Indiana State Office of Rural Health Indiana Flex Program Medicare Beneficiary Quality Improvement Project (MBQIP) Basel

1. Indiana State Office of Rural HealthIndiana Flex ProgramMedicare Beneficiary Quality Improvement Project (MBQIP) Baseline Data Indiana Rural Health Association (IRHA) Spring Into Quality Conference March 3, 2011 Beth Greenberg, BS Technologist Health Care Excel, Inc

2. Participation in Hospital Compare

3. National CAH Reporting to Hospital Compare

4. Heart Failure Measures

5. Pneumonia Measures

6. Participation in Hospital Compare

7. Outpatient Measures

8. Achieving Meaningful Use (MU) • Demonstrates use of certified Electronic Health Record (EHR) technology in a meaningful manner • Demonstrates that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information in order to improve the quality of health care, such as promoting care coordination • Uses certified EHR technology to submit information on specified clinical quality measures and other measures

9. Stage 1 MU Measures • Core Objectives (14)—all required • Menu Set Objectives (10 )—at least 5 required • Clinical Quality Measures (15 )—all required For additional information on the EHR incentive program, go to the following link www.cms.gov/ehrincentiveprograms.

10. MU Core Objectives • Use Computerized Physician Order Entry (CPOE)* • Implement drug-to-drug and drug allergy interaction checks • Record demographics • Maintain an up-to-date problem list • Maintain active medication list • Maintain active medication allergy list • Record and chart changes in vital signs • Record smoking status * Medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines

11. MU Core Objectives (continued) • Implement one clinical decision support rule • Report quality measures as specified by the Secretary • Electronically exchange key clinical information • Provide patients with an electronic copy of their health information • Provide patients with an electronic copy of their discharge instructions • Protect electronic health information created or maintained by certified EHR

12. MU Menu Set Objectives • Implement drug formulary checks • Record advanced directives • Incorporate lab results as structured data • Generate lists of patients by condition • Provide educational resources • Perform medication reconciliation

13. MU Menu Set Objectives (Continued) • Summary care record for transfers • Submit electronic data to immunization registries • Submit reportable lab results to public health • Submit electronic surveillance data to public health

14. MU Clinical Quality Measures • Emergency Department (ED) Throughput—admitted patients median time from ED arrival to ED departure for admitted patients • ED Throughput—admitted patients—Admission decision time to ED departure time for admitted patients • Ischemic stroke—Discharge on anti-thrombotics • Ischemic stroke—Anticoagulation for A-fib/flutter • Ischemic stroke—Thrombolytic therapy for patients arriving within 2 hours of symptom onset • Ischemic stroke—Antithrombotic therapy by day 2

15. MU Clinical Quality Measures (continued) • Ischemic stroke—Discharge on statins • Ischemic or hemorrhagic stroke—Stroke education • Ischemic or hemorrhagic stroke—Rehabilitation assessment • VTE prophylaxis within 24 hours of arrival • Intensive Care Unit VTE prophylaxis • Anticoagulation overlap therapy • Platelet monitoring on unfractionated heparin • VTE discharge instructions • Incidence of potentially preventable VTE

16. MU Baseline Survey

17. MU Baseline Survey – Menu Set

18. MU Baseline Survey – Menu Set (continued)

19. Metrics and 5-year National Prevention Targets • Central Line-associated Bloodstream Infections (CLABSI) • Clostridium difficile Infections (CDI) • Catheter-associated Urinary Tract Infections (CAUTI) • Methicillin-resistant Staphylococcus aureus (MRSA) Infections • Surgical Site Infections (SSI) • Ventilator-associated Pneumonia (VAP)

20. Metrics and Targets

21. Metrics and Targets (continued)

22. Hospital Inpatient Reporting Program (Formerly RHQDAPU) • Central Line-associated Blood Stream Infection (CLABSI) (NQF #0139) • January 1, 2011, Discharges (FY 2013 payment determination) • Surgical Site Infection (SSI) (NQF #0299) • January 1, 2012, Discharges (FY 2014 payment determination)

23. National Healthcare Safety Network (NHSN) • Uses standard definitions • Built in analytic tools • The Centers for Disease Control and Prevention (CDC) provides user training and support • Developing infrastructure for electronic reporting • More than 3,000 facilities submit data, from all 50 states • Allows facilities to benchmark Healthcare-assoicated Infection (HAI) rates

24. Events that can be monitored in the Device-Associated Module * For outpatient dialysis only. See Outpatient Dialysis Training Session

25. Information on Patient Safety Component: http://www.cdc.gov/nhsn/psc.html Questions: nhsn@cdc.gov

26. Contact Information: Beth Greenberg Technologist bgreenberg@hce.org (812) 234-1499, ext 222