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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
Improvement Activities
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
Patient Safety and Practice Assessment
Activity Weighting
High
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 22
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 24
• 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
• Score weight = up to 10%
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 26
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 27
Improvement Activities
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
Patient Safety and Practice Assessment
Activity Weighting
Medium
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 28
Improvement Activities
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 29
Improvement Activities
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 30
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
Promoting Interoperability and Medication Use
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 32
• 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
• Score weight = up to 10%
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
Submission MethodsRegistry
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 34
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
Submission MethodsRegistry
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 35
Improvement Activities
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
Activity WeightingHigh
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
Patient Safety and Practice Assessment
Activity Weighting
Medium
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 36
Improvement Activities
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
Activity WeightingHigh
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 37
State PDMP Overview
The Wyoming Board of Pharmacy established a Prescription Drug Monitoring Program (PDMP) in July 2004.
– W.S. 35-7-1060
38
39
Review user report for reporting period.
Retain a copy for each MIPS-eligible
provider attesting to this improvement
activity for audit files.
40
Promoting Interoperability and Medication Use
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 41
• 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
• Score weight = up to 10%
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
Explore Measures. Quality Payment Program. https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2018#measures 42
Questions?Stevi Sy, PharmDssy@mpqhf.org
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
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