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Strategies to Support MACRA Standards
October 13, 2016
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OBJECTIVES
• Discuss MACRA and the differences between the Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS)
• Identify the potential financial impacts of bonuses and penalties on healthcare providers
• Describe the ways that Holy Family Memorial is using information technology (IT) to prepare for the impact of MACRA
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Monica Nichter is the Director of Revenue Integrity and Payor Contracting for Holy Family Memorial Manitowoc, WI. With over 25 years’ healthcare leadership experience in a variety of settings, she has overseen numerous successful system implementations and process enhancements for financial recovery. Monica was also an operations leader for Medicare Advantage plans and Commercial Lines of Business for a regional health plan. She has BSN and MSN degrees from the University of Wisconsin - Oshkosh.
Monica Nichter, RN, MSN Director, Revenue Integrity and Payor Contracting, Holy Family Memorial
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Jim Deren is Director of Information Technology (IT) Healthcare Planning for CareTech Solutions, where he has performed over 40 detailed IT assessments and several IT strategic plans for hospitals in the U.S. He has over 35 years’ IT experience, including over 26 years in the healthcare industry. Mr. Deren is a certified project manager (PMP) with CPHIMS certification and a B.S. degree in education/computer science from Eastern Michigan University. He has also presented at numerous conferences.
James Deren Director of Information Technology Healthcare Planning, CareTech Solutions
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HIGHLIGHTS
• Proposed rule developed on April 27, 2016 • Final rule expected November 2016 • Current plan requires measurement of 2017 data and affects
2019 payments • On September 8 CMS announced that they will provide flexibility in
2017 to allow providers to avoid negative payment adjustments • Repeals the sustainable growth rate payment model • Providers can select one of two options: Merit Based Incentive System MIPS Advanced Alternative Payment Models (APMs)
• CMS budget neutral • Priority, BCBS and others are adopting similar programs • Overlaps several meaningful use stage 3 requirements
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TWO PATHS FOR PROVIDERS
Merit Based Incentive Payment System (MIPS) • 100 point scale known as the Composite Performance Score • 2017 data reported in 2019 • 4 Categories
• Quality • Resource Use • Clinical Practice Improvement Activities • Advancing Care Information
• Majority of providers will be subject to MIPS
Advanced Alternative Payment Models (APMs) • Can receive bonus payments • Fewer providers will meet qualifications • Must use certified EHR technology • Payments based upon quality measures • Bear more than nominal financial risk or is a medical home
model under CMMI authority
MIPS
APMs
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First Year of Medicare Part B Participation
Below low patient volume threshold
Certain participants in advanced alternative
payment models
Medicare billing charges less than or equal to $10,000 and
provides care for 100 or fewer Medicare patients in one year
NOTE: MIPS does not apply to hospitals or facilities
PROVIDERS NOT ELIGIBLE FOR MIPS
Eligible Providers Include: Physicians, PAs, NPs, dentists, Nurse Anesthetists year 1. (Therapist, audiologist, midwifes, social workers, psychologists, dieticians year 3)
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Not in APM In APM In Advanced APM
MIPS adjustments
APM-specific rewards
5% lump sum bonus
APM-specific rewards
+ MIPS adjustments
+ If you are a
Qualifying APM Participant (QP)
Potential Financial Rewards
ALTERNATIVE PAYMENT MODEL INCENTIVES
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FINANCIAL SUMMARY AND TIMELINE
2017 Activity/2019 payment adjustments • MIPS: +/- 4% Medicare FFS, • +12% for “exceptional performance” • APMS: + 5% Medicare FFS
NOTE This is the maximum adjustment. It may be scaled up or down to achieve neutral cost
American Medical Association 2016
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NEW - MACRA OPTIONS FOR 2017
Test the Quality Payment Program
• Submit some data to the quality payment program
• Ensure that provider systems are working
Participate for a Part of the Calendar Year
• Submit quality payment data for a reduced number of days
• Reduced number of days to be determined
• CMS will provide a list of quality measures
Participate for the Full Calendar Year
• May qualify for a modest payment adjustment
Participate in Advanced Alternative
Payment Model
• Would quality for a 5% incentive
MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)
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MIPS COMPONENTS
Quality Reporting
(PQRS)
Resource Use or Cost
(Value-based Modifier)
Advancing Care
Information (MU)
Clinical practice
improvement activities
MIPS
MIPS aims: • Streamline 3 independent programs • Add 4th component to promote
improvement and innovation • Provide more flexibility and choice of
measures • Retain a fee-for-service payment
option
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MIPS COMPONENT WEIGHTS AND SCORING IN 2019
Quality: (50%) (Report on 6 measures)
80 points groups <10 90 points for larger groups
Advancing Care Information:(25%) (Meaningful Use Criteria)
50 points base score 80 points performance score
Clinical Practice Improvement Activities: (15%) (Select from list of approved activities)
60 points (3-6 activities; 2 activities for small and rural practices)
Resource Use: (10%) (Submission of cost data)
10 points per measure Score is average of attributable measures
25%
15%
10%
50%
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MIPS PAYMENT ADJUSTMENTS
At Threshold No payment adjustment
Below Threshold Negative payment
adjustment
Above Threshold Positive payment
adjustment
Exceptional Performer
Bonus payment adjustment
Up to 3 x maximum adjustment (12% for year 1) “Exceptional performer” yet to be defined
The aggregated MIPS composite performance score would be compared against a MIPS performance threshold (Mean score of all clinicians during prior period) CMS updates threshold on an annual basis
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COMPOSITE SCORE CALCULATION
MIPS Category Options Possible Selections
Required Selections Value Points Maximum
Score Composite
Score
Quality
Basic Quality Measures 200 6 10 60 Population Measures > 9 providers 3 10 30 90
Population Measures < 10 providers 2 10 20 80
Total Quality 50
Resource Use Submit Cost Data 41 Total Resource Use 10
Advancing Care Information
Basic Reqs. 6 6 50 50 Performance Metrics 8 8 10 80 80 Bonus (optional registry) 3 0 1 1 1 Total Advancing Care Information 131 100 25
Clinical Practice Improvement
Patient Centered Medical Home 90 0 60 60
Other providers option a * 90 3 20 60 60 Other providers option b * 90 6 10 60 60 Total Clinical Practice Improvement 15
Composite Score 100
* may pick combination of 10 or 20 point measures to achieve 60 points
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MACRA FINANCIAL SCENARIO
MACRA SCENARIO MIPS adjustment
Sustainable Growth Rate
(0.5%)
Neutral (0%)
Low Performer
(-4-9%)
High Performer
(+4-9%)
Highest Performer
(+12%)
Advanced APM (5%)
Year 1 +/-4% $2,400,000 $2,400,000 $2,304,000 $2,496,000 $2,688,000 $2,520,000
Year 2 +/-5% $2,412,000 $2,400,000 $2,280,000 $2,520,000 $2,688,000 $2,520,000
Year 3 +/-7% $2,424,060 $2,400,000 $2,232,000 $2,568,000 $2,688,000 $2,520,000
Year 4 +/-9% $2,436,180 $2,400,000 $2,184,000 $2,616,000 $2,688,000 $2,520,000
Year 5 +/-9% $2,448,361 $2,400,000 $2,184,000 $2,616,000 $2,688,000 $2,520,000
Total 5 Years $12,120,602 $12,000,000 $11,184,000 $12,816,000 $13,440,000 $12,600,000
Difference from SGR 0 ($120,602) ($936,602) $695,398 $1,319,398 $479,398
Patients per day 15 Days per year 200 Average cost of office visit $200 % Medicare patients 20% Physicians in practice 20
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ESTIMATED FINANCIAL IMPACT ON PHYSICIAN GROUPS
CMS - HIMSS 2016
Practice Size Eligible Clinicians
Aggregate Impact
Negative Payment
Adjustments ($m)
Aggregate Impact Positive
Adjustments ($m)
Impact on this group ($m)
Impact per clinician average
Aggregate Positive
Adjustments (exceptional performance
payments) ($m) solo 100,788 ($300) $65 ($235) ($2,332) $105 2-9 eligible clinicians 123,695 ($279) $182 ($97) ($784) $295
10 - 24 eligible clinicans 81,207 ($101) $103 $2 $25 $164
25 - 99 eligible clinicians 147,976 ($95) $147 $52 $351 $230
100 or more eligible clinicians 305,676 ($57) $336 $279 $912 $539
Overall 761,342 ($833) $833 $0 $1,333
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MIPS COMPONENT SCORING OVER TIME
CATEGORY 2019 2020 2021 2022 onward
Quality 50% 45% 30% 30%
Resource use 10% 15% 30% 30%
Advancing Care Information 25% 25% 25% 25%
Clinical Practice Improvement
Activities 15% 15% 15% 15%
Penalty risk -4% -5% -7% -9%
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QUALITY REPORTING BASICS
Measures • 6 measures required out of 200 available,
reported by physicians • Include one cross-cutting measure, one
outcome • 3 population health measures (groups of
10 or more only)
Scoring • Each measure worth up to 10 points • 90 total points for groups >10 • 80 total points for smaller groups • Distribution of points for each measure
based on performance benchmarks (80% for claims reporting, 90% for registry reporting)
Bonus points • Up to 4 bonus points may be added for
reporting on outcome and high priority measures
• 1 bonus point possible for each measure captured and reported through CEHRT
• Total bonus points capped at 5% of those used to calculate the quality score
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RESOURCE USE BASICS
Measures • Continues use of VBM cost measures
(Medicare spending per beneficiary and total per capita cost) developed for hospital-level measurement
• 41 episode-specific measures potentially added
Scoring • 10 points, calculated average of all
attributable cost measures (worth 10 points each)
• 20 patient sample required for measure attribution
• Scoring is the same as currently • If patient volume insufficient for all
measures, score is zero and other MIPS categories will be reweighted
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ADVANCING CARE INFORMATION BASICS
Base measures and scoring • 50 points for achieving 6 objectives
(pass/fail) • Immunization registry reporting required;
Reporting to more than one public health registry earns bonus point
• CPOE and clinical decision support no longer required
• Provide numerator/denominator or yes/no attestation for each
• Failure to attest to “protecting patient health information” results in zero total ACI score
Performance measures and scoring • 80 points available; total combined score
exceeding 100 gets full credit • Clinicians select from measures across 3
objective areas: patient electronic access, patient engagement, HI exchange
• ACI performance category will be reweighted to zero and other MIPS categories increased if objectives don’t apply (e.g., for hospital-based clinicians)
• Clinical quality measures from Meaningful Use no longer required
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ADVANCING CARE INFORMATION SCORING
BASE SCORE Makes up to 50
points
PERFORMANCE SCORE
Makes up to 80 points
BONUS POINT Earn up to 1 point COMPOSITE SCORE
Provide numerator / denominator of the 6
requirements
How well did you perform in 8 selected
measures
Report to a registry beyond immunizations
Earn 100 or more points and receive the
full 25 points in ACI category
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ADVANCING CARE INFORMATION (MEANINGFUL USE) OBJECTIVES
Protect Patient Health Information
Electronic Prescribing
Patient Electronic Access
Public Health Reporting
Health Information Exchange
Coordination of Care Through Patient
Engagement
• Security risk analysis
• Implement and use e-prescribe
• Patient access • Patient specific
information
• View, download, transmit PHI
• Secure messaging • Patient generated
health data
• Patient care record exchange
• Request/accept patient record
• Clinical information reconciliation
• Immunization registry (Optional) • Syndromic surveillance • Electronic case reporting • Public health registry
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CLINICAL PRACTICE IMPROVEMENT ACTIVITIES BASICS
To get 100% score (15% of total): Patient centered medical home (PCMH) need to come up with 60 points. (others 30) – could mean 2 to 6 activities selected
CPIA categories
8 activity categories 90+ activities Do not need activities in each category
Scoring
60 points = 100% CPIA score 7 of 8 categories have both high (20 points) and medium (10 points) weighted activities
Exceptions Certified PCMH (60 points); other APM (30 points) Participation in upcoming CMS study on CPIA and Measurement (60 points) Non-patient facing specialties, small rural practices, physician shortage areas need fewer points (one activity for partial credit, 2 activities for full credit)
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CPIA CATEGORIES AND EXAMPLES
Expanded Practice Access • 24/7 access to clinicians/care
teams • Use of telehealth • Patient experience data used to
improve practice
Population Management • Participation in systematic
anticoagulation program • Participation in CMMI models such
as Million Hearts Campaign • QCDR participation that includes
use of data for QI
Care Coordination • Participate in Transforming
Clinical Practice Initiative • Closing the referral loop • Develop and update individual
care plans
Beneficiary Engagement • Collect / follow up on patient
experience & satisfaction data • Use QCDR for shared clinical
decision making • Provide access to enhanced
patient portal
Patient Safety & Practice Assessment • Consult PDMP for Schedule-II
opioid prescriptions of >3 days • Participate in MOC part IV • Complete AMA STEPS Forward
program
Achieving Health Equity • Timely care for Medicaid
patients (including duals) • Participate in State Innovation
Model activities • Use QCDR to screen for social
determinants of health
Emergency Response & Preparedness • Participate in Disaster Medical
Assistance teams • Participate in domestic or
international humanitarian volunteer work
Integrated Behavioral & Mental Health • Colocation of mental health
services in clinical care settings • Depression screening and follow-
up planning • Prevention & treatment for
unhealthy alcohol or tobacco use
RED are 20 points – the others are 10 (list is not all-inclusive)
ALTERNATIVE PAYMENT MODELS (APMS)
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CMS CRITERIA FOR ADVANCED PAYMENT MODELS
2 categories – APMs and Advanced APMs
MIPS APMs Measured based upon the group (similar to ACO) Must meet MIPS measures
Advanced APMs
Must belong to a specified advanced APM Must use certified EHR technology
At least 50% of clinicians in first year, 75% thereafter
Payment based on quality measures comparable to MIPS
Bear “more than nominal risk” for monetary losses Clinicians would need to reduce their rates,
withhold payments, or pay CMS when actual expenditures exceed expected expenditures.
May be a medical home model expanded under CMMI authority Expanded Medical Home models exempt from
risk Other Medical Home models have different
standards
APMs
EHR use
Quality Reporting
Financial Risk
Advanced APMs
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CURRENTLY PROPOSED ADVANCED APMS
Comprehensive ESRD Care Model
(large dialysis organization)
Comprehensive Primary Care Plus
Medicare Shared Savings Track 2
Medicare Shared Savings Track 3
Next Generation ACO Model
Oncology Care Model, 2-Sided Risk
Arrangement
Next Generation ACO Pioneer ACO 21 ACOs spread among 13
states 9 ACOs spread among 7
states
To be expanded
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MEDICAL HOME MODELS
Medical Home Models: Have a unique financial risk criterion for
becoming an advanced APM Enable participants (who are not excluded
from MIPS) to receive the maximum score in the MIPS CPIA category
• Medical Home Model APM Features:
Participants include primary care practices or multispecialty practices that include primary care physicians and practitioners and offer primary care services
Empanelment of each patient to a primary care clinic
Have at least four of the following: Planned coordination of chronic and
preventative care Patient access and continuity of care Coordination of care across the medical
neighborhood Patient and caregiver engagement Shared decision making Payment arrangements in addition to or
substituting fee-for-service payments
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HFM’S MACRA JOURNEY
Monica Nichter, RN, MSN Director, Revenue Integrity and Payor Contracting
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HOLY FAMILY MEMORIAL THOUGHT LEADERSHIP
Since 2010 HFM has been featured at: • AHA’s Healthcare Forum, Partnership for Patients and Society
for Healthcare Strategy & Market Development
• HHN Most Wired Hospital 2013-2016. Top 1% of US hospitals
• One of the 100 Great Community Hospitals for 2016 by Becker’s Hospital Review
• ACHE Congress 2010-2016
• American Society for Quality International Forum
• University of Michigan Health Management and Policy Program & Griffith Leadership Center
• Published in HealthLeaders, Hospitals and Health Networks, Becker’s, Remington Report, and Insight
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American Hospital Association “Hospitals & Care Systems of the Future” Fall 2011
PAYMENT MODEL
COLLABORATION
CULTURE
INFRASTRUCTURE
FIRST CURVE FFS
SECOND CURVE
POPULATION
HEALTH & VALUE-BASED HEALTHCARE
HOW WILL YOUR HOSPITAL SUCCESSFULLY NAVIGATE THE SHIFT?
MOVEMENT: FIRST CURVE TO SECOND CURVE
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RIGHT CARE MODEL
• The most effective evidence based approach possible
• The most cost effective, safest, highest quality and greatest value
• Achieve the greatest long term benefit to the patient and society while minimizing physical and financial risk
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TOP-QUADRANT PERFORMANCE IN QUALITY AND EFFICIENCY
HFM identified among the most
efficient hospitals in Northeast Wisconsin
*Data is Severity and Risk Adjusted
All Commercial Payers, Wisconsin (Source: BSG Analytics, 2014 data)
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HFM’S TECHNOLOGY JOURNEY
In 2003 our CMO was appointed CIO to leverage technology to improve care and safety processes.
Maximized MEDITECH Platform. Recognized that MEDITECH could not get HFM to the next level. Decision was made to move forward with Cerner. Go-live planned for April 1, 2017.
Most Wired and HIMSS EMR recognition reflect deep IT and Operations integration.
IT Strategic Plan is aligned with hospital Strategic Right Care and Innovation Plans.
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MACRA READINESS TEAM • Brett Norell, CFO – Champion • Steve Driggers, Senior Medical Advisor • Vicki Wetenkamp, Administrative Director Clinical and Service
Excellence • Kate Casey, Clinical Quality Assistant • Zarine Anklesaria, Administrative Director, Primary Care and
Continuity of Care • Jill Rauber, Director, Health Information Management • Theron Pappas, Director, Information Services • Monica Nichter, Director, Revenue Integrity and Payor Contracting • Dean Pollnow, CMO – Ad hoc
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WHERE ARE WE AT TODAY? QUALITY
• Our Quality Team works closely with the Operations and the Leadership Teams to make decisions based on fact.
• The Quality Team tracks and trends data, slices and dices it to find areas that can be improved and work closely with Leaders and Staff to facilitate those improvements.
• The Quality Team acts as consultants; as they learn requirements, regulations, etc., they make certain that the Network is informed and that we meet deadlines and data reporting requirements. Educate, educate, educate.
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WHERE ARE WE AT TODAY? DATA
• HFM is well prepared for MIPS. Breast cancer screenings Colorectal cancer screenings Diabetes management Hemoglobin A1c Tobacco use – screening and cessation intervention Pneumonia vaccination for older adults Community wide falls prevention program Working with IT to verify other measurers and the
accuracy of those measurers
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WHERE ARE WE AT TODAY? PCP
• Improvements have been made in primary care delivery Single phone line for primary care appointments Same day access HFM Right Now (e-visits) for common conditions Standard protocols Patient Portal
• Cerner platform will allow HFM to meet the requirements for Medical Home Certification
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WHERE ARE WE AT TODAY? IT •Technology investments must facilitate Second Curve care
delivery.
•Technology investments must improve patient quality
and/or safety.
•Information technology must support & accelerate
innovation and improvement
•Engaged IT – both internal/CareTech and Cerner
•CareTech and Cerner are in a consultative role regarding
MACRA readiness
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He who has the data, wins.
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INFORMATION TECHNOLOGY TO SUPPORT MACRA
Culture • IT
investments to support MACRA
• End user adoption plan
• Community engagement
• Oversight and accountability
• Quality mindset
Staffing • Educate staff
on MACRA • Engage
vendor(s) • Secure
adequate IT resources
• End user support plan
Workflow • Re-engineer
workflow for MACRA
• Implementation plan for new features
• Utilize data for decisions
Applications • Data reporting
and dashboards • New Technology • Security
measures • Certified EMR • IT Tools for
patients
Infrastructure • Data/System
reliability • Accessibility • Integration • Point of Care
devices • Disaster Recovery
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RECOMMENDED PROJECT PLAN
MACRA PROJECT PLAN 2016 2017
qtr 3 qtr 4 qtr 1 qtr 2 qtr 3 qtr 4 Assign project manager Understand the MACRA rule Determine financial implications Define scope and requirements Select MIPs or APM options Analyze current metrics to select best measures Develop project team and governance Educate all staff Engage vendor to ensure certified and capable EMR Develop detailed project plan Upgrade IT systems Implement clinical practice improvement activities Implement Advancing Care Information activities Measure resource use - Medicare claims Track core quality measures Monitor and manage MACRA project plan
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IT IMPLICATIONS AND ACTION NEEDED
General
• Determine which measures to report • Determine EHR capabilities and upgrades
needed • Upgrade to certified EHR • Workflow changes to fulfill requirements • Build tracking of composite score
Clinical Practice
Improvement Activities (options)
• Provide telehealth capabilities • 24 x 7 access to support patient access to
caregivers • IT functions to improve patient experience • Automated care plans • Decision support and alerts • Share patient data across registries
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IT IMPLICATIONS AND ACTION NEEDED
Advancing Care Information
• Registry reporting • Security assessment • Share via Health Information Exchange • ePrescribe • Patient portal and engagement tools • Patient entered data • Secure messaging
Resource Use • Submit Medicare claims • Measure quality of claims
Quality • Numerator and denominator for quality
measures • Track core quality measures (CQMs)
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RECOMMENDATION: MEASURE YOUR PROGRESS
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RESOURCES
HIMSS http://www.himss.org/news/cms-releases-macra-proposed-rule CMS https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
AAFP http://www.aafp.org/practice-management/payment/medicare-
payment/faq.html AHA http://www.aha.org/advocacy-issues/physician/index.shtml
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Kaiser Permanente
UCLA Medical Center
Holy Family Memorial
Cleveland Clinic
Which health system has achieved?
HHN Most Wired (4x) HIMSS Analytics Stage 6.5 99% Inpatient CPOE Adoption 92% Outpatient CPOE Adoption 40% Growth in clinic visits over 10 years Top 5 Patient Safety Award (Grade “A” 2015) Becker’s Hospital Review 100 Great
Community Hospitals (2016)
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Any Questions?
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