Improving Quality Outcomes in a Risk-Based World: A Davies Story Session #100, March 7, 2018

Transcription

1 Improving Quality Outcomes in a Risk-Based World: A Davies Story Session #100, March 7, 2018 David Cloyed, MS, RN-BC, Applications Manager, Nebraska Medicine Tammy Winterboer, PharmD, BCPS, Director, Clinical Effectiveness & Informatics, Nebraska Medicine Rebecca Rohrbach, DNP, VP of Population Health, NOMS Healthcare Melissa Thomas, IT Project Director, NOMS Healthcare 1

2 Conflict of Interest Rebecca Rohrbach, DNP Melissa Thomas David Cloyed, MS, RN-BC Tammy Winterboer, PharmD, BCPS All have no real or apparent conflicts of interest to report. 2

3 Agenda Case Presentations Nebraska Medicine: NOMS Healthcare: Moving the Mark on Ambulatory Clinical Quality Measures Improving Quality Scores Q & A 3

4 Learning Objectives Identify key stakeholders needed to implement changes to workflows required for successful adherence to quality metrics Describe the importance of creating a standardized process to ensure compliance with changing quality measures Design clinical decision support tools within the electronic health record (EHR) based on multidisciplinary collaborative input and feedback 4

5 Moving the Mark on Ambulatory Clinical Quality Measures David Cloyed, MS, RN-BC Applications Manager Tammy Winterboer, PharmD, BCPS Director, Clinical Effectiveness and Informatics 5

6 Nebraska Medicine $1.2 billion academic health system 8,000 employees More than 1,000 affiliated physicians Primary clinical partner of University of Nebraska Medical Center Two hospitals, anchored by tertiary/quaternary academic medical center, Nebraska Medical Center 39 specialty and primary care clinics, offering 50 specialties and subspecialties Partial ownership of two rural hospitals and one specialty hospital 809 licensed beds in Omaha and Bellevue 31,004 discharges 426,923 outpatient visits (primary and specialty) 91,800 ER visits 6

7 Putting it all together: National Challenge: Quality and Payment & on Fee Schedule +0.5% each year No change +0.25% or 0.75% 2017 Max Adjustment MIPS Performance (+/-) Reimbursement QP in Advanced APM +5% bonus (excluded from MIPS) 7

8 Measuring Quality Under MIPS/MSSP Pneumonia Vaccination Influenza Vaccination Colon Cancer Screening Breast Cancer Screening Depression Screening & Follow-Up BMI Screening & Follow-Up Fall Screening Tobacco Use Screening & Cessation Intervention Diabetes HA1c <9 and Yearly Eye Exam Controlling High Blood Pressure Antiplatelet for Ischemic Vascular Disease 9

9 Significant Gap in Quality CY 2015 (%) CY 2016, Q1 (%) Depression screen and follow-up BMI counseling yo BMI counseling >65 yo CRC screen Pneumonia vaccination Breast cancer screening Falls screen Uncontrolled HA1c ASA in Vasc Dz Tobacco use counseling Med rec BP control Local Problem 10

10 Nebraska Medicine Quality Governance Nebraska Medicine Advisory Board Board Quality Committee Patient Safety & Quality Steering Medical Staff Physician Quality Committee Nursing Quality Core Event Review Team Patient Outcomes Committee Clinical Effectiveness Peri-Op Quality Committee Ambulatory Care Committee Patient Experience Bellevue Medical Quality Committee Education & Practice Support 11

11 QUALTITATIVE QUANTITATIVE LITERATURE REVIEW Methodology & Findings Focus Groups Gap between expectations and training Lack of efficacy and control EHR documentation burden Questionnaires Questionnaires 59% lacked 59% lacked confidence confidence about about quality measures measures 71% reported inadequate quality training 71% reported inadequate quality training 70% unable to lead teams in improvement 70% unable to lead teams in improvement Demand-skill imbalance Demand-skill imbalance Locus of control Locus of control Effort-reward imbalance Effort-reward imbalance Mastery Autonomy Purpose Mastery Autonomy Purpose Design and Implementation 12

12 Voice of the Customer Measure clarity Performance transparency Gap identification Care options Best practice dissemination ~100 clicks! Documentation burden Team-based care Collaboration with managers Design and Implementation 13

13 Twelve-month ascent 1. Defined P4Q/P4V priorities 3. One location in EMR to identify all quality gaps 2. Transparency to realtime performance 5. Aligning care delivered by staff with providers 4. Efficient method to address all quality gaps and document care EXCEPTIONAL MIPS PERFORMANCE 6. Responsibility for quality shared as a team Design and Implementation 15

14 Clinical Process When patient arrives in clinic, rooming staff gather and document standard visit specific information If necessary, rooming staff gather pertinent information to be collected annually System Tools Visit Navigator Organization Rule-based Banners Rooming staff complete any unreconciled regulatory requirements within their scope Physicians evaluate patient, review visit specific and annual information and then complete required documentation Physicians review personal individual compliance metrics with quality requirements Department and service line leaders review metrics for their care areas Reminders for Rooming Staff Reminders for Providers Provider Dashboards Leader Roll-up Dashboards How Health IT was Used 16

15 Process and Tools System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff 2017 Epic Systems Corporation. Confidential. Reminders for Providers Provider Dashboards Leader Roll-up Dashboards How Health IT was Used Epic Systems Corporation. Confidential.

16 Process and Tools System Tools Visit Navigator Organization 2017 Epic Systems Corporation. Confidential. Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards 2017 Epic Systems Corporation. Confidential. Leader Roll-up Dashboards 2017 Epic Systems Corporation. Confidential. How Health IT was Used 18

17 Process and Tools 2017 Epic Systems Corporation. Confidential. Designed to remind rooming staff of measures that are within scope System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards Leader Roll-up Dashboards How Health IT was Used Epic Systems Corporation. Confidential.

18 viders s) Process and Tools Automates chart checking and reduces clicks normally spent searching for information throughout the chart System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers 2017 Epic Systems Corporation. Confidential. easure section does not change colors if there are llow-up. You will need to run the quality measure pertain to the patient. Provider Dashboards Leader Roll-up Dashboards k Quality Measures will provide real-time feedback. How Health IT was Used Epic Systems Corporation. Confidential.

19 Process and Tools: Adding Clinical Value to QMAs Integration of best practice recommendation System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards 2017 Epic Systems Corporation. Confidential. Links available to add documentation and reference material Leader Roll-up Dashboards How Health IT was Used 21

20 Process and Tools: Getting the Green Check Mark System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards 2017 Epic Systems Corporation. Confidential. Leader Roll-up Dashboards How Health IT was Used 22

21 Process and Tools System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards 2017 Epic Systems Corporation. Confidential. Leader Roll-up Dashboards How Health IT was Used 23

22 Process and Tools System Tools Visit Navigator Organization Rule-based Banners Reminders for Rooming Staff Reminders for Providers Provider Dashboards 2017 Epic Systems Corporation. Confidential. Leader Roll-up Dashboards How Health IT was Used 24

23 Minutes Rooming Rooming Staff QMAs Staff QMAs Displayed Provider QMAs Displayed Q12016 Q22016 Q32016 Q42017 Q12017 Q22017 Q Q12016 Q22016 Q32016 Q42017 Q12017 Q22017 Q3 Influenza Total Rooming Screening QMAs QMA Displayed for MAs/RNs Total Provider QMAs 10 Avg Rooming Time Value Derived 25

24 Impact of Quality Workflow CY 2015 (%) CY 2016, Q1 (%) CY 2017, Q2 (%) % Change CRC Screen Pneumonia Vaccination Breast Cancer Screening Depr Screen and F/U Falls Screen BP Control BMI counseling yo BMI counseling >65 yo Uncontrolled HA1c ASA in Vasc Dz Tobacco use counseling Med rec Value Derived 26

25 Value Derived Quality 9000 additional mammograms 18 women saved from dying of breast cancer 11,400 additional pneumonia vaccinations 11 cases of pneumonia prevented 5 cases of invasive pneumococcal disease prevented 31,200 additional colon cancer screenings documented 39 lives at less risk from colon cancer deaths Financial MACRA $27.2 Million Breast Cancer $7.7 Million Personal T1 MSSP $17.5 Million Colon Cancer $26.5 Million Employee Plans $17.3 Million Pneumonia $1.1 Million Number needed to screen: development of a statistic for disease screening. BMJ Aug 1;317(7154): Vaccine against Pneumococcal Pneumonia in Adults. N Engl J Med 2015; 373: National Cancer Institute. Cancer Prevalence and Cost Care Projections. Annualized Mean Net Costs of Care Agency for Healthcare Research and Quality. Healthcare cost and utilization project.

26 Improving Quality Scores Missi Thomas Director, Information Technology Projects Rebecca Rohrbach, DNP Vice President Population Health 29

27 NOMS Healthcare 2001 Northern Ohio Medical Specialists was formed with 32 Providers NOMS physicians formed an information technology (IT) committee to explore conversion from paper charts to an electronic health record (EHR ) platform. Later that same year - NOMS newly formed IT department began implementing an EHR system wide NCQA Level 3 PCMH Recognition Chronic Care Management Team, NOMS 360, was instituted of 35 Advanced ACO s across the nation CPC+ designation Present 216 Providers and 726 Team Members 30

28 Local Challenge We found we needed to have the ability to effectively track our Quality Measure Data via Score Cards and Registries to improve on Quality Scores. In 2013, prior to our EHR upgrade we manually reported on eight Quality Measures. By the end of 2016, after the EHR upgrade, we effectively electronically reported on 23 Quality Measures. Local Challenge 31

29 2013 Score Card Local Challenge 32

30 Score Card Local Challenge 33

31 Steps to Improved Quality Scores Interventions Design Implementation How HIT was utilized Value Derived 34

32 Interventions Upgraded our current EHR to a new EHR system Formed a Standardization Implementation Committee Created Standardized Templates Creation of Clinical Decision Support System (CDSS) Alerts Instituted Pre-Visit Planning utilizing our standardized templates and alerts to guide our staff Messenger Campaigns Flu/Pneumonia Vaccine Reminder, Medicare Wellness Kiosk Questionnaires created Medicare Wellness 35

33 November 2014 NOMS Healthcare upgraded their EHR system to eclinicalworks Interventions 36

34 August 2014 Standardization Implementation Committee (SIC) Formed Team of providers representing each specialty IT Team Administration Team Interventions 37

35 SIC Goal To standardize and create NOMS best practices across our entire organization. Created a template and report request form This allows for offices to submit their change requests or to request a new standardized template or report be created Interventions 38

36 Report Request Forms Interventions 39

37 Template Request Form Interventions 40

38 Template Request Form - page 2 Interventions 41

39 Instituted Pre-Visit Planning Created templates Alerts Diagnosis Specific Alerts, Clinical Decision Support System (CDSS) Alerts Interventions 42

40 Medicare Wellness Template Interventions 43

41 Diagnosis Specific Alert Value Derived 44

42 CDSS Alerts Value Derived 45

43 46

44 Medicare Wellness Campaign Overview Remind Medicare patients of their annual Wellness Visits Benefits Increased Revenue Engage patients for improved wellness Details Trigger: Medicare patients for whom it has been over a year (reference Service Date on claim) since they have been billed a G0438 or G0439 Message Example Portal , Text notification, Voice notification 47

45 48

46 Kiosk Questionnaire - Medicare Wellness Value Derived 49

47 Patient Care Quality Committee (PCQC) Established in 2013 to aid in practice transformation. Meets Weekly Create and disseminate quality score cards Establish thresholds for quality score cards Lead quality improvement projects utilizing the PDSA model Ensures best practices are communicated and deployed across the organization 50

48 PCQC Identified area in need of improvement Value Derived 51

49 Implementation SIC formed Standardized workflows created to enhance data extraction Standardized employee and provider EMR training specifications November 2014 eclinicalworks went live EHR KIOSK Messenger Campaigns Implementation 52

50 EMR Trainings EMR Training All new team members including physicians attend 1 ½ days of EMR training New Office Onboarding During the 1 st week of Go Live, offices are required to cut back patient volume to 50% During the second week of Go Live, offices if doing well may cut back patient volume to 25% During the third week if doing well may resume normal patient volume Implementation 53

51 How HIT was Utilized HIT Utilized 54

52 Value Derived Improved Metrics Improved Outcomes Value Derived 55

53 Sampling of our Improved Quality Scores Value Derived 56

54 Utilization (per 1000 person years): Bacterial Pneumonia Value Derived 57

55 2016 NOMS Healthcare Bacterial Pneumonia Hospital Rate Value Derived 58

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57 People Process 60 Technology

58 Questions NOMS Healthcare Rebecca Rohrbach, DNP, VP of Population Health Melissa Thomas, IT Project Director Nebraska Medicine David Cloyed, MS, RN-BC, Applications Manager Tammy Winterboer, PharmD, BCPS, Director, Clinical Effectiveness & Informatics Please complete online session evaluation 61