Annals of QPP

The Annals of QPP

Annals of QPP 2

Introduction

With the healthcare spending increasingly burgeoning,

the US government has been planning to introduce

ways to cut it down while increasing access and reduc-

ing expenses.

In the past, many programs were introduced to incen-

tivize/penalize providers in order to drive them to-

wards these goals. As the number of these programs

increased, it became difficult for providers to under-

stand what’s relevant to them. So, now Quality Pay-

ment Program (QPP) aims to tie these disparate pro-

grams together and achieve something bigger than

other programs

There are 2 tracks to choose from:

Advanced Alternative Payment Models (APMs) –

Under this, through Medicare Part B you may earn

an incentive payment for participating in an inno-

vative payment model.

The Merit-based Incentive Payment System

(MIPS) - If you decide to participate in traditional

Medicare Part B, then you will participate in MIPS

where you earn a performance-based payment ad-

justment.

Do I need to worry?

QPP is applicable to all Physicians, Physician Assis-

tants (PAs), Nurse practitioner, Clinical nurse spe-

cialist and Certified registered nurse anesthetist who

bill Medicare > $30000 annually and who provide

care to more than 100 Medicare patients.

Fig 1: Applicability of QPP

And by when?

Newbies starting with Medicare for the first time in

2017, aren’t under MIPS.

The rest:

Need to report at least 90 day data (Between Jan 1

to Dec 31st 2017)

Need to be submit this data by 31st Mar 2018 and

will get feedback

May earn a positive MIPS payment adjustment

beginning Jan 1st 2019

So what are my options?

Under Advanced APMs

Submit data for the entire year in 2017 and receive a

5% positive adjustment in 2019 if you:

Receive 25% or more of your payments through

Medicare

See 20% or more of your Medicare patients

through Advanced APM

Annals of QPP 3

Under MIPS

What if I don’t?

The adjustments start with +/-4% in 2019 but go all the way to +/-9%. This means the difference between reporting

or not reporting could be a whopping 18%.

Alright, what do I need to do for it?

QPP has four components as described below. The providers’ performance on different criteria under each of these

will lead to a category score which will be then multiplied with the weightage. The summation of the scores after

applying the weightage will be the composite score. This score becomes the single yardstick to compare provider

performance.

1. Quality – This replaces the PQRS program and has the most weightage in MIPS. In 2017, its 60% but from 2018

it will be 50%.As the impact of this category is substantial enough to pull the overall score down, providers

need to score well on this one. EHR vendors might find providers asking for capabilities broader than what

they had for PQRS. That way, they can report on the criteria where they scored the best.

2. Advancing Care Information (ACI) – This replaces EHR incentive program for providers and will have 25%

weightage in 2017 and 2018. There are several objectives and criteria for those that providers need to score on in

order to achieve a full score.

Annals of QPP 4

3. Improvement Activities – This is a new category and has over 90 activities that providers can choose from.

While all of these activities implies a process change for the providers, there will be a technology impact as

well. A full score in this category can be achieved by ensuring that the requisite processes are followed consist-

ently, which is easiest to achieve though workflow modifications in the technology being used.

4. Cost - This replaces the Value Modifier program and will have 10% weightage starting 2018. For this, CMS

would be utilizing the claims data they already receive from providers. This has no technology impact so for

EHR vendors this becomes irrelevant.

With the limited real-estate available for a whitepaper, we have chosen to cover the ACI component in detail here.

We will be detailing out other section in the following weeks to make sure that you understand the complete picture.

Advancing Care Information – A notch deeper

The clinicians have an option to submit the data during the transition year 2017 either through a 2014 edition CEHRT

or a 2015 edition certified EHR. Looking at the efforts required to upgrade from 2014 Edition, most EHR vendors

have already started their efforts to upgrade their EHRs to meet the 2015 Edition of Meaningful Use.

What will Clinicians be reporting on?

8 Objectives including 11 Measures for Clinicians using a 2014 edition CEHRT (only for transition year i.e. 2017 re-

porting year)

6 Objectives including 15 measures for Clinicians using a 2015 edition CEHRT (mandatory from 2018 reporting year)

What is the impact on EHR vendors?

To be 2015 Edition certified EHR, ensure that they meet

all the criteria for QPP and make sure their clinicians

earn a maximum benefit, EHR vendors will need to be:

How will the scoring work?

1. A CEHRT

2. At least objectives for base score

3. capabilities to earn max perfor-

mance score

4. Submission to registries for bo-

nus points

Base Score 50

Performance Score 90

Bonus Point 5

Composite Score 155

Annals of QPP 5

To earn the base Score, clinicians will be reporting on following objectives and will earn 50 points. The Base Score is

based on the measures adopted by EHR Incentive Programs. If clinicians fail to report the base score, they will

score zero for the ACI category score.

Base EHR definition:

The 2015 Edition Base EHR definition:

Includes CPOE, demographics, problem list, medication list, medication allergy list, CDS, transitions of care,

data portability, and relevant transport certification criteria

Includes “smoking status” certification criterion as patient demographic and clinical health information data

consistent with statutory requirements.

Includes “implantable device list” certification criterion as patient demographic and clinical health information

data consistent with statutory requirements

Includes “API” certification criteria as capabilities that support both the capture and query of information rele-

vant to health care quality and exchange electronic health information with, and integrate such information

from other sources.

Base Score

The following table outlies the composition of the base score for the next two years .

Annals of QPP 6

Performance score

While the base score ensures the existence of an EHR in a provider facility, the performance score intends to gauge

the ‘usage’ of it. The following table lists the criteria and the points associated for each one of those for the next two

years.

The new implementations w.r.t 2015 Edition include Implantable Device List and support of API for health infor-

mation exchange.

ACI Objectives for 2015 Edition

As QPP is a program for providers, CMS wanted to ensure that providers use IT in meaningful ways. While they

need to use a CEHRT, they also need to report on the following objectives ‘using’ that CEHRT. So for EHR vendors,

this means that they need to have a 2015 edition CEHRT in 2018 and enable providers to report of the ACI objectives

through it. In all there are 6 objectives and 15 measures to be implemented.

The clinicians need to report these measures for at least one unique patient seen during the performance period.

Lets delve into these measures to understand what is expected of EHRs to satisfy these criteria

successfully.

Annals of QPP 7

Health Information Exchange

ONC targets interoperability as one of the major pil-

lars of 2015 Edition criteria and aims to improve the

quality and safety of referral care by reducing the com-

munication gap. While sending and receiving a sum-

mary of care is mandatory to achieve a base score, rec-

onciling the clinical information can boost the perfor-

mance score.

Send Summary of Care

While the base of this measure to electronically be able

to create and exchange CCDA documents with refer-

ring clinician is unchanged, EHR vendors will now

have to update to CCDA version to 2.1 while ensuring

it is backward compatible to use 1.1. V2.1 of CCDA

adds new fields like implantable device list, goals and

health concerns. Export summary needs to be created

in real-time which implies that EHRs should allow

users to create these documents and to select the stor-

age location of these summary documents.

Request/Accept Summary of Care

A new design implemented to complete the electronic

transmission loop and support clinicians in using EHR

to support the multiple roles a clinician plays in mean-

ingfully exchanging the health information, EHR will

now support incorporating CCDA into the patient rec-

ord when a patient is referred or transferred to clini-

cian. This receipt of CCDA may be passive i.e. clinician

is sent the CCDA and it’s incorporated in EHR or Ac-

tive i.e. clinician requests a direct transfer of the CCDA

or clinician queries an HIE for the CCDA. EHR can use

APIs to allow clinician to query an HIE. When the

summary document is incorporated, a validation

needs be performed and the errors, if any, should be

displayed to the user.

Clinical Information Reconciliation (CIR)

While most EHRs have already implemented incorpo-

rating the C-CDA for the three major clinical infor-

mation sets – Medication, Medication Allergy and

Current problem list, the major change involves ability

to incorporate & reconcile clinical data from both

CCDA 1.1 and CCDA 2.1 across document templates

viz. ToC, Referral Note and Discharge Summary. Be-

sides having the ability to incorporate, most of EHRs

faced problems during incorporating the C-CDA since

every EHR used a different structure to incorporate.

While CMS assures the new version of C-CDA is more

structure, it also allows EHR to perform a validation

check to help clinician identify any errors.

Electronic Prescribing

The aim to include this objective as part of base score

is to reduce the medication errors caused by manual

interference.

EHR must be able to change, cancel and refill prescrip-

tions, receive fill status notifications and request and

receive medication history information. Besides this,

ONC ensures a reason for the prescription is given

using the Diagnosis element. For the oral liquid medi-

cations, EHR needs to limit to prescribe only metric

standard unit (i.e. mL).

This objective focuses on generating and trans-

mitting permissible prescriptions electronically

and gives an exclusion to clinicians who write

fewer than 100 permissible prescriptions.

Annals of QPP 8

Coordination of Care through Patient Engagement

Another area that ONC targets through ACI is improv-

ing patient care by engaging the patient/ patient au-

thorized representative. Patient-Generated Health data

from a non-clinical setting is incorporated into the cer-

tified EHR technology for at least one unique patient

seen by the clinician.

EHR should be able to import the documents shared

by the patient through reference or links and label,

record and access the documents shared directly or

electronically.

Secure Messaging

The measure remains unchanged w.r.t reporting. DI-

RECT implementation will now use Edge protocol for

communication and for integrity certification criterion,

a hashing algorithm with security strengths SHA-2

hash algorithm needs to be upgraded by sun setting

SHA-1.

View, Download and Transmit (VDT)

Patients will now be able to view, download and trans-

mit their health information using a third party or ac-

cessing their health information using API. Patient will

now be able to query the EHR to pull the health data at

real-time.

ONC recommends use of FHIR for this API communi-

cation. This ensures that patients can access their data

using any application of their choice that is configured

using the technical specifications of APIs. The visit da-

ta transmitted should support CCDA 2.1 version and

latest coding standards for all the CCDA templates like

Continuity of Care, Referral Note and Discharge sum-

mary document.

Patient Electronic Access

This objective focuses on providing electronic access of

health information to the patient which is a critical

step in improving patient care, increasing transparen-

cy and engaging patients. Patient (or the patient-

authorized representative) is provided timely access to

view online, download, and transmit his or her health

information. Additionally, the electronic access to pa-

tient’s common clinical data set, data category requests

will now use APIs for data transmission which makes

real-time data available to the patient. Similar to VDT

measure, ONC recommends use of FHIR standards for

communication.

Patient-Specific Education Measure

The MIPS eligible clinicians must use clinically rele-

vant information from CEHRT to identify and share

patient-specific educational resources electronically to

at least one unique patient seen by them.

There is no major change in the criterion if the stand-

ard used by them is already HL7 V3: Context Aware

Retrieval Application (“Infobutton”), Knowledge Re-

quest, Release 2. Optionally EHR vendors can add sup-

port to include tagging for identifying languages.

Protect Patient Health Information

Protection of electronic protected health information

(ePHI) is critical for EHRs. ePHI created or maintained

by CEHRT is to be secured through implementation of

appropriate technical, administrative, and physical

safeguards.

Security Risk Analysis Measure

EHRs need conduct or review a security risk analysis

in accordance with the requirements in 45 CFR 164.308

Annals of QPP 9

(a)(1), including addressing the security (to include

encryption) of ePHI data created or maintained by

CEHRT in accordance with requirements in 45

CFR164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), imple-

ment security updates as necessary, and correct identi-

fied security deficiencies as part of the MIPS eligible

clinician's risk management process. This includes in-

corporation of common security and privacy features

for auditing the changes to user privileges and access

to patient information, including emergency access

events.

Public Health and Clinical Data Registry Reporting

This is a Yes/No statement measure and helps clini-

cians earn base score points.

On completing any additional measure of the remain-

ing 4 would fetch clinician’s one additional bonus

point under ACI. This leaves EHR vendors to choose

the measures based on the specialties their customers

cater to.

Immunization Registry Reporting

The clinician has to submit immunization data and

receive immunization forecasts and histories from the

public health immunization registry or immunization

information system. This measure was part of 2014

Edition and comes up with new updates in 2015 Edi-

tion. EHRs will now need to display the immunization

history and forecast from an immunization registry by

adopting an updated Implementation Guide that clari-

fies and tightens the conformance requirements, de-

mands use of NDC for recording administered vac-

cines and requires use of CVX codes for historical vac-

cines. The communication between the public health

registries will be bi-directional.

Syndromic Surveillance Reporting (Optional)

The measure remains unchanged for ambulatory

settings w.r.t. 2014 Edition i.e. the clinician can submit

syndromic surveillance data from an urgent care.

However, for Inpatient settings, EHRs require to adopt

PHIN messaging guide for Syndromic surveillance.

Electronic Case Reporting (Optional)

This is a new measure in 2015 Edition where clinicians

will electronically submit case reporting of conditions.

EHR should have the ability to create and send a con-

strained transition of care document to a public health

agency, accept a URL in return, and be able to direct

end users to the URL. While doing this, the EHR needs

to ensure it adheres to the security requirements for

the transmission of this information. This can be used

to report vitals, vaccine adverse reactions reporting

and other public health reporting data.

Specialized Registry Reporting (Optional)

Other engagements with public health agencies in-

clude Cancer registry reporting. This brings some

modifications in implementation for EHRs by adopt-

ing to updated HL7 cancer reporting IG along with the

updated versions of coding standards like SNOMED

and LOINC.

It is mandatory to implement Immunization

Registry reporting.

Annals of QPP 10

Special highlights

While there are a lot of changes that QPP forces upon

EHR vendors, below are some that most of your

efforts will be focused on.

Clinical Quality Measures

There is no requirements for CQM reporting within

ACI. However, the providers need to submit quality

data for measures specified under the Quality perfor-

mance category. The reporting of CQMs will be done

using data captured in CEHRT to avoid unnecessary

overlap and duplicative reporting.

EHR vendors need to refine the existing list of CQMs

they certified for in 2014 Edition to move the focus

away from 3 NQF domains as required in the EHR

Incentive Program. Vendors will need to wisely

choose the measures that fit in the requirements of the

clinicians.

If none of the outcome measures are relevant to the

specialties EHR vendors cater to, they will need to im-

plement another high priority measure that fits the

specialty or practice requirement. The measures are

also categorized into specialty measure sets to ensure

right measures are selected for reporting.

This demands that the EHR vendors implement new

measure sets from the scratch. From experience we

have seen that with most implementations the archi-

tecture design is not flexible and extensible. This poses

a major concern since the measures get updated annu-

ally.

EHRs need to export QRDA Cat I using QRDA-DSTU

R3 and QRDA Cat III using DSTU R1 (September 2014

Errata)

Other changes include the capability to import QRDA

files into the EHR and ability to filter at the patient and

aggregate levels based on patient demographics, prob-

lems and provider related information.

Application Programming Interface (API)

EHRs must now be able to demonstrate use of APIs by

providing authentication using an ID or token that can

be used by the third party. This will be used when the

EHR receives a request for patient data, or for each of

the individual data categories in the Common Clinical

Data Set (CCDS) and application responds to the re-

quest for patient data associated with a specific date or

within specified date range. The response for CCDS

will be in a summary record format as adopted by

CCDA version 2.1.ONC recommends use of HL7 FHIR

standards to adopt the API implementation which is

widely used.

EHRs will have to provide documented APIs

(explaining the syntax and semantics) for use by third

parties.

CCDA

CCDA is a one stop source to see the patient’s most

recent clinical information. These export summaries

will be upgraded to C-CDA R2.using HL7 IG for

CDA® R2: Consolidated CDA Templates for Clinical

Notes, Draft Standard for Trial Use, and Release 2.1

for all the templates.

2015 Edition CCDS includes data for common data set

as defined in 2014 Edition, encounter diagnoses, cogni-

A minimum of 6 measures including one

outcome measure needs to be implemented.

Annals of QPP 11

tive and functional status. For ambulatory settings– the

reason for referral and referral details; for inpatient it

includes the discharge instructions.

New additions includes implantable device list, goals

and health concerns; while few optional sections include

patient’s BMI percentile. The CCDS references new and

updated vocabulary standard code sets.

Besides this, EHR should have the ability to set the time

period within which data would be used to create the

export summary using the relative date and time say for

first of every month, or on a specific date or time or say

when user signs a note or visit or an order.

EHR should have the capability to send and receive the

ToC or referral summaries via Edge protocol using the

XDM processing. CEHRT needs to validate the C-CDA

conformance by parsing different document types and

detecting the errors corresponding to different sections

in the document.

Or

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About the Author

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Vijayalaxmi is a Healthcare Expert at Nalashaa and has experience in business transformation, payer-provider integra-

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in Meaningful Use, PQRS, HHVBP, CPC+, CCM and MACRA implementations and has extensive exposure to Clinical

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