Quality, Advancing Care Information

(ACI), Clinical Practice Improvement

Activities (CPIA):What are they?

How are they calculated?How are they related to AQUIRE?

J. Welles Henderson, M.D.AUGS Quality CommitteeUniversity Hospitals Cleveland Medical Center

Disclosures

I have no relevant financial relationships to disclose

Quality Payment Program Submissions

QualityReplaces the Physician Quality Reporting System (PQRS)

Advancing Care

InformationReplaces the Medicare EHR Incentive Program (aka, Meaningful Use)

Improvement Activities

New performance category in Quality Payment Program

Merit-Based Incentive Payment System (MIPS) Composite Performance Score

Quality Payment Program

2017 MIPS Performance

Quality 60%

Advancing Care

Information 25%

Improvement Activities 15%

qpp.cms.gov

Quality Replaces the Physician Quality Reporting

System (PQRS) and Quality portion of the Value Modifier

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Quality

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Quality Bonus Points:

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Advancing Care Information (ACI) 25% of the total score MIPS eligible clinicians may earn a

maximum score of up to 155%, but any score above 100% will be capped at 100%

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Advancing Care Information (ACI) Base Score (50%):The base ACI measures are:1. Security Risk Analysis2. e-Prescribing3. Provide Patient Access4. Health Information Exchange

Submit a “yes” for the security risk analysis measure, and at least a 1 in the numerator for the numerator/denominator of the remaining measures.

If MIPS eligible clinicians who do not meet the 50% Base Score requirements, they will get a 0 in the overall Advancing Care Information performance category score!

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Advancing Care Information (ACI)

Performance Score 90% Determined by the

numerator/denominator of performance rate

Performance Rate 1-10 = 1% Performance Rate 11-20 = 2% Performance Rate 21-30 = 3% Performance Rate 31-40 = 4% Performance Rate 41-50 = 5% Etc., etc., etc.,

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Advancing Care Information (ACI)

Bonus Score 15% Reporting “yes” to 1 or more additional public

health and clinical data registries beyond the Immunization Registry Reporting measure will result in a 5% bonus.

Reporting “yes” to the completion of at least 1 of the specified Improvement Activities using CEHRT will result in a 10% bonus.

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Clinical Practice Improvement Activities (CPIAs) 90+ proposed activities involving:

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CPIA Scoring Overview

• CPIAs are worth points• Most are 10 points (medium weight)• Some are 20 points (high weight)

• Maximum credit is 40 points• Can be achieved by selecting any

combination of activities

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Totalpoints for

high-weight

activities

Totalpoints for medium-

weight activities

Total CPIAPoints

TotalPossibleCPIA

Points (40)

CPIAPerformance

CategoryScore

CPIA Scoring Process Summary

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Total CPIAPoints

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How can you submit QPP?

AQUIRE

AQUIRE ◦ A qualified clinical data registry (QCDR) ◦ Can be used to report clinical practice

improvement activities (CPIAs) as well as the “Quality” component of of QPP

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Benefit of utilizing a QCDR for CPIA reporting 13 CPIAs including:◦ Leveraging a QCDR: For use of standard questionnaires To promote use of patient reported outcome tools To standardize processes for screening

◦ Participation in a QCDR that: Promotes implementation of patient self-action plans Engages patients for adherence to treatment plan

◦ Use of QCDR for: Ongoing practice assessment and improvements Quality improvement such as comparative analysis

reports across patient populations

Q & A

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Thank you

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