bring any special cases to OHA’s attention and they can potentially be excluded on a one-off basis.

Follow Up After Hospitalization for Mental Illness

• Modify to accommodate documented patient

refusal

• OHA has previously denied this modification for the

HTPP program.

• TAG expressed concern that there needs to be enough

flexibility to accommodate a reasonable rate of refusal. For CCOs with small denominators, if one person refuses it can cause them to miss the measure.

• OHA will raise the small denominator concern to the

Metrics & Scoring Committee.

Assessments for Children in DHS Custody

• Modify to include follow-up referrals and

connection to appropriate services

• This would require very extensive chart review because

CCOs would have to get documentation of physical, dental and mental health referrals.

• There are other details of this measure to work out

before any modifications are made.

• The TAG does not support this modification

Additional TAG feedback

The Metrics and Scoring Committee is also considering the following related to 2018 metrics:

• CAHPS measure
• Potentially retire CAHPS satisfaction with care
• Split CAHPS access to care into adult and children
• TAG thoughts?

Additional TAG feedback

• Health aspects of kindergarten readiness measure
• Possibly a bundle of existing measures, with separate
• benchmarks. Under consideration are:
• 1. developmental screening;
• 2. immunization status;
• 3. effective contraceptive use;
• 4. prenatal care
• To consider:
• Make this challenge pool?
• Make this stand-alone measure (in addition to each separate

measure)?

Additional TAG feedback

• Equity measure (ED utilization among SPMI

population)

• Retire broader ED utilization measure and replace with

this?

• Have two separate ED utilization measures (entire

population + SPMI population)

• Bundle (separate benchmarks for each – qualify for

payment only if achieve both)

• Challenge pool

Additional TAG feedback

• Obesity
• Committee asked OHA to explore whether there are

any feasible obesity metrics for 2018

• Under consideration are:
• BMI screening and follow-up (adult)
• Percentage of patients aged 18 years and older with a BMI

documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

https://ecqi.healthit.gov/ep/ecqms-2018-performance-period/preventive-care- and-screening-body-mass-index-bmi-screening-and

Additional TAG feedback

• Weight assessment & counseling for nutrition and

physical activity (children and adolescents)

• Percentage of patients 3-17 years of age who had an
• utpatient visit with a Primary Care Physician (PCP) or

Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement

• period. Three rates are reported.
• Percentage of patients with height, weight, and body mass

index (BMI) percentile documentation

• Percentage of patients with counseling for nutrition
• Percentage of patients with counseling for physical activity

https://ecqi.healthit.gov/ep/ecqms-2018-performance- period/weight-assessment-and-counseling-nutrition-and- physical-activity

Obesity (survey responses – adult BMI screening)

• Is this measure available from your EHR vendor as a

canned report?

• Is this measure built out/enabled as a report you can run

now?

Answers # of Respondents Yes 21 No 11 Unsure 4 Other 4 Answers # of Respondents Yes 22 No 10 Unsure 1 Other 5

Comments on reporting capabilities – adult BMI screening

• We currently only take vitals (including height and weight) for our psychiatry patients, not all

the PSHH patients. If we started to do that, then we'd have data to report.

• This report requires and additional box to checked from already busy providers.
• We currently report on the HEDIS Adult BMI Assessment. These are very similar measures

with a slight variation in the followup component. Adding a new measure with the same intent but different methodologies would cause an added burden to reporting organizations.

• We need to request the report be run and then we can download the results.
• This is similar to a UDS measure report that is available via Nextgen's UDS reporting tool. But

UDS has different normal range specifications: Age 18-64: normal parameters are >=18.5 and < 25. Age 65+: normal parameters are >=23 and < 30.

• We do this annually for HRSA. We can only do a sample because the nutrition and activity

counseling are sometimes covered in provider notes to the patients but not as part of coded data.

• This is calculated at almost every visit and reported on.
• We can do a report for BMI but not followup.
• This will be in the 2017 UDS report. The 2016 report which is currently available has a

different BMI boundary for the elderly.

• Just as with depression screening, the trick will be documentation of follow-up for abnormal

BMI, which is often not done in a way that is reportable right now. Low initial probability of complete and accurate data, could improve over time.

Obesity (survey responses – weight assessment/counseling, children

• Is this measure available from your EHR vendor as a

canned report?

• Is this measure built out/enabled as a report you can run

now?

Answers # of Respondents Yes 17 No 13 Unsure 4 Other 4 Answers # of Respondents Yes 18 No 12 Unsure 3 Other 4

Comments on reporting capabilities – child

• besity
• We need to request the report be run and then we can download the results.
• The age ranges on our canned reports do not match the CMS submission page for MU.
• This is similar to a UDS measure which is available via Nextgen's UDS reporting tool. But

there is only 1 rate reported: Denominator = all children 3-17. Numerator = those with all 3: BMI documented & had counseling for nutrition & had counseling for exercise.

• The way this data is documented in the chart, I don't think there is a way to run a report in
• ur EHR to collect it.
• I am not sure how to track the information on counseling for nutrition or for physical activity.
• ***Comment regarding all measures: we do not use "canned" reports from our EHR, as they

are not validated prior to publishing. In addition, all measures that are utilized as Meaningful Use measures are available for reporting for individual providers but not on a population or with patient level detail.

• We do this annually for HRSA. We can only do a sample because the nutrition and activity

counseling are sometimes covered in provider notes to the patients but not as part of coded data.

• I did not see this report previously, I don't think it was an option for reporting.
• We could do this if providers remember to do it.
• A part of the UDS reports right now.

Wrap Up

Next meeting: June 22, 2017, 1-3 pm