FIHN PCP Pod Meeting April 6, 2017 1

FIHN PCP Pod Meeting April 6, 2017 1

EHR Measure Scores 20.97 Eye 39.11 A1c Reminder: Customer Service and Claim based Measure Scores pending 35.48 Eye 20.56 A1c 2

Abstraction concerns Many patients failed CARE-3 (ACO-39): Documentation of Current Medications in the Medical Record (49.41%) Most commonly due to lack of Route of Administration details Also many prescriptions missing dose and frequency information A similar measure replaces this for 2017 but still uses definition of a current reconciled medications list “The medication list should include all medications (prescriptions, overthe-counter, herbals, supplements, etc.) with dose, frequency, route, and reason for taking it. It is also important to verify whether the patient is actually taking the medication as prescribed or instructed, as sometimes this is not the case. “ 3

Abstraction concerns Patients are failing PREV-9 (ACO-16): BMI Screening and follow-up (82.3%) Different parameters based on age: EHR may not alert differently for 65 Age 65 and older BMI 23 and 30 Age 18-64 BMI 18.5 and 25 Many elderly patients are underweight per these parameters and are not receiving plans Others are receiving plans to eat fewer calories, low salt, low fat, etc.- this would count on a report but may be a concern for appropriateness 4

Abstraction concerns Patients are failing or being excluded from MH-1 (ACO-40) at very high rates: Depression Remission at 12 months (6.7%) Not the Depression Screening measure Denominator: Age 18 with dx of major depression or dysthymia AND an initial PHQ-9 score 9 during the encounter Numerator: Who achieved remission at 12 months as demonstrated by a twelve month ( /- 30 days) PHQ-9 score of less than 5 Denominator exclusions: permanent nursing home residents, , dx of bipolar, dx of personality disorder 5

Abstraction concerns FIHN MSSP is just above benchmark for DM Composite: Hemoglobin A1C Poor Control and Retinal Eye Exam (31.2%) 18-75 with diabetes with A1c 9%; inverse measure 18-75 with diabetes who had a retinal or dilated eye exam by an eye care professional or negative retinal exam in 12 months prior to measurement period These are composed together for the score 6

2017 Primary Focus on: Depression Screening (c f/u plan) Breast Cancer Screening Colorectal Cancer Screening Diabetes Composite Measure (HbA1C Retinal Exam) Depression Remission at 12 Months 7

Changes to MSSP 2017 Quality Measures 8

Medication Reconciliation Post Discharge DESCRIPTION: The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list DEFINITION: Medication Reconciliation –Discharge medications are reconciled with the most recent medication list in the outpatient medical record. Must include evidence of medication reconciliation and the date. Any of the following evidence meets criteria: Examples on signed documentation Current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds at discharge, discontinue all discharge meds) Current medications with a notation that the discharge medications were reviewed Notation: “reconciled the current and discharge meds” A current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service Notation that no medications were prescribed or ordered upon discharge Document in EHR for quality reporting – check box for “reconciled” or “verified” Important Note: Dose, frequency, route and reason for taking must be noted to the best of the provider’s ability 9

ACO 44: Use of Imaging for Low Back Pain Numerator Denominator Comments EHR Documentation Patients who received an imaging study (e.g. plain x-ray, MRI, CT Scan) conducted on the episode start date or in the 28 days following. Exclusions – All patients 18 -50 Measure captured years of age who had patients with a via claims. an outpatient or ER low back pain Measure reported encounter with a diagnosis during principal diagnosis of the 180 days prior; as inverted low back pain during patients with measure (i.e. the start of the cancer; recent higher percentage measurement period trauma, indicates through 28 days prior intravenous drug appropriate to the end of the abuse, treatment measurement period. neurological (proportion for impairment Exceptions - none whom imaging studies didn’t 1 occur) 0

Depression Screening with follow-up At least once in 2017- maybe during Annual Wellness Visit OR on Medicare Screening Questionnaire If PHQ-2 is positive, follow up with PHQ-9 and/or Plan May consider using z13.89 (encounter for screening of other disorder) Document Exclusions: Active dx of depression or bipolar disorder Document Exceptions: Refusals 1 1

Examples of a Follow-up Plan Additional evaluation for depression or PHQ-9 Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacologic interventions (drug therapy) Other intervention or follow-up for the diagnosis or treatment of depression 1 2

At-Risk Domain MH: Depression Remission Document Exclusions – hospice or palliative care, permanent nursing home residents, diagnosis of bipolar or personality disorder 13

NextGen Charting vs eClinicalWorks 1 4

Fall Screening Must ask the patient: Have you had two (2) or more falls in the past year, or one (1) or more with an injury? (A) Part of Annual Wellness Visit exam (AWV HRA #17) - OR (B) Consider using the Medicare Screening Questionnaire for all Medicare patients 1 5

eCW Fall Screening 1 6

eCW Fall Screening 17

Fall Screening Exceptions 18

Exception/Exclusion documentation 1 9

Depression Screening (c Followup) (A) Part of Annual Wellness Visit exam (PHQ-2 on AWV Patient Assessment) - OR (B) Consider using the Medicare Screening Questionnaire for all Medicare patients If PHQ-2 is positive, please complete PHQ-9 and CREATE A FOLLOW-UP PLAN May consider using z13.89 (encounter for screening of other disorder) 2 0

AWV Patient Assessment 2 1

Depression Follow-up Plan Additional evaluation for depression (can also be PHQ-9) Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacologic interventions (drug therapy) Other intervention or follow-up for the diagnosis or treatment of depression 2 2

eCW 2 3

Additional Plan or Exclusions 2 4

Documenting Exclusions 2 5

BMI (Body Mass Index) BMI (65yo and older) If BMI 23 write a plan to increase weight If BMI 23-30 no plan needed; weight satisfactory If BMI 30 write a plan to decrease weight (for under 65yo BMI’s should be 18.5 and 25; document if patient refuses plan) 2 6

eCW 27

Exclusions 28

Diabetes Composite HbA1c (must record, and be 9 (controlled)) - AND Current Retinal Exam: Every year for positive retinopathy, Every 2 years for negative retinopathy 2 9

eCW 30

Diabetes Composite – Retinal Exam Letter sent out to all Optometrists and Ophthalmologists on 5/11/16 Check with patients to be sure they have had a yearly eye exam We will report out to you a list of your attributed patients with diabetes who need an HbA1c and/or a retinal exam. Must have a copy of the retinal exam / report on the chart 3 1

eCW 3 2

Eye Exam Referral & Fax Form 33

Diabetes Composite – HbA1c If send out – please order test BEFORE office visit (to discuss results of the test) Medicare allows every 6 months for IGT, every 3 months for Diabetes If pt consistently remains 9, consider Endocrine consultation 34

Medicare Screening Questionnaire Use in place of the Annual Wellness Exam Have patient fill out the form in the Waiting Room Consider allowing your nurse / MA automatically order any test that needs to get done (standing order sets) Review by MD, then gets scanned into chart (e.g. Chart Documents) 35

Flu Immunization Flu season runs from Fall (8/1/15) to Spring (3/31/16) – already done for 2016 report: CAN go back and record refusals and allergies Record date if / when given in EMR If done at a pharmacy / elsewhere record the closest date possible (eg October 1st) and note that it was given there Vaccine Registry can be accessed: www.mdimmunet.org (410-767-6606) 36

Flu Immunization Exceptions Record Vaccine refusals (make sure your EMR has a “refusal” element if patient declines the shot) Also record if the patient is allergic to flu shots (list under “Allergies”), or cannot receive it due to other medical reasons (Can also list other System issues, such as the vaccine is not available, if appropriate.) 37

eCW Exclusions may be documented by selecting “Not Administered” and selecting the reason. 38

Exceptions 39

Pneumococcal Vaccination No Exclusions Give Prevnar-13 or Pneumovax to all pts 65yo No exceptions or exclusions (for vaccination refusal) If given this year, must document specific type May use state Vaccine Registry www.mdimmunet.org (410-767-6606) 4 0

Pneumococcal Vaccination It is encouraged for all practices to give the vaccine Cost (10 doses per box): Pneumovax (90732) - 76.53 per dose Prevnar-13 (90670) - 159.57 per dose Medicare Reimbursement: Pneumovax (90732) - 88.80 Prevnar-13 (90670) - 177.44 Immun Single Injection (G0009) – 25.67 4 1

Tobacco Use Must Document Smoking and Smokeless tobacco use/non-use Offer counseling Refer to an established smoking cessation program – FMH Outpatient Cessation Program (240-566-3622) With proper documentation can bill in office 99406 (Smoking and tobacco use cessation counseling visit; 3-10 minutes) or 99407 ( 10 minutes); use modifier 25 4 2

eCW 43

Exceptions/Exclusions 4 4

Mammogram For ages 50-74 yrs old, within 27 month period. Use Medicare Screening Questionnaire Officially, report does not need to be in chart. Exclusion: Bilateral mastectomies 45

eCW 46

Exclusions 47

Colorectal Cancer Screening For ages 50 – 75 years old. Use Medicare Screening Questionnaire Officially, report does not need to be in chart. Encourage FOBT (x3) for those who refuse colonoscopy Cologuard not currently accepted 48

eCW 49

Exclusions 5 0

HTN Control 5 1

MH-1 Depression Remission Depression Remission – do PHQ-9 for every visit on a patient with depression; or schedule on a yearly basis (e.g. at the time of the MC Wellness Visit) 5 2

eCW Use the same Smart Forms for the depression screening except administer PHQ-9 only 53

IVD No exception s 54

Medication Reconciliation Post Discharge Medication Reconciliation Post-Discharge Should include all medication including prescriptions, OTCs, vitamins, and supplements Should include strength, dose, route, timing (sig) (SEE SUPERUSER POD SLIDE) 55

eCW 56

Statin Therapy for Prevention and Treatment of Cardiovascular Disease 57

Exclusions 58

Exceptions 59

Questions 6 0