Reducing Medication Harm through MIPS Implementation · Acute tonsillitis Streptococcal pharyngitis...

Reducing Medication Harm through MIPS Implementation

Wyoming Quality Conference

Mountain Pacific Quality Health Foundation

1

Stevi Sy, PharmDQuality Improvement Account

ManagerMountain-Pacific Quality Health

2

Objectives

1) Define medication stewardship and identify high-risk disease states or

conditions that require standardized, written procedures for optimal patient

care

2) Discuss quality of care performance measure selection and theses

measures’ potential impact on continuous quality improvement in high-risk

patient populations

3) Discuss MIPS-eligible improvement activities for anticoagulants, antibiotics

and opioids

4) Identify medications or specialty populations that could benefit from

proactive information sharing and discuss how these activities impact

“Promoting Interoperability” (previously Advancing Care Information) MIPS

requirements3

Quality Improvement and the Role of Medication

4

Adverse Drug Events (ADEs)

Most commonly implicated drug classes

5Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115–2125.

doi:10.1001/jama.2016.16201

Anticoagulants17.60%

Antibiotics 16.10%

Diabetes Agents13.30%

Opioid Analgesics6.80%

Antiplatelets6.60% Renin-Angiotensin

System Inhibitors3.50%

Antineoplastic Agents3.00%

Sedative or Hypnotic Agents

3.00%

High-Risk Medications and ADEs

Anticoagulants

Hemorrhage

GI bleed

Hemarthrosis

Poisoning

Diabetic Agents

Hypoglycemia

Syncope

Altered mental state

Diabetic ketoacidosis

Opioids

– Asphyxia

– Respiratory arrest,

respiratory failure

– Hypoxemia

– Opioid dependence

– Opioid abuse

– Withdrawal

– Somolence

– Poisoning

6

Lessons in Stewardship

7

Stewardship

Definition of stewardship:

the conducting, supervising, or managing of something; especially: the careful and responsible management of something entrusted to one’s care

https://www.merriam-webster.com/dictionary/stewardship accessed 7/24/28 8

Familiar Forms of Stewardship

Antibiotic Prescribing and Use in Hospitals and Long-Term Care. Centers for Disease Control and Prevention. April 11 2017. https://www.cdc.gov/antibiotic-use/healthcare/index.html

Antibiotic Prescribing and Use in Doctor’s Offices. Centers for Disease Control and Prevention. May 29, 2018. https://www.cdc.gov/antibiotic-use/community/about/fast-facts.html 9

Antibiotic Stewardship

Proven to improve individual patient outcomes, reduce overall burden of antibiotic resistance and save health care dollars

At least 30% for antibiotic courses prescribed in outpatient setting are unnecessary (not needed at all)

Inappropriate antibiotic use includes unnecessary use and inappropriate selection, dosing, duration; May approach 50% of all outpatient antibiotic use

30-50% of antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate

Antibiotics cause 1 of 5 emergency department visits for ADEs

Familiar Forms of Stewardship

Antibiotic Stewardship in Inpatient Settings

• Core Element 1 and 2: Leadership Commitment/Accountability

• Core Element 3: Drug Expertise

• Core Element 4: Action

• Core Element 5: Tracking

• Core Element 6: Reporting

• Core Element 7: Education

Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Centers for Disease Control and Prevention. Dec 12 2017.

https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements-small-critical.html10

Expanding Stewardship

National Quality Partners Playbook™: Opioid Stewardship. National Quality Forum. 2018. 11

As of 2014, almost

2 million Americans

had prescription-

related opioid use

disorder (OUD).

There are clear

connections between

use of prescription

opioids and illicit

opioids.

Health care

organizations must

reevaluate their pain

management efforts.

– Offer multimodal pain

management

strategies, both

nonpharmacological

and pharmacological.

Opioid Stewardship

Expanding Stewardship

12National Quality Partners Playbook™: Opioid Stewardship. National Quality Forum. 2018.

Opioid Stewardship

1

2

3

Promote leadership commitment and culture

Implement organizational policies

Advance clinical knowledge, expertise and practice

Enhance patient and family caregiver education and engagement

Track, monitor and report performance data

Establish accountability

Support community collaboration

4

5

6

7

Themes in Stewardship

Program Components1. Secure commitment from leadership and professional staff

Identify champion(s)

2. Identify improvement opportunities

Develop processes and policies to systematically improve care

Identify process and outcome measures

3. Track progress on process and outcome measures

4. Facilitate multidisciplinary learnings on a regular basis

Can be formal didactic education or routine short learnings, e.g., daily

briefings or staff meetings or a combination

5. Use prospective analysis to identify risks or potential failures in care

Conduct patient screens to identify at-risk populations

Road Map to a Medication Safety Program. Minnesota Hospital Association. 2012.

https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf13

Themes in Stewardship

14Road Map to a Medication Safety Program. Minnesota Hospital Association. 2012.

https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Roadmap.pdf

1. Follow standardized practices

2. Establish and communicate clear expectations, driven by leadership

3. Provide education for affected/ involved staff

4. Establish structured communication process

5. Identify unanticipated outcomes

6. Educate and empower patients and families

Program Goals and Outcomes

Role of Medication Management in Quality Care

15

8-Step Approach to Appropriate Medication Prescribing

Appropriate Prescribing of Medications: An Eight-Step Approach. Polluck, M et al. Am Fam Physician 2007;75:231-6, 239-40. 16

Select

appropriate

drug therapySpecify

therapeutic

objective

Initiate therapy

with appropriate

details; consider

nonpharmacologic

therapies

Evaluate and

clearly define

patient’s

problem

1

2

3

4

Consider drug

cost when

prescribingEvaluate

therapy

regularly

Use computers

and other tools

to reduce

prescribing

errors

Give

information,

instructions

and warnings

5

6

7

8

STEPS Approach to Medication

Safety

Tolerability

Effectiveness

Price

Simplicity

de Vries TPGM, et al. Guide to Good Prescribing: A practical manual. World Health Organization. 17

Quality Payment Program Components and Patient CareAntibiotic Stewardship

18

Quality Measures

Appropriate Treatment of

Methicillin-Sensitive

Staphylococcus Aureus

(MSSA) Bacteremia

Process

Percentage of patients with sepsis due to

MSSA bacteremia who received beta-lactam

antibiotic as definitive therapy

Submission Methods

Claims, Registry

Appropriate Testing for

Children with Pharyngitis

Process

Percentage of children 3 to 18 years of age

who were diagnosed with pharyngitis, ordered

an antibiotic and received group A

streptococcus (strep) test for the episode

Submission Methods

EHR, Registry

Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 19

Appropriate Testing for Children with Pharyngitis

Quality Reporting and Performance Measures. Amerigroup RealSolutions in healthcare. February 2018. p25-27.

https://providers.amerigroup.com/ProviderDocuments/GAGA_HEDISBenchmarksandCodingGuidelines.pdf20

Identify diagnosis and

procedure codes

Acute pharyngitis

Acute tonsillitis

Streptococcal pharyngitis

Streptococcal tonsillitis

Group A streptococcal tests

Compare patients who

received group A strep tests

with appropriate diagnosis

and appropriately dispensed

antibiotics within 3 days of

diagnosis

Antibiotics are appropriate in lab-

confirmed group A strep or other

bacteria-related ailments

Improvement Activities

Antibiotic Stewardship Program

• Measure appropriate use of antibiotics for

several conditions

• May include:

Development, implementation and monitoring

of patient care and patient safety protocols

Evaluating and recommending improvements

in management structure and workflow of ASP

processes

Implement and track evidence-based policy or

practice aimed at improving antibiotic

prescribing practices

Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-

measures/quality-measures?py=2018#measures21


Initiate CDC Training on Antibiotic Stewardship

Completion of greater than 50% of Centers for

Disease Control and Prevention (CDC) antibiotic

stewardship course. Note: This activity may be

selected once every 3 years; to avoid duplicative

information, some modules may change on year-by-

year basis, but over 4 years there would be a

reasonable expectation for modules to have

undergone substantive change for the improvement

activities performance category score.

Subcategory Name

Patient Safety and Practice Assessment

Activity Weighting

Medium

Completion of CDC Training on Antibiotic

Stewardship

Completion of all CDC modules of antibiotic

stewardship course. Note: This activity may be

selected once every 3 years; to avoid duplicative

information, some modules may change on year-by-

year basis, but over 4 years there would be a

reasonable expectation for modules to have

undergone substantive change for the improvement

activities performance category score.

Subcategory Name


Activity Weighting

High


Implementation of an Antibiotic Stewardship (AS) Program

The Roadmap to Success: Implementing Outpatient Antibiotic Stewardship. Quality Improvement Organizations. 23

Assess

current AS

activities;

Identify gaps

Identify one or more

high-priority

condition(s);

Diagnosis of

pharyngitis,

bronchitis treatment

in adults, upper

respiratory infection

in children

Review antibiotic

use clinical

guidelines and

create tools for

clinical decision

support; Track and

measure adherence

to guidelines and

best practices

Identify and

address

barriers that

lead to

deviation from

best practices

Identify

opportunities

for

improvement;

Set

expectations

with staff

Promoting Interoperability and Medication Use


• Use clinically relevant information from certified EHR technology to

identify patient-specific educational resources and provide electronic

access to them

• Score weight = up to 10%

• At least one written prescription is queried for drug formulary

and electronically transmitted using certified EHR technology

• Score weight = 0

• Secure message sent using electronic messaging function of

certified EHR technology to patient or in response to secure

message from patient


Patient-Specific

Education

e-Prescribing

Secure Messaging

Quality Payment Program Components and Patient CareAnticoagulation

25

Quality Measures

Atrial Fibrillation and Atrial Flutter: Chronic

Anticoagulation Therapy

Process

Percentage of patients age 18 years and older with

nonvalvular atrial fibrillation (AF) or atrial flutter who

were prescribed warfarin OR another FDA-approved

anticoagulant drug for the prevention of

thromboembolism during the measurement period

Submission Methods

Claims, Registry

Total Knee Replacement: Venous

Thromboembolic and Cardiovascular Risk

Evaluation

Process

Percentage of patients regardless of age

undergoing total knee replacement who are

evaluated for presence or absence of venous

thromboembolic and cardiovascular risk factors

within 30 days prior to procedure (e.g. history of

Deep Vein Thrombosis [DVT], Pulmonary Embolism

[PE], Myocardial Infarction [MI], Arrhythmia and

Stroke)

Submission Methods

Registry


Quality Measures

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis

(When Indicated in ALL Patients)

High Priority Measure:

ProcessPercentage of surgical patients aged 18 years and older undergoing procedures for which venous

thromboembolism (VTE) prophylaxis is indicated in all patients, who had order for Low Molecular Weight

Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or

mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end

time

Submission MethodsClaims, Registry



Invasive Procedure or Surgery Anticoagulation Medication Management

For anticoagulated patient undergoing planned invasive procedure for which interruption in anticoagulation is

anticipated, including patients taking vitamin K antagonists (warfarin), target-specific oral anticoagulants (e.g.,

apixaban, dabigatran, rivaroxaban) and heparins/low molecular weight heparins, documentation, including

through use of electronic tools, that plan for anticoagulation management in periprocedural period was

discussed with patient and with clinician responsible for managing the patient’s anticoagulation. Elements of

plan should include the following: discontinuation, resumption and, if applicable, bridging, laboratory monitoring

and management of concomitant antithrombotic medications (e.g., antiplatelets and nonsteroidal anti-

inflammatory drugs [NSAIDs]). Invasive or surgical procedure is defined as procedure in which skin or mucous

membranes and connective tissue are incised or instrument is introduced through natural body orifice.

Subcategory Name


Activity Weighting

Medium



Participation in Systematic Anticoagulation Program

Participation in systematic anticoagulation program (coagulation clinic, patient self-

reporting program or patient self-management program) for 60% of practice

patients in transition year and 75% of practice patients in Quality Payment Program

Year 2 and future years, who receive anticoagulation medications (warfarin or other

coagulation cascade inhibitors)

Subcategory NamePopulation Management

Activity WeightingHigh



Anticoagulant Management ImprovementsACI CEHRT Bonus Eligible

Individual MIPS-eligible clinicians and groups who prescribe oral Vitamin K antagonist therapy (warfarin) must attest that, for 60% of practice patients in transition year and 75% of practice patients in Quality Payment Program Year 2 and future years, their ambulatory care patients receiving warfarin are being managed by one or more of the following improvement activities:

• Patients are being managed by an anticoagulant management service that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;

• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;

• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;

• And/or for patients who demonstrate motivation, competency and adherence, patients are managed using either patient self-testing (PST) or patient-self management (PSM) program


Subcategory Name: Population Management

Activity Weighting: High

Anticoagulation Management

31

Anticoagulation

management

service• Comprehensive

patient education

• Systematic

prothrombin time

(PT-INR) testing,

tracking, follow-up

• Patient

communication of

results, dosing

decisions

Validated

electronic

decision support

and clinical

management

Remote monitoring

or telehealthPatient self-testing or

patient self-

management

programs





access to them









Patient-Specific

Education

e-Prescribing

Secure Messaging

Quality Payment Program Components and Patient CareOpioids

33

Quality Measures

Documentation of Signed Opioid

Treatment Agreement

ProcessAll patients 18 and older prescribed opiates for

longer than six weeks duration who signed

opioid treatment agreement at least once

during Opioid Therapy documented in medical

record

Submission MethodsRegistry

Evaluation or Interview for Risk

Opioid Misuse

ProcessAll patients 18 and older prescribed opiates for

longer than six weeks duration evaluated for

risk of opioid misuse using brief validated

instrument (e.g. Opioid Risk Tool, SOAPP-R)

or patient interview documented at least once

during Opioid Therapy in medical record



Quality Measures

Opioid Therapy Follow-up Evaluation

ProcessAll patients 18 and older prescribed opiates for longer than six weeks duration who

had a follow-up evaluation conducted at least every three months during Opioid

Therapy documented in the medical record




CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain

Completion of all modules of Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that review 2016 “Guideline for Prescribing Opioids for Chronic Pain” Note: This activity may be selected once every 4 years to avoid duplicative information given that some of the modules may change on a year-by-year basis, but over 4 years there would be reasonable expectation for modules to have undergone substantive change for improvement activities performance category score

Subcategory NamePatient Safety and Practice Assessment


Completion of training and receipt of approved

waiver for provision opioid medication-assisted

treatments

Completion of training and obtaining approved

waiver for provision of medication-assisted

treatment of opioid use disorders using

buprenorphine

Subcategory Name


Activity Weighting

Medium



Consultation of the Prescription Drug Monitoring Program

Clinicians would attest to reviewing patient’s history of controlled substance prescription using state

prescription drug monitoring program (PDMP) data prior to issuance of Controlled Substance

Schedule II (CSII) opioid prescription lasting longer than 3 days. For transition year, clinicians would

attest to 60% review of applicable patient’s history. For Quality Payment Program Year 2 and future

years, clinicians would attest to 75% review of applicable patient’s history performance

Subcategory NamePatient Safety and Practice Assessment



State PDMP Overview

The Wyoming Board of Pharmacy established a Prescription Drug Monitoring Program (PDMP) in July 2004.

– W.S. 35-7-1060

38

Review user report for reporting period.

Retain a copy for each MIPS-eligible

provider attesting to this improvement

activity for audit files.

40





access to them









Patient-Specific

Education

e-Prescribing

Secure Messaging

Medication Management

Implementation of medication management practice improvements

ACI CEHRT Bonus Eligible

Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the

following:

• Reconcile and coordinate medications and provide medication management across transitions of care

settings and eligible clinicians or groups;

• Integrate a pharmacist into the care team;

• And/or conduct periodic, structured medication reviews

Subcategory NamePopulation Management

Activity WeightingMedium


Questions?Stevi Sy, [email protected]

307-472-0507

www.mpqhf.org

43

Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana, Wyoming,

Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands, under contract with the

Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not

necessarily reflect CMS policy. 11SOW-MPQHF-WY-C3-18-15

Reducing Medication Harm through MIPS Implementation · Acute tonsillitis Streptococcal pharyngitis...

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