A. DIABETES AND HEART/STROKE Data Detail

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2 A. DIABETES AND HEART/STROKE Data Detail Under the category of Effective Care, MHMC currently reports practices who have achieved national recognition for any of the Bridges to Excellence (BTE) clinical programs (Diabetes Care, Cardiac Care, Coronary Artery Disease, Hypertension Care) or the National Committee on Quality Assurance s (NCQA) programs (Diabetes Recognition Program or Heart/Stroke Recognition Program). Following are the measures for each of these programs: BTE Diabetes Care Clinical Measures: Eligible clinicians and medical practices voluntarily apply for BTE Recognition by submitting information on how they treat and manage their patients with regard to the following. 1. Blood Pressure (BP) control 2. LDL control 3. HbA1c control 4. Documentation of Ophthalmologic exam 5. Documentation of Smoking status and cessation advice and treatment 6. Documentation of Nephropathy assessment 7. Documentation of Podiatry exam For detailed guide, link to BTE Cardiac Care Clinical Measures: Eligible clinicians and medical practices voluntarily apply for BTE Recognition by submitting information on how they treat and manage their patients with regard to the following. 1. Blood Pressure (BP) control 2. LDL control 3. Complete Lipid profile 4. Use of Aspirin or another antithrombotic 5. Documentation of Smoking status and cessation advice and treatment For detailed guide, link to pdf BTE Coronary Artery Disease Clinical Measures: Eligible clinicians and medical practices voluntarily apply for BTE Recognition by submitting information on how they treat and manage their patients with regard to the following. 1. Blood pressure (BP) control 2. LDL control 3. Complete lipid profile 4. Evaluation of activity level and anginal symptoms 5. LDL drug therapy 6. Use of aspirin or other antiplatelet therapy 7. ACE inhibitor/arb therapy 8. Documentation of smoking status and cessation advice and treatment 9. Betablocker treatment after a heart attack For detailed guide, link to PTE Physician Ratings for Website Page 2

3 BTE Hypertension Clinical Measures: Eligible clinicians and medical practices voluntarily apply for BTE Recognition by submitting information on how they treat and manage their patients with regard to the following. 1. Blood pressure (BP) control 2. LDL control 3. Complete lipid profile 4. Use of aspirin 5. Documentation of urine protein test 6. Documentation of annual serum creatinine test 7. Documentation of smoking status and cessation advice and treatment 8. Documentation of diabetes screening test 9. Documentation of counseling for diet and physical activity For detailed guide, link to NCQA Diabetes Recognition Program (DRP): The DRP Program has 10 measures which cover areas including: HbA1c control Blood Pressure control LDL control Eye examinations Nephropathy Assessment Smoking status and cessation advice or treatment For more detail, link to NCQA Heart/Stroke Recognition Program (HSRP): The Heart Stroke Recognition Program (HSRP) assesses key quality performance measures that are based on national evidence based guidelines for secondary prevention of cardiovascular disease and stroke. Program measures include: Blood pressure control Complete lipid profile Cholesterol control Use of aspirin or another antithrombotic Smoking status and cessation advice or treatment For more detail, link to PTE Physician Ratings for Website Page 3

4 MHMC Reporting Details: The MHMC Pathways to Excellence (PTE) reports performance at the practice level. This is based on the belief that quality is associated with many systems and processes that reflect the practice team as a whole. If a practice gets practice level recognition in any of the above categories, it is reported on the MHMC website as follows: Ø Clinical outcomes - Adults PTE Recognition: NCQA, BTE - Level 1 Good NCQA or BTE - Level 2-3 Better If individual providers within the practice are recognized in any of the above categories, the following methodology is applied to determine the practice level performance: For a practice with 3 or more eligible providers 1, at least 2/3 s must have earned individual national recognition. For practices with two eligible providers, 50% is required. Then, the practice performance is reported as follows: Ø Clinical outcomes - Adults PTE Recognition: NCQA, BTE - Level 1 Good NCQA or BTE - Level 2-3 Better For purposes of reporting the clinical outcomes measures, good and better are defined as follows: Good - A leading national recognition organization, Bridges to Excellence, determined that the doctors who practice in this office have above average performance for: a) providing the care experts recommend b) patient results Better - A leading national recognition organization, Bridges to Excellence, determined that the doctors who practice in this office have very good performance for: a) providing the care experts recommend b) patient results Did Not Report - This practice does not submit data to any MHMC approved rating organizations. Unable to Determine - This practice does not have enough patients to determine a meaningful rating. Performance is posted on the MHMC website to reflect the recognition dates extended by the national recognition organizations. MHMC Data Collection, Analysis and Display Process for PTE PCP Adult Practices Clinical Outcomes Measures: 1 An eligible provider includes all who provide clinical care services to patients who carry their own panel of primary care patients. Physicians, nurse practitioners and physician assistants who carry their own panel of primary care patients and have worked at the practice for at least 12 consecutive months are eligible for recognition. See BTE and NCQA sites for more detailed information on eligible providers. PTE Physician Ratings for Website Page 4

5 Data Collection: Each month of the 2 nd week), the appropriate MHMC staff access Bridges to Excellence s Recognition Data Exchange (RDE) report via Dropbox using a secure password. The RDE is an Excel file that includes all updates in provider and practice information for the previous month. Data Analysis: Appropriate MHMC staff review the RDE for new recognitions, expired recognitions, and demographic changes. A report is generated of the updates (both recognition and demographics) that need to be made to the MHMC website along with notes of practices that need to be contacted for provider information (e.g., confirm address change, confirm number of eligible providers, etc.). Once f/u with practices is complete, the final update list is submitted to the data base manager to update the site. Data Output: Data base manager updates the data base with correct information monthly/ongoing. MHMC website is updated with changes quarterly, the middle of the 3 rd month of each quarter. Letters to practices informing them of recognition expiration at 6 and 3 months. B. OFFICE SYSTEMS Data Detail Under the category of Safe Care, MHMC currently reports practices who have achieved national recognition for any of the Bridges to Excellence (BTE) or the National Committee on Quality Assurance s (NCQA) Office Systems programs or has achieved Meaningful Use designation from the Federal Government. Following are the measures for each of these programs: BTE Physician Office Link: Eligible practices apply through a BTE clinical outcomes program by submitting a full- panel of patients to IPRO (BTE portal). If your practice uses a CCHIT- certified or ONC- ATCB - certified EHR (one that meets CMS meaningful use (MU) standards) and earns a clinical outcomes recognition, a level 2 Physician Office Link Office System Survey (POL OSS) recognition will be awarded. To check CCHIT or ONC- ATCB status or for further information, please visit This program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain Recognition, practices must demonstrate that they have implemented systematic office processes to reduce errors and increase quality. The program includes three levels of recognition: Level I elements assess the use of evidence- based standards of care; maintenance of patient registries to identify and follow up with at- risk patients; and provision of educational resources to patients. Level II elements assess whether practices use electronic systems to maintain patient records; provide decision support; enter orders for prescriptions and lab tests; and provide patient reminders. Level III elements assess whether a practice's electronic systems interconnect and are "interoperable" with other systems whether they use nationally accepted medical code sets or they can automatically send, receive and integrate data such as lab results and medical histories from other organizations' systems. For more information on ways to achieve BTE Office System Survey recognition, visit PTE Physician Ratings for Website Page 5

6 BTE Medical Home To earn BTE Medical Home designation, practices must demonstrate that they have adopted effective systematic office processes and that they are using those processes to deliver better care and improve patient outcomes, especially regarding chronic conditions. BTE Medical Home designation is achieved by obtaining Recognition in a combination of BTE's existing programs. as follows: Requirements for BTE Medical Home Designation: PART 1. Effective systematic office processes are identified through the achievement of Level II or III Recognition in BTE Physician Office Systems Recognition program. This program requires a practice to demonstrate that it is collecting and using information to improve the management of patient care, and that it is using electronic systems to promote patient safety. Clinicians/practices can achieve recognition in the BTE Physician Office Systems Recognition program in two ways. o Option 1 - Achieve a NCQA Patient Centered Medical Home recognition of level II or III. o Option 2 - Have a meaningful use certified electronic medical record system PART 2. Positive patient outcomes are identified through the achievement of Level II or III in any two BTE Care Recognition programs, which demonstrate that clinicians are measuring and reporting clinical performance data resulting in improved delivery of care. For further information, please visit NCQA Physician Practice Connections (PPC): Physician Practice Connections (PPC ) recognizes practices that use systematic processes and information technology to enhance the quality of patient care. Meeting PPC standards shows practices have established connections to information, patients and other providers that allow them to: Know and use patient histories Follow up with patients and other providers Manage patient populations and use evidence based care Employ electronic tools to prevent medical errors. There are nine PPC standards and three levels of recognition. Practices seeking PPC Recognition will complete a Web- based data collection tool and provide documentation that validates responses For detailed guide, link to: NCQA Patient- Centered Medical Home (PPC- PCMH) NCQA s Patient- Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time. The NCQA Patient- Centered Medical Home standards strengthen and add to the issues addressed by NCQA s original program. The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient s family. Care is facilitated by registries, information technology, health information exchange and PTE Physician Ratings for Website Page 6

7 other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. For detailed brochure on NCQA s Patient- Centered Medical Home 2011, please visit Meaningful Use Federal Government The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology. MHMC s PTE program also recognizes practices who have achieved Meaningful Use. Practices can contact MHMC at to find out details as to how to attest to having received Meaningful Use. For additional information, please visit and- Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/30_Meaningful_Use.asp. MHMC Reporting Details: The MHMC Pathways to Excellence (PTE) reports performance at the practice level. This is based on the belief that quality is associated with many systems and processes that reflect the practice team as a whole. If a practice gets practice level recognition in any of the above categories, it is reported on the MHMC website as follows: Ø Office Systems Survey Method PTE Recognition: NCQA PPC, or BTE POL Level 1 Good NCQA PPC, or BTE POL Level 2-3 Better Meaningful Use Better NCQA PCMH - Level 1 Better NCQA PCMH - Level 2 or 3 Best If individual providers within the practice are recognized in any of the above categories, the following methodology is applied to determine the practice level performance: For a practice with 3 or more eligible providers 2, at least 2/3 s must have earned individual national recognition. For practices with two eligible providers, 50% is required. For purposes of reporting the office systems survey measures, good, better and best are defined as follows: 2 An eligible provider includes all who provide clinical care services to patients who carry their own panel of primary care patients. Physicians, nurse practitioners and physician assistants who carry their own panel of primary care patients and have worked at the practice for at least 12 consecutive months are eligible for recognition. See BTE and NCQA sites for more detailed information on eligible providers. PTE Physician Ratings for Website Page 7

8 Good - A leading national recognition organization, Bridges to Excellence, determined that the doctors who practice in this office have above average performance for: a) providing the care experts recommend b) patient results Better - A leading national recognition organization, Bridges to Excellence, determined that the doctors who practice in this office have very good performance for: a) providing the care experts recommend b) patient results Did Not Report - This practice does not submit data to any MHMC approved rating organizations. Unable to Determine - This practice does not have enough patients to determine a meaningful rating. Performance is posted on the MHMC website to reflect the recognition dates extended by the national recognition organizations. MHMC Data Collection, Analysis and Display Process for PTE PCP Adult Practices Office Systems Measures: Data Collection: Each month (@middle of the 2 nd week), the appropriate MHMC staff access Bridges to Excellence s Recognition Data Exchange (RDE) report via Dropbox using a secure password. The RDE is an Excel file that includes all updates in provider and practice information for the previous month. Data Analysis: Appropriate MHMC staff review the RDE for new recognitions, expired recognitions, and demographic changes. A report is generated of the updates (both recognition and demographics) that need to be made to the MHMC website along with notes of practices that need to be contacted for provider information (e.g., confirm address change, confirm number of eligible providers, etc.). Once f/u with practices is complete, the final update list is submitted to the data base manager to update the site. Data Output: Data base manager updates the data base with correct information monthly/ongoing. MHMC website is updated with changes quarterly, the middle of the 3 rd month of each quarter. Letters to practices informing them of recognition expiration at 6 and 3 months. C. PATIENT EXPERIENCE Data Detail Under the category of Patient Experience, MHMC currently reports data on a very limited number of physician practices with plans to spread to other practices in the future. The MHMC reports on domains from the Clinician & Groups Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) survey. Practices use various data vendors as their source for this information and the domains measured and reported are as follows: PTE Physician Ratings for Website Page 8

9 Overall Doctor Rating: Rating of the doctor on a scale from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor possible Willingness to Recommend: Would you recommend this doctor's office to your family and friends? ( Follow Up on Test Results: During your most recent visit, did this doctor order a blood test, x- ray, or other test for you? (If yes,) Did someone from this doctor's office follow up to give you those results? Office Staff Courtesy and Respect: Clerks and receptionists were helpful Clerks and receptionists were courteous and respectful Doctor Communication: Doctor explained things in a way that was easy to understand Doctor listened carefully to patient/[respondent] Doctor gave easy to understand instructions about taking care of health problems or concerns Doctor knew important information about patient s/ medical history Doctor respected patient s/[respondent s] comments Doctor spent enough time with the patient PTE Physician Ratings for Website Page 9

10 MHMC Reporting Details: The MHMC reports out the percent of the total number of survey respondents who gave the most favorable answers (often referred to as top box ) to the questions. Specifically: For Overall Doctor Rating, those who rated doctors a 9 or 10 (out of 10) For all remaining 5 domains, those who responded Yes, Definitely MHMC Data Collection, Analysis and Display Process for PTE PCP Adult Patient Experience Measures: Because of a pilot project directed by Maine s Aligning Forces for Quality initiative, the MHMC has been able to report patient experience on a very small number of primary care practices. Currently, there is no analysis done to assign a good, better, best rating to practices but the top box data is reported for consumers. The MHMC is currently working on a process for being able to offer reporting to other practices and is working with the PTE Steering Committee to determine a rating methodology to be announced in the future. PTE Physician Ratings for Website Page 10