Minnesota Statewide Quality Reporting

Minnesota

Statewide

Quality

Reporting

and

Measurement

System

(SQRMS):

Clinic

and

Provider

Registration,

and

Clinical

Quality

Data

Submission

Requirements

January

8

&

10,

2013

Denise

McCabe

Quality

Reform

Implementation

Supervisor

Minnesota

Department

of

Health:

Protecting,

maintaining

and

Quality

measures:

Statutory

requirements

•

Minnesota

Statutes,

§ 62U.02,

Subd.

1

and

3

•

The

commissioner

of

health

shall

develop

a

standardized

set

of

measures

by

which

to

assess

the

quality

of

health

care

services

offered

by

health

care

providers…

•

The

commissioner

shall

establish

standards

for

measuring

health

outcomes,

establish

a

system

for

risk

adjusting

quality

measures,

and

issue

annual

Partnership

between

MDH

and

MN

Community

Measurement

•

MDH

has

a

5

‐

year

contract

with

MN

Community

Measurement

(MNCM)

as

lead

member

of

consortium

including

the

Minnesota

Medical

Association

(MMA),

Minnesota

Hospital

Association

(MHA),

Stratis Health

and

University

of

Minnesota.

MN

Community

Measurement

&

MDH

roles

and

responsibilities

MDH

MNCM

• Selects measurement areas and measures 

for development

• Obtains input from the public at various 

steps of rulemaking

• Annually promulgates rules that define the 

uniform set of measures

• Publicly reports measures

• Develops vision for further evolution of 

SQRMS

• Performs research in support of identifying 

new areas of measurement

• Works with groups of stakeholders on the 

review of existing and development of new 

measures, including their specifications

• Develops annually for the State’s 

consideration recommendations of the 

uniform set of quality measures

• Develops recommendations for risk 

adjustment

• Holds public meeting at which to present 

recommendations and obtain feedback

• Facilitates data collection and management 

of information collected from physician 

clinics, ambulatory surgical centers, and 

hospitals

Registration

requirements

•

Minnesota

Administrative

Rules,

Chapter

4654,

and

appendices

•

Physician

clinics

must

register

annually

with

MNCM

•

The

primary

purpose

of

annual

clinic

and

provider

registration

is

to

facilitate

the

collection

of

clinical

quality

measures

for

SQRMS

–

Clinic

and

provider

registration

determines

quality

measure

submission

requirements

Registration

requirements

•

MDH

also

uses

clinic

and

provider

registration

for

its

Provider

Peer

Grouping

(PPG)

initiative

(Minnesota

Statutes,

62U.04)

–

Providing

full

and

accurate

information

during

registration—including

the

providers

that

practice

at

each

clinic—is

important

–

Information

submitted

by

physician

clinics

during

annual

clinic

and

provider

registration—including

FTE

information—is

used

in

PPG

to

properly

credit

each

physician

clinic

with

the

services

they

provided

to

their

patients

–

The

methodology

and

tools

for

calculating

full

‐

time

equivalents

(FTE)

have

been

enhanced

to

simplify

registration

and

improve

precision

–

Registered

provider

information

is

NOT

tied

to

the

data

submitted

for

Reporting

requirements

•

Each

physician

clinic

must…

–

Submit

data

required

to

calculate

the

applicable

quality

measures,

including

the

data

necessary

to

perform

risk

adjustment

for

each

applicable

quality

measures

for

all

health

care

services

provided

by

the

physician

clinic

–

Submit

the

data

using

the

standardized

electronic

format

and

procedures

–

Report

on

a

full

population

basis

if

it

had

an

electronic

medical

record

system

in

place

for

the

entire

prior

measurement

period

Annual

update

of

quality

reporting

rules

1. MDH

invites

interested

stakeholders

to

submit

recommendations

on

the

addition,

removal,

or

modification

of

standardized

quality

measures

to

MDH

by

June

1

2. MNCM

submits

preliminary

recommendations

to

MDH

mid

‐

April;

MDH

opens

public

comment

period

3. MNCM

submits

final

recommendations

to

MDH

by

June

1;

MDH

opens

public

comment

period

4. MNCM

measure

recommendations

are

presented

at

a

public

forum

toward

the

end

of

June

5. MNCM

submits

final

measure

specifications

to

MDH

by

July

15

6. MDH

publishes

a

new

proposed

rule

by

mid

‐

August

with

a

30

‐

day

public

comment

period

7. Final

rule

adopted

by

the

end

of

the

year

Jan

Feb

Mar

Apr

❶

❷

May

Jun

❸

❹

Jul

❺

Aug

❻

Sep

Oct

Nov

❼

Resources

•

Subscribe

to

MDH’s

Health

Reform

ListServ to

receive

weekly

email

updates

–

http://www.health.state.mn.us/healthreform/announce/index.h

tml

•

SQRMS

website

–

http://www.health.state.mn.us/healthreform/measurement/ind

ex.html

•

For

questions

about

SQRMS,

contact:

–

Denise

McCabe,

[email protected]

,

651.201.3569

Minnesota

Clinic

&

Provider

Registration

and

Clinical

Quality

Reporting

MN

Community

Measurement

•

_Publicly

_reports

_health

_care

_quality

_measures

with

the

goal

of

improving

the

health

of

patients

•

_2004:

_HEDIS

_measures

_by

_medical

_group

–

Health

plan

data

•

2006:

DDS

measures

by

clinic

site

–

Data

submitted

by

clinics

•

2010:

Statewide

Quality

Reporting

and

Measurement

System

2013

Timelines

Time Task Portal Opens Portal Closes

Winter 

2013

Register MN Clinics & Providers December 2012 February 8, 2013 Data Submission:

‐Optimal Diabetes Care ‐Optimal Vascular Care ‐Depression Care Measures

January 14, 2013 January 14, 2013 February 4, 2013 February 15, 2013 February 15, 2013 February 28, 2013 Complete Health Information Technology Survey February 15, 2013 March 15, 2013 Patient Experience of Care Survey February 24, 2013 April 2, 2013

Summer 

2013

Data Submission:

‐Optimal Asthma Care

‐Colorectal Cancer Screening

‐Maternity Care: Primary C‐section Rate

July 15 2013 July 15, 2013 July 15, 2013 August 16, 2013 August 16, 2013 August 16, 2013 2014 Data Submission:

‐Total Knee Replacement (2012 Dates of  Procedure)

Implement tools now (Jan 2013)

April 2014 May 2014

2015 Data Submission:

‐Spine Surgery Measures (2013 Dates of  Procedure)

Implement tools now (Jan 2013)

Getting

Started

on

MNCM

Website:

www.mncm.org

Getting

Started

on

MNCM

Data

Portal:

https://data.mncm.org/login

Registration

•

Download

instructions from

mncm.org

or

MNCM

Data

Portal

from

the

Resource

tab

•

Access

the

MNCM

Data

Portal:

https://data.mncm.org/login

–

First

time

users

must

request

login/password

•

Necessary

registration

information:

–

Medical

group

information

–

Clinic

and

specialty

information

–

Provider

information

and

file

upload

•

Clinic

specialties

determine

which

measures

a

clinic

is

required

to

submit

data

for

•

Must

complete

registration

before

February

8,

2013

•

Registration

must

be

completed

before

data

can

be

submitted

to

Clinic

Registration

and

Reporting

•

Registration:

–

Register

any

and

all

clinic

locations

in

the

state

of

Minnesota

where

primary

or

specialty

care

ambulatory

services

are

provided

for

a

fee

by

one

or

more

physicians

•

Clinical

Quality

Reporting:

–

You

may

submit

data

as

a

single

entity

(“roll

‐

up”)

if

all

of

the

following

apply,

clinics

must:

•

Have

common

ownership

AND

•

Have

a

majority

(more

than

half)

of

common

clinic

staff

working

across

multiple

locations

– must

rotate

between

all

clinics,

AND

•

The

total

clinical

staff

across

all

locations

is

no

greater

than

20

full

‐

time

equivalent

(FTE)

–

A

clinic

site

must

still

be

registered

even

if

the

data

from that site will be submitted using the roll up

Provider

Registration

•

Register

all

providers

who

bill

through

a

medical

group’s

clinic

– Upload file of providers and required information

•

Providers

include:

– Physicians (MD, DO, physicians with medical degrees from other countries and those 

who are locum tenens, residents and fellows)

– Advance practice registered nurses (e.g., Certified Nurse Practitioners, Certified Nurse 

Specialist, Certified Nurse Midwife)

– Physicians assistants

•

Required

information:

– National Provider Identify or Provider ID number

– Provider Type and Board Certified Specialty

– Medical license number

– Full‐time equivalent (FTE) status for each clinic where the provider practices 

• Please see Clinic and Provider Registration Instructions Appendix C for examples on how to 

calculate FTE

• There is also a tool in the portal that will assist in calculating FTEs for providers based on how 

Measures

for

Required

Reporting

•

_{Winter 2013:}

–

Optimal

Diabetes

Care

–

Optimal

Vascular

Care

–

Depression

Remission

at

Six

Months

•

Spring 2013:

–

Health

Information

Technology

(HIT)

Survey

–

Patient

Experience

of

Care

Survey

(Data

submitted

by

Survey

Vendors)

•

_{Summer 2013:}

–

Colorectal

Cancer

Screening

–

Optimal

Asthma

Care

–

Maternity

Care:

Primary

C

‐

Section

Rate

•

_{Throughout 2013}

Optimal

Diabetes

Care

•

Specialties:

Family

Medicine

(includes

General

Practice),

Internal

Medicine,

Geriatrics,

Endocrinology

•

Exempt

clinics

:

Less

than

10%

adults

in

clinic

population

•

Dates

of

service:

January

1,

2012

– December

31,

2012

•

Denominator:

– ICD‐9‐CM codes that define diabetes mellitus

– Patients ages 18 to 75

– Visit criteria (2 face‐to‐face visits with provider in last 2 years for diabetes AND 1 visit to 

the clinic in the last 12 months for any reason)

•

Composite

or

“all

‐

or

‐

none”

measure

•

Numerator:

– Number of patients who meet all of the following targets: • Blood sugar control (Target: HbA1c less than 8.0)

• Blood pressure control (Target: Less than 140/90)

• LDL or “bad” cholesterol control (Target: Less than 100)

• Aspirin documentation

– Patients withco‐morbidity of ischemic vascular disease:  daily aspirin use or documented  contraindication

– Patients withoutco‐morbidity of ischemic vascular disease:  passes component automatically

Optimal

Vascular

Care

•

Specialties:

Family

Medicine

(includes

General

Practice),

Internal

Medicine,

Geriatrics,

Cardiology

•

Exempt

clinics:

Less

than

10%

adults

in

clinic

population

•

Dates

of

service:

January

1,

2012

– December

31,

2012

•

Denominator:

–

ICD

‐

9

‐

CM

codes

that

define

ischemic

vascular

disease

(IVD)

–

Patients

ages

18

to

75

–

Visit

criteria

(2

face

‐

to

‐

face

visits

with

provider

in

last

2

years

for

IVD

AND

1

visit

to

the

clinic

in

the

last

12

months

for

any

reason)

•

Composite

or

“all

‐

or

‐

none”

measure

•

Numerator:

–

Number

of

patients

who

meet

all

of

the

following

targets:

• Blood pressure control (Target: Less than 140/90)

• LDL or “bad” cholesterol control (Target: Less than 100)

• Aspirin documentation (Target: Daily aspirin use or valid contraindication)

• Tobacco‐free status

Depression

Remission

at

6

Months

•

Specialties:

Family

Medicine

(includes

General

Practice),

Internal

Medicine,

Geriatrics,

and

Psychiatry/Behavioral

Health

professionals

(if

there

is

a

physician

on

staff

at

the

clinic

site)

•

Exempt

clinics:

Less

than

10%

adults

in

clinic

population

•

Dates

of

service:

January

1,

2012

– January

31,

2013

–

13

months

reported

to

include

grace

period

+30

days

•

Total

population

submission,

no

samples

•

Patient

Health

Questionnaire

(PHQ

‐

9)

•

Numerator

/Denominator:

#

adult

pts

with

depression

&

PHQ

‐

9

score

<5

at

6

months(+/

‐

30

days)

#

adult

pts

(18+)

with

depression

or

dysthymia

AND

index

contact

PHQ

‐

9

>9

Optimal

Asthma

Care

•

Specialties:

Family

Medicine

(includes

General

Practice),

Internal

Medicine,

Pediatrics,

Allergy/Immunology,

Pulmonology

•

Dates

of

service:

July

1,

2012

– June

30,

2013

•

Denominator:

–

ICD

‐

9

‐

CM

codes

that

define

asthma

–

Patient

age

groups:

5

to

17

&

18

to

50

–

Visit

criteria

(2

face

‐

to

‐

face

visits

with

provider

in

last

2

years

for

asthma

AND

1

visit

to

the

clinic

in

the

last

12

months

for

any

reason)

•

Composite

or

“all

‐

or

‐

none”

measure

•

Numerator:

–

Number

of

patients

who

meet

all

of

the

following

targets:

• Patient’s asthma well controlled (Target: Differs by type of asthma control tool 

administered to patient)

• Patient not at elevated risk of exacerbation (Target: Less than two visits to 

emergency department and hospitalizations)

• Patient is educated about asthma (Target: Written asthma management plan 

Colorectal

Cancer

Screening

•

Specialties:

Family

Medicine

(includes

General

Practice),

Internal

Medicine,

Geriatrics,

Obstetrics/Gynecology

•

Exempt

clinics:

Less

than

10%

adults

in

clinic

population

•

Dates

of

service:

July

1,

2012

– June

30,

2013

•

Denominator:

–

Patient

ages

50

to

75

–

Visit

criteria

(2

face

‐

to

‐

face

office

visits

in

last

2

years

AND

1

visit

to

the

clinic

in

the

last

12

months)

•

Numerator:

–

Number

of

patients

who

are

up

‐

to

‐

date

with

Maternity

Care:

Primary

C

‐

Section

Rate

•

Specialties:

Family

Medicine

(includes

General

Practice),

Obstetrics/Gynecology,

Perinatology

–

Clinics

that

have

eligible

providers

who

perform

C

‐

section

deliveries

•

Dates

of

service:

July

1,

2012

– June

30,

2013

•

Total

population

submission,

no

samples

•

Denominator:

–

ICD

‐

9

and

CPT

codes

that

identify

deliveries

–

Singleton

deliveries

with

one

liveborn baby

–

Nulliparous

flag

(woman’s

first

pregnancy

and

delivery)

•

Numerator:

–

Number

of

newborns

delivered

via

C

‐

section

•

Prenatal

Care

Flag:

–

Every

patient

must

have

prenatal

care

flag

(Flag

of

1

or

2)

populated

–

Used

to

indicate

medical

groups/clinic’s

involvement

in

patient’s

prenatal

care

Total

Knee

Replacement

•

Specialties:

Orthopedic

Surgeons

who

perform

TKR

•

Starting

with

dates

of

procedure:

January

1,

2012

– December

31,

2012

–

LONG

lag

time

for

post

‐

op

collection

(15

months

post

‐

op);

First

data

submission

will

be

in

May

2014

•

Denominator:

–

Primary

and

Revision

Knee

Replacement

by

CPT

Codes

(ICD

‐

9

codes

are

also

available

if

a

system

cannot

search

by

CPT

codes)

–

Full

population

measure,

no

sample

–

Rates

stratified

by

Primary

or

Revision

•

Measures:

–

Average

change

in

patients’

post

‐

op

functional

status

at one year (9 to 15 months post

‐

op)

Spine

Surgery

Measures

•

Specialties:

Orthopedic

Surgeons

and

Neurosurgeons

who

perform

lumbar

spinal

discectomy/

laminotomy

and

lumbar

spinal

fusion

procedures.

•

Dates

of

Procedure:

January

1,

2013

– December

31,

2013

– Need to implement assessment tools as soon as possible

– LONG lag time for post‐op collection (15 months post‐op); First data submission will be 

in May 2015

•

Denominator:

– CPT and ICD‐9 codes that identify each population

– Full population measure, no sample

– Rates stratified by clinical condition for the procedure

– Two populations:

• Lumbar Discectomy/Laminotomy

• Lumbar Spinal Fusion

•

Measures:

– Three months post‐op for discectomy population (6 to 18 weeks post‐op)

– One year post‐op for spinal fusion population (9 to 15 months post‐op)

– Various outcome and process measures for each population

– Functional status tools: Owestry Disability Index, EQ5D Quality of Life, Visual Analog Pain 

Scale

Results

•

Minnesota

Department

of

Health

report

(DDS

or

SDS)

•

MN

Community

Measurement

(DDS):

–

www.mnhealthscores.org

–

Health

Care

Quality

Report

•

Health

plans

and

Minnesota

Bridges

to

Excellence

will

communicate

with

you

Data

Submission

Requirements

•

Follow

timelines

•

Agree

to

MNCM

Site

Terms

of

Use

Agreement

(signed

electronically

on

MNCM

Data

Portal)

•

Submit

data

for

all

applicable

clinic

sites

and

in

required

format

(.csv)

•

_Participate

_in

_validation

_process

•

Have

rates

publicly

reported

on

www.mnhealthscores.org

and

in

the

annual

Health

Care

Quality

Report

Denominator

Certification

•

_Assurance

_that

_patient

_population

(denominator)

is

identified

according

to

measure

specifications

•

_Each

_measure

_has

_its

_own

_denominator

certificate

and

is

available

on

the

MNCM

Data

Portal

•

_{Documentation}

_needed

–

Describe

process

used

to

identify

patients

•

Denominator

template

form

•

Source

code,

query,

screen

shots

–

Upload

certificate

to

MNCM

Data

Portal

MNCM

i

f

l t

d ill

Total

Population

versus

Sample

•

Total

population

–

Most

precise

rates

–

Submit

total

population

when:

•

Measure

requires

total

population

submission

(e.g.,

Depression,

Primary

C

‐

section,

Total

Knee

Replacement)

•

EMR

was

in

place

for

a

full

measurement

period,

including

the

12

months

prior

to

the

measurement

period

(i.e.,

EMR

was

in

place

at

any

stage

of

implementation

as

of

1/1/2011

or

7/1/2011

depending

on

measures)

•

Random

sample:

–

Can

be

submitted

if

total

population

submission

is

not

required

as

noted

above

–

Minimum

number

each

clinic

must

submit:

•

60

patients

per

clinic,

per

measure

•

If

there

are

less

than

60

eligible

patients

at

a

clinic,

submit

all

patients

Data

Collection

•

_Can

_happen:

–

After

denominator

method

is

certified

–

After

billing

and

patient

records

are

complete

for

dates

of

service

for

the

measure

•

Data

collection

methods

–

EMR

extraction

–

Manual

data

abstraction

•

Data

collection

tools

(Found

under

Resources

tab)

–

Data

Collection

Guides

Data

Submission

Methods

•

Process

of

submitting

data

via

the

secure

internet

MNCM

Data

Portal

•

Two

methods

accepted

for

state

requirement:

–

Direct

Data

Submission

(DDS):

Clinic

uploads

file

onto

the

MNCM

Data

Portal

–

Summary

Data

Submission

(SDS):

Clinic

calculates

and

submits

summary

counts

for

each

data

element

Data

Submission

Methods

(cont.)

•

Primary

payer

type

identification

–

DDS:

MNCM/Health

plans

determine

payer

type

–

SDS:

Clinic

determines

payer

type

–

Payer

Types:

Commercial/Private,

Minnesota

Health

Care

Programs,

Medicare,

Uninsured/Self

‐

pay

•

_Health

_plan

_P4P

_and

_MN

_Bridges

_to

_Excellence

–

DDS:

must

be

used

to

qualify

for

P4P

programs

Data

Validation

•

All

medical

groups

are

subject

to

a

validation

audit

•

Audit

conducted

to

validate

that

the

submitted

data

matches

the

source

data

in

the

patient

medical

record

•

Collaborative

process

between

MNCM

and

clinic

•

Occurs

after

data

submission

and

prior

to

public

reporting

•

MNCM

utilizes

the

NCQA

“8

and

30”

process

for

validation

audits

Thank

you!

•

MNCM

site:

www.mncm.org

–

Download

registration

instructions

–

Learn

about

upcoming

Q&A

sessions

•

MNCM

Data

Portal:

https://data.mncm.org/login

–

Register

clinics

and

providers

–

Register

contact

info

to

receive

communications

–

Resources

tab

•

Download

planning

calendar

•

_Download

_data

_collection

_guides

_and

_tools

•

FAQs

by

measure/topic

•

Questions

about

registration

and

technical

support

–

[email protected]

Minnesota Clinic & Provider

Registration

and

Clinical Quality Reporting

2013 Preparations

MN Community Measurement



Publicly reports health care quality measures with the

goal of improving the health of patients



2004: HEDIS measures by medical group



Health plan data



2006: DDS measures by clinic site



Data submitted by clinics



2010: Statewide Quality Reporting and Measurement

2013 Timelines

37

Time Task Portal Opens Portal Closes Winter

2013

Register MN Clinics & Providers December 2012 February 8, 2013 Data Submission:

-Optimal Diabetes Care -Optimal Vascular Care -Depression Care Measures

January 14, 2013 January 14, 2013 February 4, 2013 February 15, 2013 February 15, 2013 February 28, 2013 Complete Health Information Technology Survey February 15, 2013 March 15, 2013 Patient Experience of Care Survey February 24, 2013 April 2, 2013

Summer

2013 Data Submission:-Optimal Asthma Care

-Colorectal Cancer Screening

-Maternity Care: Primary C-section Rate

July 15 2013 July 15, 2013 July 15, 2013 August 16, 2013 August 16, 2013 August 16, 2013 2014 Data Submission:

-Total Knee Replacement (2012 Dates of Procedure)

Implement tools now (Jan 2013)

April 2014 May 2014

2015 Data Submission:

-Spine Surgery Measures (2013 Dates of Procedure)

Implement tools now (Jan 2013)

Getting Started on

MNCM Website:

www.mncm.org

Getting Started on

MNCM Data Portal:

https://data.mncm.org/login

Registration



Download instructions from mncm.org or MNCM Data Portal

from the Resource tab



Access the MNCM Data Portal:

https://data.mncm.org/login



First time users must request login/password



Necessary registration information:



Medical group information



Clinic and specialty information



Provider information and file upload



Clinic specialties determine which measures a clinic is required

to submit data for



Must complete registration before February 8, 2013



Registration must be completed before data can be submitted

to MNCM

Clinic Registration and Reporting



Registration:



Register any and all clinic locations in the state of Minnesota where

primary or specialty care ambulatory services are provided for a fee

by one or more physicians



Clinical Quality Reporting:



You may submit data as a single entity (“roll-up”) if all of the

following apply, clinics must:

Have common ownership AND



Have a majority (more than half) of common clinic staff working across

multiple locations – must rotate between all clinics, AND



The total clinical staff across all locations is no greater than 20 full-time

equivalent (FTE)



A clinic site must still be registered even if the data from that site

will be submitted using the roll-up method. During clinic registration,

you will indicate the main site that will submit the data.

Provider Registration



Register all providers who bill through a medical group’s clinic



Providers include:

 Physicians (MD, DO, physicians with medical degrees from other countries and those who are locum tenens, residents and fellows)

 Advance practice registered nurses (e.g., Certified Nurse Practitioners, Certified Nurse Specialist, Certified Nurse Midwife)

 Physicians assistants



Required information:

 National Provider Identify or Provider ID number  Provider Type and Board Certified Specialty

 Medical license number

 Full-time equivalent (FTE) status for each clinic where the provider practices

 Please see Clinic and Provider Registration Instructions Appendix C for examples on how to

calculate FTE

 There is also a tool in the portal that will assist in calculating FTEs for providers based on how

many hours per week and months they worked at your clinics

Measures for Required Reporting



Winter 2013:



Optimal Diabetes Care

Optimal Vascular Care



Depression Remission at Six Months



Spring 2013:



Health Information Technology (HIT) Survey



Patient Experience of Care Survey (Data submitted by Survey Vendors)



Summer 2013:



Colorectal Cancer Screening

Optimal Asthma Care



Maternity Care: Primary C-Section Rate



Throughout 2013



Implement Functional Status Tools for:

 Total Knee Replacement Measure (2012 Dates of Procedure, Reporting occurs

2014)

Optimal Diabetes Care



Specialties: Family Medicine (includes General Practice), Internal Medicine,

Geriatrics, Endocrinology



Exempt clinics : Less than 10% adults in clinic population



Dates of service: January 1, 2012 – December 31, 2012



Denominator:

 ICD-9-CM codes that define diabetes mellitus  Patients ages 18 to 75

 Visit criteria (2 face-to-face visits with provider in last 2 years for diabetes AND 1 visit to the clinic in the last 12 months for any reason)



Composite or “all-or-none” measure



Numerator:

 Number of patients who meet all of the following targets:

 Blood sugar control (Target: HbA1c less than 8.0)  Blood pressure control (Target: Less than 140/90)

 LDL or “bad” cholesterol control (Target: Less than 100)  Aspirin documentation

 Patients withco-morbidity of ischemic vascular disease: daily aspirin use or documented contraindication  Patients withoutco-morbidity of ischemic vascular disease: passes component automatically

 Tobacco-free status

Optimal Vascular Care



Specialties: Family Medicine (includes General Practice),

Internal Medicine, Geriatrics, Cardiology



Exempt clinics: Less than 10% adults in clinic population



Dates of service: January 1, 2012 – December 31, 2012



Denominator:



ICD-9-CM codes that define ischemic vascular disease (IVD)

Patients ages 18 to 75



Visit criteria (2 face-to-face visits with provider in last 2 years for IVD AND 1

visit to the clinic in the last 12 months for any reason)



Composite or “all-or-none” measure



Numerator:



Number of patients who meet all of the following targets:

 Blood pressure control (Target: Less than 140/90)

 LDL or “bad” cholesterol control (Target: Less than 100)

 Aspirin documentation (Target: Daily aspirin use or valid contraindication)

Depression Remission at 6 Months



Specialties: Family Medicine (includes General Practice),

Internal Medicine, Geriatrics, and Psychiatry/Behavioral

Health professionals (if there is a physician on staff at the

clinic site)



Exempt clinics: Less than 10% adults in clinic population



Dates of service: January 1, 2012 – January 31, 2013



13 months reported to include grace period +30 days



Total population submission, no samples



Patient Health Questionnaire (PHQ-9)



Numerator /Denominator:

# adult pts with depression & PHQ-9 score <5 at 6 months(+/- 30 days)

# adult pts (18+) with depression or dysthymia AND index contact PHQ-9 >9

Optimal Asthma Care



Specialties: Family Medicine (includes General Practice),

Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology



Dates of service: July 1, 2012 – June 30, 2013



Denominator:



ICD-9-CM codes that define asthma

Patient age groups: 5 to 17 & 18 to 50



Visit criteria (2 face-to-face visits with provider in last 2 years for asthma AND 1

visit to the clinic in the last 12 months for any reason)



Composite or “all-or-none” measure



Numerator:



Number of patients who meet all of the following targets:

 Patient’s asthma well controlled (Target: Differs by type of asthma control tool

administered to patient)

 Patient not at elevated risk of exacerbation (Target: Less than two visits to emergency

department and hospitalizations)

 Patient is educated about asthma (Target: Written asthma management plan contains all

Colorectal Cancer Screening



Specialties: Family Medicine (includes General Practice),

Internal Medicine, Geriatrics, Obstetrics/Gynecology



Exempt clinics: Less than 10% adults in clinic population



Dates of service: July 1, 2012 – June 30, 2013



Denominator:



Patient ages 50 to 75



Visit criteria (2 face-to-face office visits in last 2 years AND 1 visit to

the clinic in the last 12 months)



Numerator:



Number of patients who are up-to-date with appropriate screening

exam



Colonoscopy (Target: Had screening in last 10 years), OR

Sigmoidoscopy (Target: Had screening in last 5 years), OR



Stool Blood Tests (Target: Had screening during measurement year)

Maternity Care: Primary C-Section Rate



Specialties: Family Medicine (includes General Practice),

Obstetrics/Gynecology, Perinatology



Clinics that have eligible providers who perform C-section deliveries



Dates of service: July 1, 2012 – June 30, 2013



Total population submission, no samples



Denominator:



ICD-9 and CPT codes that identify deliveries

Singleton deliveries with one liveborn baby



Nulliparous flag (woman’s first pregnancy and delivery)



Numerator:



Number of newborns delivered via C-section



Prenatal Care Flag:



Every patient must have prenatal care flag (Flag of 1 or 2) populated

Total Knee Replacement



Specialties: Orthopedic Surgeons who perform TKR



Starting with dates of procedure: January 1, 2012 – December

31, 2012



LONG lag time for post-op collection (15 months post-op); First

data submission will be in May 2014



Denominator:



Primary and Revision Knee Replacement by CPT Codes (ICD-9

codes are also available if a system cannot search by CPT codes)



Full population measure, no sample



Rates stratified by Primary or Revision



Measures:



Average change in patients’ post-op functional status at one year (9

to 15 months post-op)



Functional status tools: Oxford Knee Score and EQ5D (Quality of

Life)

Spine Surgery Measures



Specialties: Orthopedic Surgeons and Neurosurgeons who perform lumbar spinal

discectomy/ laminotomy and lumbar spinal fusion procedures.



Dates of Procedure: January 1, 2013 – December 31, 2013

 Need to implement assessment tools as soon as possible

 LONG lag time for post-op collection (15 months post-op); First data submission will be in May 2015



Denominator:

 CPT and ICD-9 codes that identify each population  Full population measure, no sample

 Rates stratified by clinical condition for the procedure  Two populations:

 Lumbar Discectomy/Laminotomy  Lumbar Spinal Fusion



Measures:

 Three months post-op for discectomy population (6 to 18 weeks post-op)  One year post-op for spinal fusion population (9 to 15 months post-op)  Various outcome and process measures for each population

 Functional status tools: Owestry Disability Index, EQ5D Quality of Life, Visual Analog Pain Scale

Results



Minnesota Department of Health report (DDS or SDS)



MN Community Measurement (DDS):



www.mnhealthscores.org



Health Care Quality Report



Health plans and Minnesota Bridges to Excellence will

communicate with you regarding their individual P4P

programs

Data Submission Requirements



Follow timelines



Agree to MNCM

Site Terms of Use Agreement

(signed

electronically on MNCM Data Portal)



Submit data for all applicable clinic sites and in required

format (.csv)



Participate in validation process



Have rates publicly reported on

www.mnhealthscores.org