Reconciling Abstracted to Electronic Quality Measures Tuesday, March 1, 2016 Keith F. Woeltje, PhD, MD, VP and Chief Medical Information Officer BJC HealthCare Center for Clinical Excellence Liz Richard, MHS, MBA, Managing Director Encore, A Quintiles Company 1
Conflict of Interest Keith F. Woeltje, PhD, MD Has no real or apparent conflicts of interest to report. 2
Conflict of Interest Liz Richard, MHS, MBA Receives a salary from Encore, A Quintiles Company. 3
Agenda BJC who we are, where we are and why quality is paramount Electronic clinical quality measure (ecqm) landscape and future Why are there differences between abstracted CQMs and ecqms? ecqm assessment: goal, approach and outcome Driving quality improvement with ecqms 4
Learning Objectives Prepare for an ecqm assessment Describe why it is important to understand the current state of ecqms before moving to a new Electronic Health Record (EHR) List the steps involved in conducting an ecqm assessment Explain how an ecqm assessment can drive next steps to improve the quality of your reporting 5
Introduction: Benefits Realized for the Value of Health IT Satisfaction Treatment/Clinical Quality of care, safety Electronic Secure Data Patient Engagement & Population Management Data reporting, evidence-based medicine Overall improvements in prevention Savings Financial/business http://www.himss.org/valuesuite 6
Polling Question 1 How many ecqms are required for the IQR Program in 2016? 1. 4 ecqms 2. 8 ecqms 3. 16 ecqms 4. I do not know 7
BJC Who We Are, Where We Are and Why Quality Is Paramount 8
BJC by the Numbers Hospitals 11 Employees 26,583 Physicians 3,900 Staffed Beds 3,378 Hospital Admissions 142,278 Home Health Visits 215,967 Emergency Department Visits 481,300 Net Revenue Community Benefit Charity & Unreimbursed Care Medical Education & Research Safety Net Services Community Health Programs $4 billion $589 million $301 million $167 million $101.4 million $24.6 million 9
Quality Measures Framework Donabedian Model Structure Process Outcome CQM Components Initial patient population Denominator Numerator Exclusions Exceptions 10
What Makes a Good Quality Measure? 1 2 3 4 5 6 Transparency: the evaluation criteria are clear Measure validity: evidence-based and validated by appropriate organizations (e.g., National Quality Forum or professional societies) Data validity: data used are from objective sources Risk adjustment: appropriate risk adjustment is incorporated in the measures Timeframe: data used reflect current performance Volume (for comparison between facilities): a sufficient number of hospitals and patients are evaluated for meaningful comparisons 11
Electronic Clinical Quality Measures (ecqms) Electronic Clinical Quality Measures (ecqms) are quality measures with electronic specifications. The specifications include the data elements, logic, and definitions for each measure in a format that can be captured or stored in Certified Healthcare Information Technology 12
ecqms at BJC ecqms will expand to play a key role for value-based care delivery and reimbursement Needed to evaluate the organization s approach to ecqms: Capture Aggregation Management Reporting Goal to centralize process and consolidate the number of systems used Transitioning to a single Electronic Health Record 13
ecqm Landscape and Future 14
Polling Question 2 Are ecqms on your organization's radar? 1. Yes-we are well positioned 2. Yes-we need to work on them 3. Yes-we need to get started 4. No 15
Why Are ecqms Important? ecqms are required to be electronically submitted in 2016 for the Inpatient Quality Reporting Program (IQR) ecqm requirements will increase from 4 in 2016 to 16 (proposed) in 2017 ecqm performance will be publically reported in the future Move to align quality programs and decrease the reporting burden will increase the importance of ecqms Driving quality improvement with ecqms requires accurate measure performance 16
2015 Quality Measures Programs PCMH PQRS Commercial Risk Contracts HEDIS MU EP TJC and others ACO MSSP & Leapfrog Commercial MU EH CMS Quality Reporting (IQR) NSQIP SCIP STS Diagram used with permission from Dr. Tonya Hongsermeier, VP and Chief Medical Information Officer at Lahey Health Electronic Submission Option 17
ecqm Requirements Are Here Chart-abstracted measures Analyze Remediate Test Submit Analyze Remediate Test Submit Analyze Remediate Test Submit Analyze Remediate Test Submit 2015 No ecqms 2016 4 ecqms 2017 16 ecqms 2018 16+ ecqms 2019 ## ecqms Annual IQR Updates New specifications New measures Remove topped out measures Meaningful Use Modified Stage 2 Meaningful Use Stage 3 *The Physician Quality Reporting System (PQRS) will follow a similar timeline 18
Differences Between Abstracted and ecqms 19
2016 Today+ Abstracted vs. ecqms Capture Data documented in patient record Interpret Chart review by abstraction/ coding staff Calculate Extracted Validated Using a 3 rd -party software tool Submitted by Quality Department Sample size All patients Capture Interpret Calculate Data must be codified to ecqm requirements Structured data entered into EHR by clinician Data calculated and reported electronically Electronically submitted on a schedule Certified EHR Technology 20
Another View SCIP-9 The abstractor can find whether evidence-based care was followed by looking in multiple places. Scanned documents Nursing notes Physician notes Nursing orders: EHR screenshots are illustrative examples only. 21
Another View SCIP-9 The ecqm calculation depends on the data being in a structured format in a consistent place. Nursing orders: EHR screenshots are illustrative examples only. 22
ecqm Assessment Goal and Approach 23
Goals of BJC emeasure Assessment Assess ecqms measure performance of ecqms as compared with their abstracted CQM counterparts Assess ecqm calculations and reporting and identify alternative options for accurate ecqm submission and monitoring 24
ecqm Assessment Approach Project Initiation Kick-off & Discovery Sessions emeasure Review and Analysis Analyze and Compile Findings Review Final Findings Schedule Kickoff and Discovery Sessions Identify participants Send request for information Conduct project kick-off with key stakeholders Review the information requested Conduct focused discovery sessions with clinical and data analysts Conduct discovery session on reporting tools for EHRs Review ecqm report logic for EHRs Review ecqm report configuration Review ecqm reports from the EHRs Analyze findings from discovery sessions, report logic and report configuration sessions Document measure findings Develop risk assessment by measure Identify gaps and action plan Present final emeasure findings and reporting alternatives to executives and stakeholders Review gaps, findings and task plan for remediating gaps Compare measure performance for abstracted CQMs with similar ecqms Develop findings and alternatives for ecqm reporting options 25
MU ecqm vs. IQR CQM Reporting Comparison Measure Facility A Facility B MU ecqm IQR CQM MU ecqm IQR CQM AMI-2 88% 100% ED-2 227 192 PC-01 100.00% 4% PN-6 (ICU) 100% 100% PN-6 (Non- ICU) 49% 100% SCIP-1 92% 99% 0% 99% SCIP-9 63% 99% STK-2 95% 100% 61% 100% STK-3 68% 94% 0% 92% STK-4 97% 100% 0% 100% STK-6 95% 97% 62% 100% VTE-1 73% 99% 50% 100% VTE-2 100% 92% 45% 100% VTE-3 35% 100% VTE-4 96% 100% VTE-6 60% 0% 26
ecqm Assessment Outcomes 27
ecqm Risk Assessment Summary Facility A Measure ED-2 Functionality/ Certification Workflow Adoption Content Reporting STK-2 STK-3 STK-4 STK-6 VTE-1 VTE-2 VTE-3 VTE-4 VTE-6 PN-6 SCIP-INF-1 SCIP-INF-9 28
ecqm Findings Summary Workflows resulting in missing or incomplete data Variation in documentation to support data capture Deficiencies in adoption of recommended workflows Missing interfaces to support data capture 29
Reporting Findings Summary Multiple tools to calculate and report, with concerns about accuracy No single source of truth for measure definitions May not support the expansion of emeasure programs Extensive maintenance concerns for vendor #1 Limited flexibility of tool configuration for vendor #2 Inability to support the complexity of emeasure reporting as BJC transitions from multiple EHRs to the new EHR 30
Maintenance ecqm Report Alternatives Consideration EHR-Vended Reporting Tool Self-Certified Reporting Tool Non-EHR Vendor ecqm Reporting Tool Flexibility in Content Flexibility in Workflow Report Customization Capability Extract-Transform-Load Not Needed No Measure Specification Updates No Calculation Engine updates No Report/Dashboard Updates Support of ecqm Continuity Level of Effort Low High Medium 31
Driving Quality Improvement with ecqms 32
Non-ICU CLABSI Electronic Rates (NICER) 33
CMS Mandated NHSN Reporting MRSA bacteremia LabID events C. difficile LabID event We re already actually reporting ecqms! 34
Manual vs. Electronic Surveillance Bloodstream Infection Method Sensitivity (%) Specificity (%) PPV (%) NPV (%) Best computer algorithm 81 72 62 81 Computer + manual Central Venous Catheter Infection Control Practitioner 81 90 81 90 65 75 57 79 35
Other Internal ecqms BJC started Best in Class (BIC) in 2003 to focus not only on federal mandates but also on internal quality improvement. Preventable Harm initiative (2008-2012) reduced preventable harms by 60% Initial measurement burden was high Developed electronic measures for pressure ulcers, hypoglycemia 36
BJC Pressure Ulcers Dashboard G C A J F C D I H E A B C D E F G H I J A B C D E F G H I J I 1.73% J 0.80% H 0.80% A 3.20% B 8.53% G 14.40% F 5.87% E 0.13% D 3.33% C 61.20% 37
Polling Question 3 Do you utilize ecqms beyond requirements for MU and IQR? 1. Yes 2. No 3. Not sure 38
Final Thoughts ecqm measurement goes beyond regulatory requirements EHR data elements for ecqms should assessed for quality of the data Complex or changing EHR landscapes can make ecqm reporting more difficult Gaps must be remediated after identification 39
Summary: Benefits Realized for the Value of Health IT Satisfaction Treatment/Clinical Quality of care, safety Able to remediate to capture needed ecqm data electronically Electronic Secure Data Data reporting, evidence-based medicine Improve ecqm performance, transparency between ecqms and EHR content/workflows Patient Engagement & Population Management Overall improvements in prevention ecqms target best practice medicine to manage patients and populations of patients Savings Financial/business Reporting ecqms for IPPS/IQR for 2016+ and savings associated with improved quality fewer costly adverse outcomes http://www.himss.org/valuesuite 40
Questions Keith F. Woeltje, PhD, MD, VP and Chief Medical Information Officer BJC HealthCare Center for Clinical Excellence Liz Richard, MHS, MBA, Managing Director, Value Realization Encore, A Quintiles Company 41