All right. So I'm supposed to talk about clinical practice improvement activities and then how ACQUIRE can meet some of these requirements. So we've kind of touched a little bit on it already, but I think I'm going to try to give more granularity to the clinical practice improvement activities portion. But before I do that, so some of the points that Jill brought up, I want to give you a little bit more information. Again, you'll get this on your slide set. So there was a question about QRUR. So this is what you do. You go out to CMS.gov and then just type in QRUR, and it actually walks you through how to obtain access and then how to go to portal.cms.gov to get your data. And then you're going to probably want your practice administrator to pull it for all the people in the group, and then this way you'll have the data and can kind of compare. But it's CMS.gov, just type in QRUR. The other thing was about not having the portal, that patient portal. So I'm going to have to explain the scoring a little bit on the ACI. So basically, to get the full score, you get 100 points. But you have the opportunity to get 155 points. So you can actually get more than 100, but once you hit 100, you get 100% of the 25%. But there's a little bit of a nuance that you've got to know. They divide the topics into base, performance, and bonus measures. So what that means is that the four base measures that you have to have in place to even get a score more than zero is you've got to have HPI protection, you've got to have e-prescribing, you've got to have health information exchange, and you've got to provide patient access. So what that means is that if you look at your base score, and if you don't have those first four things, your total score is just automatically zero. I don't know if they've changed that. I got these slides in January. Are you aware, Jill? I think at go your own pace. You still have to do the full four, and then that gets you your test base. Right. But the scoring, I believe, is still the same. Okay, yeah. So if you're, I think, going full tilt, you're going to have to have this in place. But if you're in the lower tier of go on your own, then you can prevent getting a penalty and possibly a smaller bonus. But the point is that at some point, which probably is the year after next, right, when you go full tilt, you're going to have to have all four of those components. So if you have those four, you already start at 50 points. So now what you're trying to do is go to get 50 more points. And this is where it's kind of interesting. So each of these things that are called base performance count as 10 points. But the thing is that if you have health information exchange and provider patient access, which already is a requirement for a base, it counts double. So you actually get 20 points. So you're actually at 70. And then if you do any 5 through 9, you get 10 points for each. And then they allow you to get bonus points somewhere between 5 to 10 for any of these things. So if you have any more surveillance, more than just immunization, that's 5 or 10 points. So again, you'll end up with at least half the points by getting those four base measures. But then from that point on, you just want to look to see to get to the 100. And then you got your 100 points, which is 25% of your score. So to me, this was the easiest way to visualize this. This is from MGMA. And this just kind of made it just fall into place. Oh, and if you don't have an EMR because you're a hospital-based provider, then you automatically, you know, ACI doesn't count for anything in your score. It's reweighted. And then if you're in a rural area, there's hardship exceptions. So there's no Internet connectivity. And I actually know places up in Upper Michigan that it doesn't exist. Extreme or uncontrollable circumstances or lack of control over availability. So there are exceptions. Just an alternative payment model. What I wanted to show that there is a test called nominal risk standards that somebody will have to do to make sure that you have enough risk involved. And this is what I wanted to just make sure everybody has. These are who qualify this list under 2017 as advanced APM. So you've got to go to your organization and say, are we one of these? And then you'll know whether you're going to be a MIPS APM or an advanced APM. Okay. So that was just the catch-up stuff that I thought would be helpful. So the ACO track two and three, those are two-sided risk ACOs. There are very few of those in the country. It would be unusual for a sort of non-pioneer ACO to be a track two or three, right? So when we're looking at those folks, these are like the MEOs, the billings clinics, folks that were in the pioneer group. The next-gen ACO group is a little larger. You're possibly in that. But more likely, if your academic community is in an ACO, you're in an ACO track one, which is not an advanced APM. It's a MIPS APM, right? So that's still good. I mean, it'll help you do your MIPS work, but it won't get you the 5% advanced APM bonus money. So you just need to be aware. There are a little over 200 oncology care model applicants. If they could pull your whole institution, that would be great. That list is on CMS's website. We can get it to you. That is about a 50-50 split, I'd say, private practice versus academics. There are some big academics in there. Comprehensive ESRD care models, that is predominantly being driven by the dialysis companies. So DaVita, Fresenius, those guys. So we'll probably don't have anybody near that. CPC Plus is primary care. The P is primary care. It's a care coordination. It's in eight states, I believe. Many of those states, it's a partnership with private insurance as well. So, again, maybe your organization would be covered under that. But, boy, you want to ask a lot of questions and find that out. So CMS today has a new proposal out for what they're calling ACO Track 1 Plus. It's that MSSP ACO Track 1 Plus for 2018. They're trying to move all of the ACO Track 1s over to being advanced APMs for 2018. So this is something we all need to be very cognizant of because that could change the game for our academic colleagues if that moves over. Cardiac payment model got delayed. That model may or may not be ready for 2018 now. We'll see. Then the joint replacement, CCJR, if any of you are with hospitals that are having to do CCJR, which is a joint replacement APM, that is also being retooled. To possibly be available for our orthopedic surgeon colleagues to be an advanced APM in 2018. So CMS does realize that they do not have enough advanced alternative payment models for all physicians or even close to it. They're very open to that. They understand that. They're aware of it. That's why AUGS is getting in the game and what John and Jerry will talk to you about later. But I don't want folks to think that you're going to get covered in an advanced APM because you're in academics. Right? That is not, not, not the case. So we need to be very good on our game in regards to asking a lot of questions internally in our institutions to make sure if we think we're going this route, or even if we think we're going a MIPS APM route, that we are very clear and that you are on the list. These APMs will be required to submit a quarterly list to CMS of all the physicians that are covered under their APM. So if you're a community-based practice person and an ACO came to you and wanted you to be involved with them and you're not quite sure you're involved, but maybe you're involved and you've got to check at some point from them, you've got to check and make sure that they're going to put you on their list and submit you in the quarterly updates. Otherwise, you will not be in it. So that's how CMS is going to check. So it's really important if you want to try this route, which many of you may want to, that you really do a lot of good investigation to make sure you're covered. All right. So I thought it was good to stop because you probably know more than 99% of the people. I can guarantee you that you probably know more than your administrators. And if you ask them this question, you're going to have to go back and say, I'm not sure. So I did that in January. They came back and said, okay, we're an ACO track one. And then the CEO of the system said, okay, we're going for track one plus. All right. So I don't have any disclosures again. And what I'm going to do, and actually, once I show you, this is probably going to be the easiest part that you guys are going to deal with with QPP. So I'm going to discuss what these clinical practice or performance improvement activities, CPIA or IA, are. I'm going to show you, and this is where we were kind of talking about, this is a moving target. And so they're going to have these things that you do. You're going to have a list of 90. And Joe, I know you know the term, but I'm just going to say they sunset things when there's no way to differentiate between people. What we do now is not going to be what we do five years from now. And the bar is going to rise. And it's not just doing this. What they're really forcing you to do is, in your practice, make things better. And then I'm going to just show you where I think ACQUIRE will help meet the requirements for improvement activities. So put it in perspective. This is fixed. This is going to account for 15% of your score. So quality and cost are going to move toward being 30% each. ACI is always going to be 25%. And improvement activities are always going to be 15%. And what they've done, and let me just see here. We're going to make sure that you get this PDF. But what I did was I went to the Federal Register and pulled out all 800 pages. I can't even remember how many pages there were. But I went through. So you can kind of see it's page 77,817. And I pulled out just the table that has the 94 metrics. So this is what you're going to want to sit down and look at when you start planning on how to get the 40 points. And when you look at that list, it's going to divide it into nine categories. So what do you do to expand your practice access? What do you do in terms of population management? What do you do for care coordination? How do you engage your beneficiary? What kind of safety things do you do and how do you assess it? Do you participate in an APM? What do you do to achieve health equity? How do you integrate behavioral and mental health into your practice? And then how well are you in terms of preparedness for emergency situations or response to them? And when you look at it, again, it's more than 90. But you can kind of see that each one, it's not equal. So the most that are there are beneficiary engagement and safety and practice assessment. So, and again, that's the way that the table will look. So the subcategory is one of the nine. The activity is what they say you need to meet. The weighting is important because I mentioned you have to get 40 points. So they weight activities as medium, which is 10 points, or high, which is 20 points. And so to get that 15% of the final score, to get 40 points, you do medium or high. Now, there's some exceptions, and for clinicians that are in small, rural, and underserved practices or don't actually do face-to-face patient care, they double the points. So you get 20 points for medium and 40 points for high. So what they'll do for your score is you'll get the total number of points you get. They divided it by 40, multiply it by 100. And so if you get 40 points, you get 100% on that thing. And anything below that, it's incremental. If you look at it visually, from the 90, you either got to do four medium projects, two high projects, or one high and two medium. Now, don't ever say I never gave you anything for Christmas, Hanukkah, or Kwanzaa. We already have automatic points. So if you are in MOC Part 4, which is anybody not in MOC Part 4 here? Okay, so you got 10 points. If you're in the OGS Registry, so you're all going to sign up when it goes live, you get 10 points. Okay, so there's 20. If you sign up with the State Prescription Monitoring Program, so in Michigan it's called MAPS. In Ohio, now I forgot what it's called because I moved away. But anyway, you sign up. That means you get 10 points. And then use, which Jill, correct me if I'm wrong, but my understanding, if you use it once, you've used it. I.e., you don't have to use it on every patient to get the 10 points. You just got to use it. And then the last one, and this is where I think, you know, I'll jump. This is where Acquire is going to help you. Now that we have the capability to use both PQRS and non-PQRS measures, if you go and data mine something specific that you're doing, take it and use it to make something better in your practice, that's 10 points. So there's your 40. So we're done talking about CPS. And the thing that Bob didn't tell you, of the 90, there are 12 that are connected to being in a Qualified Clinical Data Registry. So let's say you don't know what's going on with your state prescription service, but you signed up for Acquire, and you do some level of quality improvement with it. So mine your data and go fix something at your institution or participate in a quality meeting that AUTS has about quality using Acquire data. Yeah, there's many things related to that, to being in a Qualified Clinical Data Registry. There's also some general things about care coordination that you may want to try to document, et cetera. But really, if you're in a registry, I mean, it's basically you're going to get your 60 plus your 25%. I mean, it's really pretty much, you can see how those societies who have offered their members registries are now really, those specialties are kind of in the lead here, and that's something we have to think about. Now, so we didn't really touch on this, but I will look later. So this metric you attest, okay? It's not like the quality where there's numbers and stuff. You say, yes, I did it, or no, I didn't. One of the quirks that I just found out is that you actually may be able to count the Acquire as both your MOC-4 and being part of a registry. So in other words, that activity itself counts for a total of 20 points. And I'm assuming that we're going to continue to apply for MOC-4 credit because it expires December 31st of 2017. But what you do is you have to fill an application out with AABOG saying we want this to count as an MOC Part 4 activity, and then they usually give you three years. I just did this for a maternal mortality. Don't we as AUG send a list? We send a list of Acquire participants, I think, to AABOG, right? There's something. Right. Yeah, we're doing something there, Bob, that we can help folks. Yeah, so what happens is then it pops up on my board space, and I click it, and I say I did it, and then it gives me the credit. And you get three CME credits, too, by the way. So Acquire may actually count for MOC as well as being in a registry. So that made your life easier. They're using the same activity for double. Right. There's nothing that says you can't. There's nothing that says you can't. Right, yeah. I mean, you're just attesting, I did this, I did this, I did this. If you do one thing and it covers three things, well, then you're lucky. Happy days. Right? So that's why you want to really look at this list of 90. That's why when you look at the list of 12 activities for the QCDRs, you're going to be like, wow, a lot of these things are the same thing. Right? They sound kind of the same. So there's a lot of reuse in this space. Now, that's going to change, right? This is the first list that's ever been done. There's been discussion about what the update process will be for this list, just like what the update process is to add new measures. But at the moment, the list is fairly simple in the fact that you do some major things, and it's going to get you multiple clinical improvement activities that will score for you. So don't bring it up. Just a test. Otherwise, if they find out, then maybe they'll get rid of that. All right. So anyway, so I'm assuming that we're going to continue to apply to the MOC-4, and usually it's three years they give you. With that being said, and, you know, it should be easy to get to 40 points, I'm just going to kind of give you some tips, because what I anticipate is that it's not going to be this easy in the future. So one of the tricks that I'm doing right now, and, again, I told you I'm the AAMC faculty to teach safety and quality to faculty, and faculty don't know it, is that what I've done is taken a strategy as DIO, where since the residents and fellows are required to do quality improvement as part of the residency, I actually have told them to go do their activities with people in their practice, with the docs or attendees in the practice, so that not only does it help them get their quality improvement project out of the way, but it kind of teaches the faculty and the resident how to do it, because this is what you're going to get paid on when you're out in the real world. So what I do is I give this list, the 90, to all the program directors to give to all the residents and say, these are your quality improvement projects. So the ones that I thought are going to be kind of on the horizon, and I've actually started implementing this, I'm going to show you three examples that I would say, and then I'm going to show you the easiest approach, because you're going to have to start doing activities in your office at some point. And what I'm going to show you is the IHI model for improvement. So the things that I'm teaching the residents right now is the first CPIA is using the AHRQ survey of patient safety, and then submitting it to that big database, and then compare yourself. So you can actually go to AHRQ, you can go to what's called the Medical Office Survey on Patient Safety Culture, you can download all the material, all the questionnaires, blah, blah, blah, and then just utilize it, upload your data, and now you've got something to use. Those of you that are in education, the reason why this would help you is that part of the requirements for residents is that they get safety data that's reported, and then get it back, and then utilize it to make improvements. So that's one of the CLAIR requirements for residencies. A second one is collection of patient experience and satisfaction data. And so this is, we all know about HCAHPS from the hospital. Well, there's a CG, or CG-CAHPS, which is called the Group Survey, or Group Clinician HPS, whatever it stands for. It's the same kind of thing that you can download and use it in your office. And it comes in Spanish and all the other, several other distant languages. So now you've got something, and this one counts for 20 points. Then the third one is kind of what I talked to you about with registering for your prescription drug monitoring program. So if you register, you get 10 points. But if you register and utilize it where you look at 60% your first year, or 75% of your second year on, of scripts for opioids greater than three days, if you meet that metric, then you get 20 points. So those are the three that I'm using as examples when I'm teaching the residents and faculty about how to start doing quality improvement, true quality improvement in their practice. So now I'm sure all of you guys have heard there's Six Sigma, there's Lean, there's Baldrige, there's Toyota. There's so many different improvement methodology out there. But you guys need to realize we're seeing patients, we're doing work. We don't have time to do that stuff. So you pick what's the simplest. I think even the PDSA or PDCA is a little bit too complicated. You want something simple, and that's why I recommend the IHI model. And basically what it is, it's that you use what's called the A measure changes. Then once you figure out what you're going to do, you put it through the cycle, and then you document your improvement. And the reason why you want to do this is that just like CME, just like any other things, they're going to come and audit. They haven't figured out how they're going to do it yet, but when you get a $10 to $1 you spend return on audits, it's worth their while. So you don't attest to anything unless you can prove it. Quality improvement, basically you just identify a problem. Again, in this situation, it's one of those 90 on the list and any future one. You have a specific objective process to get through it, and then you basically show that you solved the problem. And then these things you've got to realize that when you start looking at how things work in your office, the stuff that happens is because your system that you have in place lets it happen. People don't go to work and say, I'm going to make this mistake. It's because the system's set up that they can make that mistake. So you want to go to IHI, and you want to download this charter form. And this charter form basically helps you organize how you're going to fix the process. So let's just say checking the prescription opioid database. So what you're going to want to do, and then on the back of that, there's actually a check sheet that you can use to see and make sure you're on the right track. And what you're going to want to do is start purposely thinking, how are we going to fix this? So you want to make sure you have the right people on the team. And so the team, basically you want your frontline people, you want your manager, because they're in the day-to-day leadership. You may want somebody with some technical expertise, like your IT person. You know, how well can we integrate it so that I click on this button on my EMR, and it takes me straight there. And then somebody who can say, yeah, we're going to fix this. But forming your teams are important. And then one of the tricks is when you get the team, if you make all the systems set up so you're the one that's always doing everything, it'll never get done, because you're just too busy. You want to bake it into the process so it's automatic. And that's where the frontline people help you. And you basically just start asking yourself some questions. What's the problem? Again, off the list. How will you know when you correct the problem? So you're going to have to have some measurement. And what is the best way to correct the problem? And that's what your team is going to sit down and fill that form out. So the other thing is that these measures have to be done for 90 days. So that's the minimum that it needs to run. So when you say by when, it better be at least 90 days out from when you implemented it. You know, there's just some things on how to pick a proper aim statement, but you want to know how good you want to get it by when and for whom. So, for example, beneficiary engagement may be your quality improvement goal. So, you know, I don't know. I'm sure most of you have seen this, the SMART goal settings. Specific, measurable, attainable, relevant, and time bound. It's always good to pick one of the IOM aims. So pick something that makes it safe, something that makes it effective, that's patient-centered, that provides care timely, that's efficient, or provides care equitably. You know, you want to first make an aim. And I think talking with what you had brought up about looking, we're doing it backwards. So what Medicare is doing is making us look at the measurements. Well, we should be really focusing on what's the aim. What are we trying to do for the patients? So you're right. We're not looking at it exactly the right way, and we're kind of going from bottom up. So this is the way the template looks. So you just, you know, write some sentences in the boxes. Then the measures, and this is what, you know, PQRS is doing. So once you implement your process, you want to have something measurable to show that you're getting your goal, or, i.e., proving that you've met the 60% check on scripts. And, you know, it's not much different from research except for one big thing. In research, you don't know what's going to happen. In quality improvement, you already determine what's going to happen. You're just doing something to work there. But it's really the only difference in terms of quality improvement versus research. Well, there's other ones, but that's the main point. And you want to make sure that you, you know, have outcome measures. That's what you ultimately want to change. But when you implement some process change in your office, you're going to want to take some process measures. So if the MA is going to be the one that somehow is supposed to be checking that database, you're going to want to check, and usually they don't know that you're checking, to see what their compliance rate is in terms of checking it. Okay, and then balancing measures. And this is one of the things that you learn once you start doing QI projects. Sometimes you goof something else up when you're trying to change something. So they're called unintended consequences. I call it WBATCH, what bad things could happen. So you always want to be thinking about, okay, we're going to change this. What bad could happen? So, you know, just you want to have some good measures. Again, your measure may be very specific, like with the checking the pain or the medication database, or it's something that you make up. When I sit down with faculty and residents and say, okay, what's your aim going to be? I always say, I want to improve it by 100%. Don't be so bold. Just pick a number that's achievable, especially if you're trying to get paid. So say I'll increase it by 20%, by 30%. The whole point is just show it improves, but don't go for the gusto, because if you don't make it, then you may not, you know, meet the metric that will get you where you want to be. So there's a box for measures. And then when you put it into action, you know, you want to make sure that the team has the ability to make the changes. You know, what changes can you make? Now, have any of you guys tried to improve something in the office that didn't work? So, and this is the hardest thing, and this is why it is a good idea for residents to do it under training, because it's hard. So, because what you want to change, once it goes through the system, doesn't necessarily mean that outcome is going to happen, because there's things that occur within the system. There's the variations that we see. There's what people know, and there's the psychology of change that starts having an effect on what you're trying to change. And so it's actually called the lens of profound knowledge. And it's by Deming, who's like the god of quality improvement. And so basically, you know, when it goes through the lens, you guys got to remember that any idea you have, the first thing the system wants to do is negate it. It's not a good idea. The other thing is the variation. So we think, well, everybody should use this suture during episiotomy. Well, in my experience, you know, I use this chromic, and I had better outcomes. All my patients, I don't ever have a problem. So you're going to run into that, especially if you're trying to do it in an apartment, right? Knowledge is not that everyone may think it's a good idea. So here, and I see this all the time in, like, hospitals, something happens on the floor, the nurses say, okay, we need to do this. So everything's changed. They change it, but then something else happens that makes it worse. Because, you know, they look at – and it's not just nurses, I mean everybody. They look at something, this is how we fix it, but they don't think it through. And then human behavior, you know, we all know that it's very resistant to change. And so, you know, you change people with motivation. And in this case, what are they using? It's money, right? Penalties or bonuses. So that's a big motivator. The other motivator is – and I don't know if this is going to ever happen, but it may, but if our name gets attached to those measures and it's out on the – available to the public, there's nothing that drives physicians more in competition. So, you know, I think the stage has been set that we're going to be forced to do it. So – and then the last thing is that, you know, if you're really going to take this seriously, when you improve these things, your goal is sustainability. You're not just doing it for 90 days and then forget about it until the next billing cycle. You want the change to improve and you want it to become baked in to what you do. You want – there's nothing that says you can't use the same CPIAs that you used last year next year. Okay? And that's what's called the ramp of complexity. And then third, you know, you want to make sure that you document this stuff so that if you get audited, you can prove that you've done the activity. Now, whether you met your metric or not, I doubt that they would penalize you. But if you don't have anything to show that you even did anything, then you're going to get penalized. And this is just – so, again, going back to this quality improvement, you take your PDSA cycle. When you improve it, it now becomes what's called the SDCA or the standard cycle. So that's how you're going to do it from now on, a better way. But then the next year, you take the same activities, improve something else in it, and report it that year. So the thing is, is that in terms of trying to improve care for the patients, this is the way it works. You can't do everything, so pick the things that you think are going to make the most effect and keep making it better. So from the standpoint of CHOIR, and I think this will help, what I did was put a table of the difference on what we were, qualified registry, to what we are now, a qualified clinical data registry. And so you can kind of see – I think the most important is the top there. You do have to report 50 percent of your Medicare Part B patients. That's required. And then on the QCDR, you have to report 50 percent of all your patients. And just real quick on how you report. So again, we're not doing costs this year, but cost is not going to be reported by us. Cost is going to be what the government pulls from what we submit. So we're really only responsible for three of the four metrics. And again, one, you can use a different method for each metric. And depending on what we're looking at, you can actually self-attest for ACI or the computer part and the CPIAs. But again, if you're going to self-attest, keep your documentation. So we're really set up right now for quality, but I would think that there's going to be discussion that, well, we make it easier so people can attest for the other two on ACQUIRE. I don't know. Has that been even discussed? No, there is. Yeah. I mean, when we had to submit ACQUIRE's paperwork for the Qualified Clinical Data Registry and the Qualified Registry, we, in the paperwork, said that we felt we would be able to offer CPIA reporting as well for people who were in ACQUIRE and that we would also potentially be able to help with ACI as well. So, you know, that is our hope, particularly with a 90-day reporting period for both. I think it's going to be a little harder, to be quite honest, with the ACI information, because when we did that, we thought we would be more integrated with EMRs than is happening with this first generation. But CPIA, definitely I think that we can help people and put their information in on that as well. So, you know, we're going to evolve here, but I think that, you know, we're hoping to get information out to folks about particularly the CPIA activities over the course of the year. I wasn't going to talk about the web interface, but CMS, if you're a group of more than 25, you have... Yeah, GPRO. GPRO, yeah, then you have that option too. And is it supposed to make it easier? Well, so that's the big academics, and actually I think it's 100-plus, not 25-plus, and we're not sure CMS is going to keep GPRO long-term, but it does lock you down to a particular set of measures. So that is one thing you have to really understand your benchmarks and understand if your academic institution is going that route, those are the measures they will select from, and you have to hope they're doing a good job, right? Well, you want to find out. You don't want to hope, right? You want to go in there and ask for that benchmark. It's your number. Right? No hoping here. Because one of the things we haven't said yet today is if you report as a group, the group's score then becomes attributed to every MPI number in the group, right? So if your group screws up, everybody gets that same score. If the group does well, everybody gets that same score. That's why we keep saying today go ask your group, whether it's the practice administrator, whether it's the chief financial officer for the faculty practice plan, the quality officer for the faculty practice plan, or for your academic physician organization. You know, find that person and sit down with them. Now, you might end up on a committee for your group, but wouldn't that be great, right? Because then you would be in the leadership to pick. That happened to one of my physicians who I sent on a mission. He came back and he said, you know, I'm now on the committee. I said, yes. He was like, really? But I think that's, you know, that'll happen, and that's good. But you have to go ask these individuals, and you have to find them. Thank you.

ACQUIRE

QRUR

ACI scoring

HPI protection

e-prescribing

MIPS score

IHI model for improvement