SIM HIT Assessment. Table 1: Practice Capacity to Support Data Elements

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1 SIM HIT Assessment This interactive document allows the Clinical Health Information Technology Advisors (CHITAs) to work with a SIM practice to institute sustainable quality improvement. The SIM HIT Assessment: - Allows the practice s CHITA to understand the current state of data capture and quality measure reporting capabilities - Focuses on the data elements, clinical quality measure reports, and other HIT tools that support care for patients in alignment with SIM s goals of improved health through integrating advanced primary care activities, behavioral health services, and payment reform - Helps the CHITA to understand the practice dynamics around using data to improve care - Will enhance practice knowledge, instill autonomy and confidence in data development, data use and data submission - Demonstrates where practices stand on issues of information technology and preparing for alternative payment models (APM) In completing this assessment, both the practice and CHITA should have a clear picture of current data quality, measure validity and reporting procedures, as well as be able to identify practice priorities, barriers and opportunities for improvement. Finally, the practice will be asked about other HIT priorities being advanced by the SIM project in Colorado. These include increasing practices connected to the health information exchanges (HIEs), expanding telehealth services, and improving broadband internet access. Your CHITA and Practice Facilitator will be able to provide you with more information on these resources throughout your time in SIM. Data Elements These are the data elements necessary to address the conditions included in the SIM core measure set. Please indicate the status of each data element in the following table: Table 1: Practice Capacity to Support Data Elements SIM Data Elements (preliminary) Patient Linking Number Date of Birth Gender Ethnicity Race Diagnostic codes linked to each visit CPT codes linked to each visit Medications Problem List Height

2 Weight BMI BMI percentiles (for children) BMI follow up plan (for children) Exercise counseling BMI follow up plan (for children) Nutrition Blood pressure - Diastolic Blood pressure - Systolic Substance abuse screening Substance abuse follow up plan Dates of alcohol or other drug dependent treatment Depression screening for patients 12+ years old Maternal depression screening Depression follow up plan Fall risk assessment Standardized way to assess risk for child developmental, behavioral, and social delays Asthma - Medication prescription start dates Immunizations Colon cancer screening results Mammogram results Hemoglobin A1C results Green Data captured in discrete fields accurately and consistently on all patients in practice Yellow Red Data captured in discrete fields with concern for accuracy and/or consistency Data elements not captured in discrete fields What are the key barriers to consistently and accurately track data elements?

3 SIM Clinical Quality Measures (CQMs) SIM focuses attention on 13 CQMs (see Table 2). SIM practices are asked to submit numerators and denominators quarterly. The CHITA will work with the practice to assess reporting capacity and whether the practice can generate accurate reports. Table 2: SIM Clinical Quality Measures Measure Title Measure Summary NQF CMS Screening for Clinical Depression and Follow-Up Plan Depression Remission at 12 Months Maternal Depression Screening Substance Use Disorder: Alcohol and other Drug Dependence Substance Use Disorder: Tobacco Substance Use Disorder: Alcohol Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan - Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. The percentage of children who turned 6 months of age during the measurement year, who had a face- to-face visit between the clinician and the child during child s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following. - Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. - Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user v v v4 NA 137v5 135v N/A Controlling High Blood Pressure (Hypertension) The percentage of patients years of age who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90) during the measurement year v5 Diabetes: Hemoglobin A1c Poor Control Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period v5 Falls: Risk Assessment (Safety) Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period v5

4 Medication Management for People with Asthma Body Mass Index (BMI) Screening and Follow-Up Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Developmental Screening in the First Three Years of Life The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current reporting period documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current reporting period. Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported: A) Percentage of patients with height, weight, and body mass index (BMI) percentile documentation. B) Percentage of patients with counseling for nutrition. C) Percentage of patients with counseling for physical activity. Percent of children screened for risk of developmental, behavioral, social delays by using standardized tool in first 3 years of life. Includes 3 age specific indicators assessing whether children are screened by 12, 24 or 36 months N/A v v N/A

5 Table 3: SIM CQM Reporting Capabilities Please indicate the status of each Measure: NQF CMS Screening for Clinical Depression and Follow-Up Plan v6 Depression Remission at 12 months v5 Maternal Depression Screening v4 Substance Use Disorder: Alcohol and other Drug Dependence v5 Substance Use Disorder: Tobacco v5 Substance Use Disorder: Alcohol 2152 N/A Controlling High Blood Pressure (Hypertension) v5 Diabetes: Hemoglobin A1c Poor Control v5 Falls: Risk Assessment (Safety) v5 Medication Management for People with Asthma 1799 N/A Body Mass Index (BMI) Screening and Follow-Up v5 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Developmental Screening in the First Three Years of Life v NA Green Yellow Red Already have the report and we trust the data are accurate Have the report, but we do not fully trust that the data are accurate Do not have the report, but can get it/build it Black Blue No chance of getting report from system/vendor We do not see patients of this age at our practice, measure does not apply

6 Does your practice use software tools or registries outside of your EHR to produce clinical quality measures (i.e. PRIME, Azara, i2i, PopHealth, DARTNet, etc.)? Yes No If yes, which one(s): Are there key barriers to reporting SIM measures that your CHITA should be aware of? The Colorado SIM Initiative is developing an ecqm demonstration project that would collect CQMs from your EHR and report them to multiple agencies on your behalf more efficiently. Would your practice or organization be interested in joining this demonstration project? Yes No I don t know

7 Population Health Registry Capabilities Please indicate if your Practice Site has access to and uses a registry to manage patients with the following conditions. Table 4: Registry Capabilities Condition No registry available Registry available, but not used regularly Registry available and used regularly N/A we do not see patients with this condition Depression Maternal Depression Alcohol Dependence Tobacco Use Disorder Other drug dependence (i.e. opioids) Hypertension Diabetes Patients at risk of falls Asthma Obesity Children with suspected or confirmed developmental delays

8 General HIT Information Does the practice participate in any of the following EHR incentive programs? (Check all that apply) Medicare Quality Payment Program (MIPS/APM) Medicaid EHR Incentive Program Other (Please specify) Tell us about your EHR product in further detail. Select your EHR System/Product Name: Allscripts Enterprise EHR Allscripts Professional EHR Allscripts TouchWorks EHR Amazing Charts Aprima Athenahealth ClearPractice CureMD eclinicalworks EHR 24/7 ElationEMR emds Epic Evident GE Centricity Greenway Intergy Greenway Prime Suite Greenway SuccessEHS HealthFusion Kareo EHR Medisoft Clinical Medicat Meditab MedWorxs NextGen OpenEMR Physician's Computer Company Practice Fusion Practice Partner Practice Studio Other (Specify) EHR Version: Does your EHR have a CHPL ID? You can search for your systems CHPL ID on this ONC website: Yes No Don t Know If YES, please specify CHPL ID: How is your EHR hosted? Client Server (hosted locally) Cloud Based (hosted by EMR Vendor) Don t know How is your EHR supported? Call EMR Vendor directly Call 3 rd party vendor Don't know

9 Health Information Exchange Can your EHR import and export in Quality Reporting Document Architecture (QRDA) format? Import & export Import only Export only Cannot import or export Don't know Can your EHR import and export in Consolidated Clinical Document Architecture (C-CDA) format? Import & Export Import Only Export Only Cannot import or export Don't know Does your Practice Site have access to the following features of Health Information Exchanges? Results delivery (i.e. labs, images, etc.) Yes No Don t Know Patient event reports (ADT- admission, discharge, transfer) Yes No Don t Know Single sign-on from EHR interface Yes No Don t Know Longitudinal patient record Yes No Don t Know Care summary view Yes No Don t Know Care summary send Yes No Don t Know Care summary query and retrieve Yes No Don t Know Other (specify): Would the practice like additional support to integrate HIE services into clinical workflows? Yes No Don t Know

10 Telehealth Does the practice provide services via telehealth? (This would include telemedicine, Project ECHO, electronic consultation (econsult) or other tele-modalities that allow remote providers to have input into patient care.) Yes No If NO, skip to the Broadband section below If YES, please continue with the Telehealth questions Please list/ describe the telehealth services provided at your Practice Site. Does your practice bill for services provided via telehealth at the same rate as services provided in person? Yes No If NO, please describe why not

11 Broadband Is your broadband adequate for your practice s needs? Yes No If NO, please describe why not

12 HIT Concerns Finally, please rank order your most pressing HIT concerns with 1 being the most important item and 12 being the least important item. HIT Item Building and validating new ecqms (in terms of vendor costs and staff time) Reporting CQMs to outside entities (such as commercial payers and quality improvement projects) Acquiring and using telehealth technology Using cost and quality data to inform contracts with payers IT to support internal business planning and clinic operations Connecting to a HIE Coordinating patient care with other subspecialties including behavioral health Building and using registries to manage groups of patients Risk stratifying the practice's patient population Rank of Importance (1-12) Accessing cost and utilization data Optimizing documentation workflows in your current EHR Managing EHR vendor problem Please list any other HIT concerns at your Practice Site that were not included above.