Case Studies

Scientific Poster - Excelling at MIPS Reporting and Quality Improvement

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Excelling at MIPS Reporting and Quality Improvement Introduction: CMS is required by law to implement the Quality Payment Program, which rewards value and outcomes through the Merit-based Incentive Payment System (MIPS). Eligible providers who bill Medicare Part B are required to submit data in four areas: Quality, Improvement Activities, Advancing Care Information (now known as Promoting Interoperability), and Cost on an annual basis. One of the busiest endoscopy centers in Florida will detail how they achieved exceptional performance for their 2017 MIPS submission and set the practice up for success in quality improvement in years to come.This case study will provide insights and recommendations on how providers can prepare for the 2018 MIPS data submission due on March 31, 2019. Methodology: The practice used the 2017 MIPS submission as an opportunity to drive documentation and quality improvement across the organization. One of the main challenges they faced was that their current electronic medical record (EMR) was not automatically generating the Quality Data Codes (QDCs) required for the MIPS Registry Measures. The practice worked with a Qualified Clinical Data Registry (QCDR) to identify measures to target for MIPS submission and used data that was already being generated in the provider workflow to document quality actions for these measures. This approach to documentation of quality was iterative over multiple data pulls, identifying data elements for numerator credit to accurately capture the true performance, despite coding gaps. In addition, the QCDR's quality dashboard allowed the practice to continuously monitor quality measures to increase performance scores and select the top six performing measures for MIPS submission. The practice calculated the measures in Table 1 for 2017 and are adding the following measures for 2018: • Measure 275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy • Measure 439: Age Appropriate Screening Colonoscopy Measure ID Measure Name Points Measure 110 Preventive Care and Screening: Influenza Immunization 10 Points Measure 113 Colorectal Cancer Screening 10 Points Measure 400 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk 10 Points Measure 343 Screening Colonoscopy Adenoma Detection Rate 8 Points Measure 226 Preventative Care and Screening Tobacco User: Screening and Cessation Intervention 8 Points Measure 128 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 6 Points Results and Discussion: By partnering with their QCDR, the practice was able to achieve a 100% score for the Quality Performance Category while maintaining the optimal workflow in their EHR, reducing the burden on their providers. Preparation for the 2017 MIPS submission allowed Gastroenterology Associates of Pensacola to identify best practices for aggregating data, auditing measure results, and preparing for a successful MIPS submission. The MIPS program kicked off a focus on quality improvement and ultimately improved patient care and outcomes, while also achieving bonus payments in 2020 by monitoring quality measures throughout the year to optimize their MIPS submission. References: • Quality Payment Program: www.qpp.cms.gov • Quality Payment Program Resource Library: www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Resource-library.html • SPH Analytics: www.sphanalytics.com Abstract Author: Amanda Taylor, EHR Specialist Gastroenterology Associates of Pensacola, PA ataylor@endo-world.com Abstract Category: Practice Management Table 1: MIPS Measures Points for 2017 1. Data Integration from EMR First, we identified what we were already doing to meet the requirements of the measures and how that could be quantified in a report without any modifications to existing workflows. Once we established what we were already documenting discretely, we looked into what we were doing that we weren't documenting and decided the least invasive way that we could adjust workflows to begin documenting it in a way it could be tracked in the reports. Workflow modifications were made and orderable items were created where necessary. Our EHR did not allow for the documentation of QDC codes within the dictionaries so we worked with SPH Analytics to find alternative codes – usually dictionary codes – accompanied by item descriptions 2. Data Quality and Optimization Once workflows were finalized and implemented, we began auditing the data. Where there were discrepancies, the details were reported to SPH Analytics who investigated the source and made adjustments to the reporting criteria. This process was repeated until each measure had at least one clean audit. 4. Streamline Workflows 3. Quality Performance Monitoring 5. MIPS Submission At the end of the reporting period, SPH Analytics used the data from the performance period to estimate our performance score including approximate bonus points. After consent was obtained, SPH Analytics submitted the data to CMS. Quality Improvement Work Flow: We use the data in the dashboard to track performance within the practice. We monitor and track performance rates to define baseline performance rates that we should expect for each measure allowing us to identify deviations and address them when they occur. During monitoring, we also study the performances by NPI. When we find outliers, we investigate and track them back to specific offices and/or staff. At that point we are able to address workflow issues one-on-one and improve patient care. Dashboard shows the top 6 measures recommended for MIPS reporting Provider scorecard view allows you to compare provider performance Drill down to detailed measure performance and reporting rates across all measures that the practice is tracking

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