2011 Clinical Measures Enhancements For Reporting February 15, 2012

1. 2011 Clinical Measures Enhancements For Reporting February 15, 2012

2. Objectives for Today’s Presentation • Today’s presentation is designed to help grantees understand: • What the new measures are and why they are being added • How to complete and submit Clinical Measures data on Tables 6B and 7 of the 2011 UDS

3. Background and Overview of the Clinical Measures

4. Background and Overview 2011 UDS Clinical Measures • The 2011 Clinical Measures enhancements were vetted in the same way as earlier measures • Published initially as PAL 2010-12 on 8/30 • http://bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201012.pdf • Subsequently announced in Federal Register • Comments and recommendations solicited from health centers, PCAs, PCOs, and the general public • Comments were reviewed and package was approved by OMB January 3, 2011 • Introduced in the 2010-11 UDS Training

5. Background and Overview 2011 UDS Clinical Measures • Four Clinical Measures in three clinical areas have been added to the measures which will be used in grant applications and in the UDS • Weight assessment and counseling for children and adolescents • Adult weight screening and follow-up • Tobacco use assessment and cessation counseling pair • Asthma – Pharmacological treatment • Two existing measures are being modified • Vaccines for children are updated to current standards • Hemoglobin A1C goals for diabetics are expanded

6. Background and Overview Today • Data to document performance on these four new measures are being collected during CY-2011 • No new data over and above that needed for rigorous charting should be necessary • Electronic Health Records (EHRs) may be used • Chart reviews may still be used as appropriate • Use of CPT Category II codes may simplify process • No new clinical activities should be necessary to report the Clinical Measures • Data will be submitted in the 2011 UDS

7. Clinical Measures and the HRSA Data Strategy

8. Clinical Direction Focus on Quality • New clinical measures will allow BPHC and health centers to demonstrate the quality of patient care using an enhanced set of measures which are part of the CMS “Meaningful Use” data set • New measures focus on preventive health care • Most have AMA CPT-II codes • All qualify under the Meaningful Use rules

9. Clinical Direction Focus on Comparability • New clinical measures are being adopted by a wide range of non-330 organizations • Permits BPHC to demonstrate the quality and value of care provided at health centers • Permits health centers to obtain comparable information in their states and the nation • BPHC will continue to provide reports which permit health centers to identify appropriate individual targets for quality improvement

10. Clinical Direction Focus on Integration • BPHC will integrate these new clinical measures into the SAC and BPR grant applications • First year will permit its use as baseline data • In the future, baseline data can be edited

11. Clinical Direction Focus on Meaningful Use • 2011 Clinical Measures reporting further prepares grantees to meet CMS’s “Meaningful Use” implementation requirements • The additional Measures promote and support implementation of EHR data collection and reporting procedures by health centers • Measures are recognized by the National Quality Forum (NQF)

12. Quality of Care Measures

13. Overview Quality of Care Measures - 1 • The new measures will be included on Table 6B as quality of care measures, consistent with the manner in which BPHC has been reviewing Primary Prevention measures in the past. • These measures are all “process” measures: • If patients receive timely routine and preventive care, then we can expect improved health status

14. Overview Quality of Care Measures - 2 • Weight assessment and counseling for children and adolescents • IF clinicians ensure that patients’ Body Mass Index Percentile is recorded, and patients (and parents) are counseled on nutrition and physical activity regardless of the patient’s weight THEN the likelihood of obesity and its sequela will be reduced • Adult Weight screening and follow up • IF clinicians routinely calculate and record the BMI for adult patients, identify patients with weight problems and develop a follow up plan for overweight and underweight patients, THEN the likelihood of the debilitating sequela of serious weight problems can be reduced

15. Overview Quality of Care Measures - 3 • Tobacco use assessment • IF patients are routinely queried about their tobacco use (including smokeless tobacco) THEN providers will be able to intervene more quickly and effectively and reduce the incidence of cancer, asthma, emphysema, and other tobacco related illnesses • Tobacco use intervention • IF tobacco users are provided with an effective mix of counseling and pharmacologic intervention THEN tobacco users will be more likely to quit smoking and will therefore have a lower incidence of cancer, asthma, emphysema, and other tobacco related illnesses

16. Overview Quality of Care Measures - 4 • Pharmacological treatment of asthmatics • IF patients identified with persistent asthma are provided with appropriate pharmacological intervention THEN they will be less likely to have asthma attacks, they will require fewer emergency room visits and be less likely to develop complications related to asthma including death • Childhood immunizations • IF children receive their vaccinations in a timely fashion THEN they will be less likely to contract vaccine preventable diseases or to suffer from the sequela of these diseases

17. Child and Adolescent Weight Assessment and Counseling(NQF 0024)

18. Child and Adolescent Weight Measure • Percent of patients in universe with weight assessment and counseling documented • Requires documentation of 3 separate elements; all must be documented during the measurement year: • Documentation of BMI percentile (not BMI or weight + height. Actual percentile must be recorded.) • Documentation that patient (or patient’s parent as appropriate) has been counseled on nutrition documentation that patient (or patient’s parent as appropriate) has been counseled on physical activity • Measure calculation: Line12 Column c (patients with compliance documented) Line12 Column b (patients in universe or sample)

19. Child and Adolescent Weight Universe and Exclusions • All children and adolescents who were between 2 and 17 years during the measurement year (i.e., born between 1/1/1994 and 12/31/2009) and • Had at least one medical visit during the measurement year • In an environment which had equipment present to measure weight and height • Were first ever seen prior to their 17th birthday

20. Child and Adolescent Weight Documentation of Compliance • BMI Percentile is noted in chart or EHR • Well child templates should display BMI percentile, not just BMI or height and weight. • BMI growth charts may also document • Counseling on nutrition and activity should be in charts and EHRs • May be narrative form or check box • Must be specific, i.e., not “counseled pt.” • Anticipatory guidance to parent is counted when documented in child’s record

21. Child and Adolescent Weight Completing the UDS: Line 12 • Column a: Number of children and adolescent medical patients aged 2 to 17 who were seen during the measurement year. • Column b: Will be 70 unless a comprehensive EHR is present, in which case column b will be equal to column a. • Column c: Number (of those reported in column b) who have a recorded BMI percentile and recorded counseling on nutrition and recorded counseling on physical activity Children and adolescents aged 2 – 17 with a BMI percentile AND counseling on nutrition and physical activity documented for the current year

22. Child and Adolescent Weight Data on Overweight/Obese Children • National Data 16% • Health Center Patient Survey 21% • Healthy People 2020 Goal 14%

23. Adult Weight Assessment and Required Followup(NQF 0421)

24. Adult Weight and Follow-up Measure • Percent of patients in universe with a calculated BMI recorded and with appropriate followup if indicated. • Requires possible documentation of 2 separate elements both of which must be documented in the past six months or during the current visit: • Documentation of BMI (not weight and height – actual calculated BMI must be recorded.) • If patient is overweight (BMI = 25 or over for patients under 65, 30 or over for patients over 65) or if patient is underweight (BMI < 18.5) Documentation of a followup plan by provider or by a referral provider • Measure calculation: Line13 Column c (patients with compliance documented) Line13 Column b (patients in universe or sample)

25. Adult Weight and Follow-up Universe and Exclusions • All adults who were age 18 or older during the measurement year (i.e., born before 12/31/1993) and • Had at least one medical visit during the measurement year • In an environment which had equipment present to measure weight and height • Were ever seen after their 18th birthday

26. Adult Weight and Follow-up Documentation of Compliance • BMI is noted in chart or EHR • Nursing templates (or encounter forms) would normally show BMI • Templates usually show height and weight; BMI may need to be calculated and recorded separately • AND (if patient is overweight or under-weight) follow up weight management plan is documented • May be with provider • May be by referral (successful completion not required)

27. Adult Weight and Follow-up Completing the UDS: Line 13 • Column a: Number of adult medical patients aged 18 and over seen during the measurement year. • Will be roughly same as adjusted 18+ year olds on Table 3a • Column b: Will be 70 unless a comprehensive EHR is present, in which case column b will be equal to column a • Column c: Number (of those reported in column b) who have a recorded BMI and recorded followup plan if patient is overweight or underweight.

28. Adult Weight and Follow-up Data on Overweight/Obese Adults • National Data 68% • Health Center Patient Survey 75% • Healthy People 2020 Goal 61%

29. Tobacco Use Assessment(NQF 0028a)

30. Tobacco Use Assessment Measure • Percent of patients in universe queried about tobacco use in the measurement year or the prior year. • Requires documentation that provider or support staff asked patient if they used tobacco and the patient’s response. • Measurement calculation: Line14 Column c (patients with compliance documented) Line14 Column b (patients in universe or sample)

31. Tobacco Use Assessment Universe and Exclusions • All adults who were age 18 or older during the measurement year (i.e., born before 12/31/1993) and • Had at least one medical visit during the measurement year • Had at least two medical visits ever • Were ever seen after their 18th birthday • No exclusions (Note that because of the two visit rule, universe is different than Adult weight)

32. Tobacco Use Assessment Documentation of Compliance • Tobacco use (not “smoking”) is noted in chart or EHR. • Documentation that provider or support staff asked patient if they used tobacco and the patient’s response. • CPT Category II Codes can be used to record: • 1000F = Patient was queried about use • 1034F = smoker • 1035F = smokeless tobacco user • 1036F = non-tobacco user

33. Tobacco Use Assessment Completing the UDS: Line 14 • Column a: Number of adult medical patients aged 18 and over seen during the measurement year. • Will be roughly same as adjusted 18+ year olds on Table 3a • Column b: Will be 70 unless a comprehensive EHR is present, in which case column b will be equal to column a • Column c: Number (of those reported in column b) for whom documentation demonstrates that patient was queried about tobacco use

34. Tobacco Cessation Intervention(NQF 0028b)

35. Tobacco Cessation Intervention Measure • Percent of universe of known tobacco users who received tobacco use intervention during the measurement year or the prior year • Requires documentation that provider (or appropriate support staff): • Provided tobacco cessation counseling and/or • Provided pharmacological intervention – i.e., a prescription was written or a drug dispensed • Measure calculation: Line15 Column c (patients with compliance documented Line15 Column b (patients in universe or sample)

36. Tobacco Cessation Intervention Universe and Exclusions • All adults who were age 18 or older during the measurement year (i.e., born before 12/31/1993) who were known to be tobacco users and • Who had at least one medical visit during the measurement year • Who had been seen at least twice ever • Who were ever seen after their 18th birthday • No exclusions

37. Tobacco Cessation Intervention Documentation of Compliance • Chart note or EMR coded to demonstrate counseling or pharmacological intervention • Documentation that provider or appropriate staff provided cessation counseling and/or • Documentation of prescription written or drug dispensed (may include OTC medications) • CPT Category II Codes can be used to record: • 4000F = Patient was counseled to quit tobacco use • 4001F = Pharmacologic therapy: Prescription was written or drug dispensed

38. Tobacco Cessation Intervention Completing the UDS: Line 15 • Column a: Number of adult medical patients aged 18 and over identified as current tobacco users • Will have no relation to 18+ year olds on Table 3a • Column b: Will be 70 unless a comprehensive EHR is present, in which case column b will be equal to column a • Column c: Number (of those reported in column b) for whom documentation demonstrates that tobacco cessation counseling or pharmacologic intervention occurred (last 24 months presumed but not required)

39. Asthma: Pharmacologic Therapy(NQF 0047)

40. Asthma Measure • Percent of patients aged 5 – 40 with mild, moderate, or severe persistent asthma who were prescribed preferred or acceptable alternative pharmacologic therapy • Requires documentation that medication was prescribed or dispensed • Measurement calculation: Line16 Column c (patients with compliance documented) Line16 Column b (patients in universe or sample)

41. Asthma Universe and Exclusions • All patients aged 5 to 40 during the measurement year (i.e., born between 1/1/1971 and 12/31/2006) who: • Were currently diagnosed with (mild, moderate, or severe) persistent asthma • CPT Category II Codes can be used to record: 1038F = persistent asthma (not 1039F – intermittent asthma) • Had at least one medical visit during the measurement year • Had at least two medical visits ever • No exclusions

42. Asthma Documentation of Compliance • Copy of prescription or note that prescription was given during the current year • For inhaled corticosteroids • For acceptable alternative pharmacologic therapy: • Leukotriene modifiers • Cromolyn sodium • Nedocromil sodium • Sustained release methylxanthines

43. Asthma Completing the UDS: Line 16 • Column a: Number of patients aged 5 to 40 with persistent asthma seen during the measurement year • Will be similar to patients seen with primary diagnosis on Table 6a. No age limits on table 6a. • Column b: Will be 70 unless a comprehensive EHR tracks this condition, in which case column b will be equal to column a • Column c: Number (of those reported in column b) for whom documentation demonstrates that appropriate pharmacotherapy was provided

44. Modification ofTwo Year Old Immunizations(NQF 0038)

45. Two Year Old Immunizations Measure • Percent of children who turned two during the measurement year who were fully immunized on their second birthday • All listed vaccines should have been given by 19 months – 24 months builds in a 6 month grace period • Vaccinations may be given by health center or others as long as it is documented • Measurement calculation: Line10 Column c (patients with compliance documented) Line10 Column b (patients in universe or sample)

46. Two Year Old Immunizations Universe and Exclusions • All patients who turned two during the measurement year (i.e., born between 1/1/2009 and 12/31/2009) who: • Had at least one medical visit during the measurement year • Was first ever seen before their second birthday • No exclusions

47. Two Year Old Immunizations Documentation of Compliance • Documentation of required vaccines or for any vaccine: • Shows evidence of having had the disease or • Shows evidence of allergy to a vaccine or its components • Documentation can be obtained from state-wide or other registries

48. Two Year Old Immunizations Documentation of Compliance • Fully compliant means compliant for each of 14 diseases spelled out in the guidance: • 4 DTP/DTaP • 3 IPV • 1 MMR • 3 Hib • 3 HepB • 1VZV (Varicella) • 4 Pneumococcal conjugate • 2 HepA • 2 or 3 RV (Rotavirus) • 2 Flu

49. Two Year Old Immunizations Completing the UDS: Line 16 • Column a: Number of two year old medical patients seen in measurement year • Will be similar to patients reported on table 3A • Column b: Will be 70 unless a comprehensive EHR tracks immunizations, in which case column b will be equal to column a • Column c: Number (of those reported in column b) who had each and every vaccine or, for any they did not have, had allergy or disease documented

50. Quality of Care Measure Table 7 – Diabetes(NQF 0575)