CCHN Clinical Quality Improvement Plan

CCHN Clinical Quality Improvement Plan This Document is a Collaborative Work By HIT Sub Committee Clinical Advisory Work Group Colorado Clinical Advisory Network Colorado Dental Health Network CODAN Colorado Community Managed Care Network I. Background and Purpose In the State of Colorado, the number of residents who are under or uninsured for health benefits is growing. Based upon current trends, the current number of approximately 800,000 uninsured is expected to exceed one million by or before 2019. In concert with the health care reform initiatives that are being pursued nationally, the Colorado Community Health Network (CCHN) is leading a major initiative known as Access for All Colorado (AAC). AAC is focused on analyzing access to care issues to positively impact health care policy, procurement of health care system financing and infrastructure needed for medical care delivery with the ultimate goal of measurably improving the health of the residents of Colorado. The purpose of this Clinical Quality Improvement Plan is to focus on the ongoing development and use of standardized measures that reasonably reflect the clinical impact of care and services upon individuals and populations served by community health centers throughout Colorado. This Clinical Quality Improvement Plan describes the structure and process by which clinical metrics will be developed, produced and distributed to stakeholders such as CCHN administrative and clincal leadership, operations personnel and clinicians at the point of care who may wish to benchmark clinical performance. The Clinical Quality Improvement Plan is intended to be informed by and provide guidance to the Access for All Colorado initiative regarding the measurement of health status, efficiency and effectiveness of health care delivery. Internal stakeholders and the working relationships with one another in the process of advancing clinical quality is summarized in Figure 1. below. Version 6.0 9/14/09 1

Figure 1. Clinical Quality Improvement Plan : Organizational Structure and Interactive Relationships A. CCHN Board of Directors Business Strategy Information Systems Strategy B. HIT Committee C. D. CCAN CDHN Clinical Strategy Reporting E. CAWG Clinical Guidance Technical Support F. CCMCN CACHIE CHC Clinical Workflows Design and Implementation G. CODAN Version 6.0 9/14/09 2

II. Narrative to Fig.1: Organizational Structure and Interactive Relationships A. CCHN Board of Directors monitors health care reform trends and works to advance the legal, legislative and regulatory agenda of CCHN. Through the Board s interaction with CCAN and CDHN, the clinical strategy to improve and account for quality of care may be coordinated with the Board s business strategy; together, the Board of Directors, CCAN, and CDHN collaborate to advance the mission effectiveness of CCHN. B. HIT Committee The HIT Committee is a sub committee of the CCHN Board of Directors. The HIT Committee provides guidance in the establishment and implementation of CACHIE. Included in the scope of CACHIE s activity is the establishment of technical competence requirements to support the extraction, transformation, and loading (ETL) of data and analysis of clinical information. C. Colorado Clinical Advisory network (CCAN) CCAN is a committee of medical directors of 15 federally qualified health centers and allied community health centers throughout Colorado. CCAN meets quarterly to track and discuss developments in health care policy and to advise CCHN on matters affecting or potentially affecting the delivery of services to patients of CHCs. CCAN is the principal body which guides strategy in the quest to achieve clinical excellence in the day to day course of caring for patients with the resources available to CHCs. CCAN is also the main forum through which clinical best practices are shared across CHCs in Colorado. D. Colorado Dental Health Network (CDHN) The CDHN is the dental profession correlate of CCAN. Through its committee, Dental Directors provide clinical guidance to CCHN regarding all matters, such as health policy, legislation, resource planning and others, affecting the practice of dentistry throughout the CHCs in Colorado. With the growing body of evidence pointing to the inter dependence of dental with medical well being, CDHN works closely with CCAN to create clinical integration of dental and medical services, as well as advisement on supporting policy and resource allocation planning required to optimize the quality of care and clinical impact on health outcomes within the community served. E. Clinical Advisory Working Group (CAWG) The CAWG is an ad hoc Sub committee of the HIT Committee which is focused on the tactical processes of developing consensus among the CHCs in identifying evidence based clinical measures and documenting how such measures are to be clinically defined for purposes of facilitating uniform data capture, analysis, and clinical reporting to CHCs. A summary of CAWG s operating mission, and goals are appended as Exhibit A. F. Colorado Community Managed Care Network (CCMCN) CCMCN is an independent entity which works in close collaboration with CCHN to provide the business infrastructure required to manage and coordinate business and clinical initiatives between the Colorado Access HMO and CCHN and its component member CHCs. CCMCN is also the principal implementer and operator of the Colorado Associated Community Health Information Exchange or CACHIE, a clinically focused health information exchange planned among Community Health Centers in Colorado. G. CODAN CODAN is involved in coordinating operations within and among community health center members to enhance mission effectiveness of CCHN. In collaboration with all other stakeholders, CODAN provides input into clinical workflow design, project management and implementation of clinical initiatives as may be required to meet targeted clinical performance goals and objectives. Version 6.0 9/14/09 3

III. Clinical Quality Improvement Plan : Clinical Metrics A. For purposes of this Clinical Quality Improvement Plan, Clinical metrics are measures which quantify either a clinical process of care or clinical outcomes affecting either an individual, cohort or a defined population of patients. B. Preferred Attributes of Metrics a) Evidence based, nationally established, regularly updated b) Metrics considered actionable in the eyes of the CHC provider caring for individual patients or cohorts of patients C. Types of Clinical Metrics 1. Process of care metrics or reports a) These are reports which track cohorts of patients for which specific evidence based medical services may be due for optimal management of chronic diseases. These reports may be referred to as registries. For example, one diabetic registry may show patients who have had a retinal exam and those who need to have it done. 2. Outcomes Metrics a) Reports which measure the clinical and/or cost of care impact of intervention on a comparable groups of patients; e.g., Utilization of the Hospital Emergency Room or Admissions for Acute Asthma ; or, reports which measure the cost of medical care, over time, and across comparable, case severity adjusted cohorts of patients. D. How New Clinical Measures or Metrics may be Introduced into Production 1. Through conversations with the clinical leadership at CCAN, CDHN and other stakeholders, the CAWG identifies list of the diseases/conditions that are most important for clinical reporting and quality improvement. This determination is influenced by established mandatory reporting requirements, current and future QI initiatives, and diseases/conditions which the CHCs feel have the greatest impact on their patients and are ripe for action and improvement. This list is not static but evolves to meet CHC needs. 2. Research and Development Process: For any given disease/condition, CAWG: a) Surveys and compiles the quality reporting currently done by the CHCs; b) Compiles the relevant nationally recognized measures (e.g. NCQA). c) CAWG also seeks to define measures in way that accounts for the range of sophistication of EMR use at the CHCs. For example, some CHC use templates for data entry, where the use of a disease specific template could be used to indicate that a patient has a given disease. This alone as a definition, would not work for CHCs without this disease template. Version 6.0 9/14/09 4

d) This information is then presented to CAWG members who discuss the measures and how the measures should be defined. The goal is to gain consensus in selecting the most valuable measures and defining those measures selected. e) Lastly, the CAWG also decides upon the supplemental information that makes the measures and reports actionable for the CHCs. The CAWG thinks of this information as the registry components which would be reported to support action at the patient level by the CHCs. 3. Measures may be introduced for consideration by the CAWG by: a) Any member of the Colorado Clinical Advisory Network (CCAN), the Colorado Dental Health Network (CDHN), or CODAN b) CCHN Board c) CCHN/CCMCN HIT Committee d) Chief Medical Officer of HCPF e) Any member of the CAWG f) By invitation from CAWG, any person or entity considered to possess clinical subject matter expertise in a specific domain of clinical, epidemiological or public health interest E. Review of Metrics : As the assembly and maintenance of clinical measures requires resources to support in an ongoing fashion, the complete set of clinical measures will be reviewed for their clinical value and/or amended on an ongoing basis throughout the year by CAWG in collaboration with CCAN and/or CDHN. IV. Clinical Quality Improvement Plan : Reporting A. Types of Clinical Reporting 1. Retrospective: Reports which summarize characteristics of the processes of care and/or outcomes involving a defined cohort of patients receiving services within defined dates of service. This reporting may address health status and/or best practices in clinical work flow. 2. Concurrent (to the point of care): Patient specific information made available to the provider at the point of care which may guide specific evidence based services which may be indicated either for general wellness and prevention; and/or for guidance of optimal management of a specific condition/s. B. Types of Administrative Reporting 1. Progress Report on Statewide Clinical Reporting Current status of the Statewide clinical reporting data set, ongoing activity and efficacy of CHC adoption will be reported to the CCHN Board of Directors at their discretion and at least annually. 2. Data Quality Version 6.0 9/14/09 5

a) A report will be generated by CACHIE and CWAG that will address how clinical data collected from disparate EHR systems can be made clinically valid and useful when aggregated into a single clinical report. This Report is intended to provide guidance to CHC clinical and/or IT staff as they configure their respective EHR systems and clinical workflows to record clinical data in a uniform manner. V. Clinical Quality Improvement Plan : Current Clinical Measures, and Status of Development August 2009 A. Consensus on Clinical Measures/Reports Disease/Condition Coordinator Report requirements Clinician consensus on composition of report & registry measures with narrative definitions Diabetes LS 4/15/09 Asthma LS CVD LS HTN (UDS) LS Depression LS/CT 5/6/09 new date 6/3/09 Tobacco LS/HS 7/1/09 IZ @ 2 yrs MOF Chronic Pain CT 5/20/09 Cancer Prevention CT/PT (pap, mmg, crc) UDS Clinical LS Active CHC patient LS 4/15/09 Moved or Gone MOF Elsewhere (MOGE) Qualifying 6/3/09 encounter Technical Specifications Clinician + data base engineer specifications of requirements Data mapping Report Format Report Validity verification Version 6.0 9/14/09 6

2. Other Items Item Description Due Date Complete CAWG Mission & Goals Discussed 3/12/09 Confirmed 4/1/09 Yes Reviewed Dz/Condition Priorities CCHN Board Presentation CAWG Communication Universe of Pt Definition DM (AHRQ), HTN, CVD, Depression, Asthma (covers kids), IZ <2 yrs (Important & actionable), UDS, Tobacco Cessation (HRSA) (3/12/09) Chronic Pain (TCHF), Cancer Screening (TCHF) added priority for TCHF grant. All placed on status chart Presentation date: June 2009 Pat Tellez to draft document outline 4/29/09 Need to develop a better process for communicating work to other CHC, to allow input and use Based on MOGE and when last seen for a billable encounter. Registry population or the denominator for a report may vary by CHC & disease/condition, ie 18 months for DM report, 3 years healthy adult. DM registryuniverse of pts. Discussed 3/12/09 Confirmed 4/1/09 4/29/09 4/15/09 Yes, open to discussion with new opportuniti es Diabetic Pt definition (Prototype Diagnosis) Exclusion notification Stick with ICD 9 codes dating back 3 years for now. Medications may not be readily available from all systems. Need a process to assist CHC with identifying those patients for whom review and verification of the diagnoses is necessary due to the high probability of erroneous dx. No HbA1c result or result <6 No DM medication prescribed Less than X DM ICD 9 codes over a certain time period (may be most useful for integrated system) Report and registry populations are not identical. Registry population will be more lenient Need a process for CHC to notify CACHIE regarding exclusions that does not require input to CHC EMR. Not the patients excluded will also need to be reviewed periodically, or reviewed based on the reason for exclusion. (Incorrect old dx, where the dx may become true in the future) 4/15/09 4/15/09 Version 6.0 9/14/09 7

Clinical Reporting 1) Current Reports: This document would be a compendium of finalized metrics in production which: a) Identify the metric and describe the rationale for why it was chosen b) Cite some references and/or benchmarks for that measure/report c) Possibly provide a mock up example of the desired reports 2) Metrics Under Review: This would simply list new metrics that have been submitted into the processing cycle for consideration either by CCAN, CDHN or CAWG; once a measure is adopted, it becomes a Report in Preparation 3) Reports in Preparation: This is a clinical measure or report that has been accepted as a standard measure or report but has not as yet been completed and placed into production. Version 6.0 9/14/09 8

EXHIBIT A Colorado Associated Community Health Information Exchange (CACHIE) Clinical Advisory Work Group CACHIE: Lisa Schilling, MD, Molly O Fallon CHC Staff: Goal: Provide input to optimize CAHCIE reporting value to CHCs at both the clinic and systems level Purpose: 1. To assist CACHIE staff decisions regarding quality reporting: Identify report types where CACHIE assistance provides the most value to CHCs: i. Mandated and required by all i.e. UDS, etc. ii. Reports for bench marking, best practice identification, and to inform population based intervention strategies (similar to HDC) iii. Individual CHC ad hoc reports, Provide input regarding quality measurements, Provide input regarding the requirements of a quality reporting tool. 2. Recommend and prioritize future CAHCIE clinical focus based on: Common clinical issues Reporting requirements Population based concerns Participant Expectations: Participate in meetings by phone (or in person) not more than monthly through December 2008. We plan on holding all meetings by phone to accommodate all members and avoid unnecessary travel. Review and comment on CACHIE draft documents and decisions. Time expectation: Conference call 60 minutes twice per month through December 2009. An average of 6 8 hours per month to review draft documents In December 2009 revisit the purpose of the workgroup and determine next steps for this group. CACHIE staff responsibilities: Support the functions of the group, including organizing and facilitating meetings, Provide overview of measures & elements to be collected for the initial pilot report, Provide information regarding mandated reports, eg UDS measures, Provide the work group with a reporting tool requirements draft to review. Version 6.0 9/14/09 9