The CMS Pilot Program
CMS started a pilot program called
the Doctor’s Office
Quality–Infor-mation Technology (DOQ-IT)
Pro-ject in 2004 and included it as part
of its national quality initiative for
the 8th Statement of Work (SOW)—
a 3-year contract running from
Au-gust 2005 through July 2008. The
53 Medicare Quality Improvement
Organizations (QIOs) that cover all
US states, territories, and the
Dis-trict of Columbia were responsible
for implementing DOQ-IT in each
of their coverage areas. CMS
creat-ed 2 roadmaps for addressing the
components of the DOQ-IT Project:
1. An EHR roadmap for adopting
an EHR system
2. A care management roadmap for
improving the functional and
clinical outcomes in patients with
chronic disease after an EHR
sys-tem has been implemented
Both of these roadmaps provide
step-by-step directions for
choos-ing the best EHR system to run a
more efficient practice and utilize
the capabilities of an EHR system
to implement care management.
QIO consultants are providing
as-sistance to DOQ-IT physicians in
following these guidelines.
Howev-er, all physicians interested in
im-plementing and using EHR
sys-tems for care management can
benefit from the materials
avail-able with these roadmaps.
Materi-als can be obtained by going to the
CMS MedQIC Web site at
www.medqic.org and clicking on
Physician Offices.
Adopting an EHR System
The recruitment phase of the
DOQIT Project, which identified a
specific number of primary care
physicians (PCPs) who were
interest-ed in acquiring EHR systems in each
state or jurisdiction, is completed.
QIO consultants work with these
practices to assist in selection and
implementation of an EHR system.
The EHR roadmap provides
phases for adopting EHRs in a
systematic way (Table 1). This
ap-proach separates EHR
implemen-tation into individual components,
with each step building on the
pre-vious. By using this approach,
im-portant details have not been
over-looked and practices have moved
forward successfully.
Applying Care Management
Strategies
The goal of the DOQ-IT Project is
to improve the quality of care
pa-tients receive by helping physicians
monitor and improve the healthcare
services they provide. Care
manage-ment improves functional and
clini-cal outcomes in patients with
chron-ic disease and reduces the need for
additional medical services that
re-sult from disease complications. It
also supports prevention, early
de-tection, and early treatment of
dis-ease to yield the best outcomes. As
with the EHR adoption strategy,
this CMS roadmap assists
physi-cians with implementing care
man-agement into routine clinical
prac-tice (Table 2).
When the EHR systems have
been implemented and evaluated
and the DOQ-IT physician
prac-I
n 2004, the US Department of Health and Human Services (DHHS)
released an outline for a 10-year plan to transform the delivery of
health care by building a new health information infrastructure, including
electronic health records (EHRs) and a network to link health records
nationwide. At that time, DHHS Secretary Tommy Thompson
emphasized that America needs to move much faster to adopt
information technology (IT) in our healthcare system. “Electronic health
information will provide a quantum leap in patient power, doctor power,
and effective health care. We can’t wait any longer.”
1The Centers for
Medicare and Medicaid (CMS) is fully supporting this effort.
E
HR Systems Promote
Quality Improvement and
Practice Efficiencies
tices understand system
capabili-ties, QIO consultants will begin
working with the physician
prac-tices on implementing care
man-agement for continued quality
im-provement. CMS has identified
topics that it will use to measure
performance by having physicians
transmit data from their EHRs to a
CMS data warehouse. The
identi-fied topics are shown in Table 3.
CMS maintains a list of EHR
system vendors that have declared
their support for the DOQ-IT
Pro-ject. The vendors have signed a
DOQ-IT letter of intent, declaring
their pledge to meet program
ex-pectations of capturing and sending
clinical quality data that meet CMS
requirements. Currently, a limited
number of DOQ-IT physicians are
able to transmit this data to a CMS
clinical warehouse because only a
few EHR vendors have products
that can perform this function.
Physician Quality
Reporting Initiative
CMS is taking additional steps to
support the federal government’s
10-year plan to transform the
de-livery of health care with IT by
introducing a program for
physi-cians to voluntarily and
confiden-tially report data about designated
quality measures. The 2006
Physi-cian Voluntary Reporting Program
(PVRP) has been discontinued and
has been replaced by the Physician
Quality Reporting Initiative (PQRI).
PQRI is designed to find the most
ef-fective methods of using
CMS-iden-tified measures in routine practice to
improve quality of care. By
partici-pating in PQRI, physicians will have
hands-on experience with CMS’s
data collection process and receive
confidential feedback reports with
Table 1.
Roadmap for Adopting an EHR
Assessment Planning Selection Implementation Evaluation Improvement
Phase
Action
Individual needs of the practice are identified. Project plan is established.
An EHR vendor is selected.
A “go-live” date is established. Physicians and staff are trained on the new system. Data interfaces are complet-ed and testcomplet-ed.
Effectiveness of the EHR system is measured.
Workflow processes are continuously improved and care management begins.
Table 2.
Roadmap for Implementing Care Management
1.Define the subpopulation of patients in need of care management. 2. Choose a physician performance measurement set of quality measures. 3. Use a clinical information system to track quality measures.4. Establish patient goals for quality improvement.
5. Analyze the current workflow processes to identify areas for improvement. 6. Implement a change in the workflow process.
7. Measure and analyze results.
8. Repeat actions 6 and 7 until goals are reached. 9. Sustain the improvement.
Table 3.
CMS Topics and Measures for Care Management
Chronic Disease Management• Coronary artery disease • Diabetes
• End-stage renal disease (ESRD) • Heart failure
• Hypertension Preventive Care
• Adult immunization (influenza and pneumococcal) • Blood pressure measurement
• Breast cancer screening • Colorectal cancer screening
• Low-density lipoprotein (LDL) cholesterol level • Tobacco use
information on their reported
per-formance rates compared with
oth-ers on a national level.
Why Physicians Should
Participate
When PVRP was introduced, it
was not associated with a financial
incentive. This, however, changed
with the passage of the Tax Relief
and Health Care Act of 2006 (HR
6111) in late 2006. The law
in-cludes a 1.5% bonus payment
(pay-for-reporting) for physicians
who report data on quality
meas-ures via CMS’s PQRI beginning in
July 2007. Additional reasons for
participating include:
• PQRI provides physicians with
confidential reports they can use
to benchmark their performance
compared to other physicians.
CMS has stated that this
infor-mation is not intended to be
shared with the public.
Howev-er, at the de-identified aggregate
level, CMS may release
informa-tion as part of lessons learned in
this program.
• PQRI participation will give
physicians the opportunity to
ensure that their claims
proces-sor and office software can
sup-port a CMS resup-porting process.
How to Participate
For 2007, eligible professionals
need not enroll or file an intent to
participate. Physicians can
partici-pate by reporting the appropriate
quality measure data on claims
submitted to their Medicare claims
processing contractor.
In order to satisfactorily meet
the requirements of the program
and receive the bonus payment,
certain reporting thresholds must
be met. When no more than three
quality measures are applicable to
services provided by a physician,
each such measure must be
report-ed in at least 80% of the cases in
which the measure is reportable.
When four or more measures are
applicable to the services provided
by an eligible professional, the
80% threshold must be met on at
least three of the measures
report-ed.
Physicians should select and
re-port measures that are applicable
to their practice. While reporting
for the 2007 PQRI begins with
claims for dates of service as of
Ju-ly 1, 2007, eligible professionals
should become familiar with the
2007 PQRI measures before the
re-porting period begins.
The 2007 PVRP quality measures
were posted on December 5, 2006
under the title "2007 Physician
Vol-untary Reporting Program (PVRP)
Quality Measures." This December
5, 2006 document identifying
sixty-six quality measures is accessible
on the "Transition From Physician
Voluntary Reporting Program"
PQRI page. On January 22, 2007
the AQA Alliance, through its
con-sensus-based process, adopted eight
other measures. These eight
addi-tional measures are now included in
the PQRI measures for 2007.
How to Submit Quality
Measure Information
The usual source of clinical data
for quality measures is
retrospec-tive chart abstraction, but data
col-lection through chart abstraction
can be burdensome. Consequently,
the PQRI focuses on ways to
ob-tain valid quality measure data as
efficiently as possible. CMS is
col-lecting quality information on
services provided to the Medicare
population by using the
adminis-trative claims system.
CMS has defined a set of HCPCS
(healthcare common procedure
coding system) codes, known as
G-codes
and CPT Category II codes,
to report data for the calculation of
the physician quality measures.
These codes supplement the usual
claims data with clinical data that
can be used to measure the services
rendered to beneficiaries. Each
measure has an appropriate G-code
or CPT Category II code, which is
submitted on the Medicare claim
form generated after a covered
serv-ice has been performed.
Physicians simply add the
ap-propriate codes to their claims
and submit their claims in the
routine fashion. CMS has
work-sheets to will assist in the
sub-mission process.
2006 Physician Voluntary Reporting Program (PVRP)
2007 Physician Quality Reporting Initiative (PQRI)
CMS launched the Physician Voluntary Reporting Program (PVRP) in 2006 to better analyze the quality of care provided to Medicare beneficiaries by using a set of codes established by Medicare. PVRP-specific G-codes and CPT® Cat-egory IIs could be reported voluntarily by using the existing administrative sys-tem for physician claims. The 2006 PVRP ended December 31, 2006. Partici-pating physicians may continue to access a confidential feedback report (regarding their practice's performance in 2006) via QualityNet Exchange.The PVRP was replaced by the 2007 Physician Quality Reporting Initiative (PQRI), as authorized by the Tax Relief and Health Care Act of 2006. Under the 2007 PQRI, eligible professionals who successfully report specified meas-ures will earn a payment bonus, subject to a cap. The reporting period for the PQRI will be July 1 through December 31, 2007. There is no need to enroll to participate in the PQRI. Details about the 2007 PQRI are available on the CMS website: www.cms.hhs.gov/PQRI
2007 PQRI Physician Quality Measures
1. Hemoglobin A1c control in type 1or 2 diabetes mellitus
2. Low-density lipoprotein control in type 1 or 2 diabetes mellitus 3. High blood pressure control in
type 1 or 2 diabetes mellitus 4. Falls: Screening for fall risk 5. Heart failure:
angiotensin-convert-ing enzyme (ACE) inhibitor or an-giotensin-receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD)
6. Antiplatelet therapy prescribed for patient with coronary artery dis-ease
7. Beta-blocker therapy for patient with prior myocardial infarction 8. Beta-blocker therapy for LVSD 9. Antidepressant medication during
acute phase for patient with new episode of major depression 10. Stroke and stroke rehabilitation:
computed tomography (CT) or magnetic resonance imaging (MRI) reports
11. Stroke and stroke rehabilitation: carotid imaging reports
12. Primary open-angle glaucoma: op-tic nerve evaluation
13. Age-related macular degeneration: antioxidant supplement pre-scribed/recommended
14. Age-related macular degeneration: dilated macular examination 15. Cataracts: assessment of visual
functional status
16. Cataracts: documentation of pre-surgical axial length, corneal pow-er measurement, and method of intraocular lens power calculation 17. Cataracts: presurgical dilated
fun-dus evaluation
18. Diabetic retinopathy: documenta-tion of presence or absence of macular edema and level of severi-ty of retinopathy
19. Diabetic retinopathy: communi-cation with the physician manag-ing ongomanag-ing diabetes care 20. Perioperative care: timing of
anti-biotic prophylaxis: ordering physi-cian
21. Perioperative care: selection of prophylactic antibiotic: first- or second-generation cephalosporin 22. Perioperative care: discontinuation
of prophylactic antibiotics (noncar-diac procedures)
23. Perioperative care: venous throm-boembolism (VTE) prophylaxis (when indicated, in allpatients)
24. Osteoporosis: communication with the physician managing ongoing care postfracture
25. Melanoma: patient medical history 26. Melanoma: complete physical skin
examination
27. Melanoma: counseling on self-ex-amination
28. Aspirin at arrival for acute myocar-dial infarction (AMI)
29. Beta-blocker at time of arrival for AMI
30. Perioperative care: timing of pro-phylactic antibiotic: administering physician
31. Stroke and stroke rehabilitation: deep vein thrombosis (DVT) pro-phylaxis for ischemic stroke or intracranial hemorrhage 32. Stroke and stroke rehabilitation:
discharged on antiplatelet therapy 33. Stroke and stroke rehabilitation:
anticoagulant therapy prescribed for atrial fibrillation at discharge 34. Stroke and stroke rehabilitation: tissue plasminogen activator (tPA) considered
35. Stroke and stroke rehabilitation: screening for dysphagia 36. Stroke and stroke rehabilitation:
consideration of rehabilitation services
37. Dialysis dose in ESRD patient 38. Hematocrit level in ESRD patient 39. Screening or therapy for
osteo-porosis for women aged 65 years and older
40. Osteoporosis management follow-ing fracture
41. Osteoporosis pharmacologic ther-apy
42. Osteoporosis: counseling for vita-min D, calcium intake, and exer-cise
43. Use of internal mammary artery (IMA) in coronary artery bypass graft (CABG)
44. Preoperative beta-blocker in pa-tient with isolated CABG 45. Perioperative: discontinuation of
prophylactic antibiotics (cardiac procedures)
46. Medication reconciliation 47. Advance care plan
48. Assessment of presence or ab-sence of urinary incontinence in women aged 65 years and older 49. Characterization of urinary
inconti-nence in women aged 65 years and older
50. Plan of care for urinary inconti-nence in women aged 65 years and older
51. COPD: spirometry evaluation 52. COPD: bronchodilator therapy 53. Asthma: pharmacologic therapy 54. ECG performed for nontraumatic
chest pain
55. ECG performed for syncope 56. Vital signs for community-acquired
pneumonia
57. Assessment of oxygen saturation for community-acquired pneumonia 58. Assessment of mental status for
community-acquired pneumonia 59. Empiric antibiotic for
community-acquired pneumonia
60. (GERD: assessment for Alarm Symptoms
61. GERD: upper endoscopy for pa-tients with alarm symptoms 62. GERD: biopsy for barrett’s
esoph-agus
63. GERD: barium swallow- inappro-priate use
64. Asthma assessment: percent of patients who were evaluated dur-ing at least 1 office visit within 12 months for the frequency of day-time and nocturnal asthma symp-toms
65. Appropriate treatment for children with URI
66. Appropriate testing for children with pharyngitis
67. Myelodysplastic syndrome (MDS) and acute leukemias: baseline cy-togenetic testing performed on bone marrow
68. Myelodysplastic syndrome (MDS): documentation of iron stores in patients receiving erythropoietin therapy
69. Multiple myeloma: treatment with bBisphosphonates
70. Chronic lLymphocytic leukemia (CLL): baseline flow cytometry 71. Hormonal therapy for stage IC-III,
ER/PR positive breast cancer 72. Chemotherapy for stage III colon
cancer patients
73. Plan for chemotherapy document-ed before chemotherapy adminis-tered
74. Radiation therapy for invasive breast cancer patients who have undergone breast conserving sur-gery
For details go to: www.cms.hhs.gov/PQRI/ Downloads/PQRIMeasuresList.pdf
PVRP Physician Quality
Measures
In 2007 CMS introduced 74
evi-dence-based, clinically valid PQRI
measures that are included in
nu-merous guidelines endorsed by
physicians and medical societies.
The measures are divided by
physi-cian specialty and physiphysi-cians
re-port data for only the measures
within their specialties. The
abbre-viated list appears on page 23.
Measure specifications
informa-tion can be downloaded at www.
cms.hhs.gov/PQRI/Downloads/PQ
RIMeasuresList.pdf
Earning More
Reimburse-ment Through Reporting
IT in physician offices is becoming
an integral component for practice
efficiency. DOQ-IT and PVRP are
supporting the government’s plan
to build a health information
infra-structure and meet CMS’s vision
for the 8th SOW and beyond: the
right care for every person every
time.
By becoming part of the plan,
physicians can help improve the
quality of patient care, make their
practices more efficient, and get
paid for reporting.
MPM
Andrew Miller, MD, MPH, is the Director of Physician Services at Healthcare Quality Strategies, Inc. (HQSI), the feder-ally designated QIO for New Jersey. HQSI is an independent, nonprofit com-pany committed to accelerating improve-ment in healthcare quality through a col-laborative and interactive process with the healthcare community.
This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare QIO for New Jersey under contract with CMS, an agency of the US DHHS. The contents presented do not necessarily reflect CMS policy. 8SOW-NJ-GEN-07-01
Reference
1. US Department of Health and Human Services. Thompson launches “Decade of Health Information Tech-nology” [press release]. July 21, 2004.
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R O V I D E R
A
C T I O N
Impact to You
Physicians have the ability to increase their reimbursement by 1.5% from Medicare by participating in the Physician Voluntary Reporting Program (PVRP). This reporting and the improvement of these measures can be greatly improved through the use of electronic health record (EHR) systems.
What You Need to Know
Physicians need to know how to submit their data to the PVRP. CMS is collecting this quality data by using the administrative claims system. This is the first step in Medicare’s and other insurers' move to pay-for-performance.
What You Need to Do
Under the 2007 PQRI, reporting specified quality improvement measures can result in a payment bonus. The reporting period is July 1 - December 31, 2007. Enrollment is not required for participation. Details available on the CMS website: www.cms.hhs.gov/PQRI
Medicare Will Provide Beneficiaries with Physician Performance Results as Part of Its
Value-driven Healthcare Initiative
The Centers for Medicare & Medicaid Services (CMS) an-nounced in February that the Delmarva Foundation for Med-ical Care (Delmarva), one of its quality improvement organiza-tions, has entered into subcontracts with 4 regional
collaboratives, as part of the Better Quality Information to Im-prove Care for Medicare Beneficiaries (BQI) Project.
These regional collaboratives will combine Medicare data with data from other insurers to produce information on the performance of healthcare providers for the benefit of Medicare beneficiaries.
The following regional collaboratives have signed subcon-tracts: Indiana Health Information Exchange (IHIE), Massa-chusetts Health Quality Partners (MHQP), Minnesota Com-munity Measurement (MNCM), and Wisconsin Collaborative for Healthcare Quality (WCHQ).
The results of the BQI Project will be used for two primary purposes: first, to provide performance information to physi-cians that will assist them in improving the quality of care they are delivering to Medicare beneficiaries; and second, to give physician performance information to Medicare benefici-aries to help them with physician selection.
“This is an important advancement,” said CMS Acting
Ad-ministrator Leslie Norwalk. “The BQI project will give Medicare beneficiaries a broad overview of provider perform-ance, resulting in better choices in meeting their health care needs. The regional collaboratives, spurred by great leader-ship from physicians and others in the healthcare community, will also provide critical information to physicians and Medicare on the best practices for data collection, aggrega-tion, and reporting.”
The BQI Project is part of Department of Health and Hu-man Services' Secretary Mike Leavitt’s Value-driven Health-care Initiative, which is based on the following 4 corner-stones: interoperable health information technology (health IT); transparency of price information; transparency of quality information; and the use of incentives to promote high-quality and cost-efficient health care. The Initiative directs federal agencies, to the extent permitted by law, to share information with beneficiaries on the quality of services provided by doc-tors, hospitals, and other healthcare providers.
Additional information on each regional collaborative as well as the Secretary’s Value-driven Healthcare Initiative is available at: www.hhs.gov/transparency
