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

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

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

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

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

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

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

Putting it all together: National Challenge: Quality and Payment 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 & on Fee Schedule +0.5% each year No change +0.25% or 0.75% 2017 Max Adjustment MIPS Performance (+/-) 4 5 7 9 9 9 2019 9 Reimbursement QP in Advanced APM +5% bonus (excluded from MIPS) 7

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

Significant Gap in Quality CY 2015 (%) CY 2016, Q1 (%) Depression screen and follow-up 41 49 BMI counseling 18-65 yo 42 44 BMI counseling >65 yo 59 58 CRC screen 16 19 Pneumonia vaccination 35 40 Breast cancer screening 37 35 Falls screen 36 46 Uncontrolled HA1c -- 45 ASA in Vasc Dz 84 82 Tobacco use counseling 90 91 Med rec 89 91 BP control 60 57 Local Problem 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

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

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

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

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

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 17 2017 Epic Systems Corporation. Confidential.

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

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 19 2017 Epic Systems Corporation. Confidential.

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 20 2017 Epic Systems Corporation. Confidential.

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

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

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

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

Minutes Rooming Rooming Staff QMAs Staff QMAs Displayed Provider QMAs Displayed 180000 160000 140000 120000 100000 80000 60000 40000 20000 0 2016 Q12016 Q22016 Q32016 Q42017 Q12017 Q22017 Q3 160000 140000 120000 100000 80000 60000 40000 20000 0 2016 Q12016 Q22016 Q32016 Q42017 Q12017 Q22017 Q3 Influenza Total Rooming Screening QMAs QMA Displayed for MAs/RNs Total Provider QMAs 10 Avg Rooming Time 9 8 7 Value Derived 25

Impact of Quality Workflow CY 2015 (%) CY 2016, Q1 (%) CY 2017, Q2 (%) % Change CRC Screen 16 19 45 137 Pneumonia Vaccination 35 40 59 48 Breast Cancer Screening 37 35 51 47 Depr Screen and F/U 41 49 70 43 Falls Screen 36 46 68 26 BP Control 60 57 63 11 BMI counseling 18-65 yo 42 44 49 11 BMI counseling >65 yo 59 58 61 5 Uncontrolled HA1c -- 45 42 7 ASA in Vasc Dz 84 82 85 4 Tobacco use counseling 90 91 94 3 Med rec 89 91 94 3 Value Derived 26

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. 1998 Aug 1;317(7154):307-12. Vaccine against Pneumococcal Pneumonia in Adults. N Engl J Med 2015; 373:91-93. National Cancer Institute. Cancer Prevalence and Cost Care Projections. Annualized Mean Net Costs of Care. https://costprojections.cancer.gov/annual.costs.html. 27 Agency for Healthcare Research and Quality. Healthcare cost and utilization project. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-conditions-readmissions-payer.pdf

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

NOMS Healthcare 2001 Northern Ohio Medical Specialists was formed with 32 Providers 2007 - 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. 2012 NCQA Level 3 PCMH Recognition 2013 - Chronic Care Management Team, NOMS 360, was instituted 2013-1 of 35 Advanced ACO s across the nation 2017 - CPC+ designation Present 216 Providers and 726 Team Members 30

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

2013 Score Card Local Challenge 32

2015-2016 Score Card Local Challenge 33

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

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

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

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

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

Report Request Forms Interventions 39

Template Request Form Interventions 40

Template Request Form - page 2 Interventions 41

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

Medicare Wellness Template Interventions 43

Diagnosis Specific Alert Value Derived 44

CDSS Alerts Value Derived 45

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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 email, Text notification, Voice notification 47

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Kiosk Questionnaire - Medicare Wellness Value Derived 49

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

PCQC Identified area in need of improvement Value Derived 51

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

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

How HIT was Utilized HIT Utilized 54

Value Derived Improved Metrics Improved Outcomes Value Derived 55

Sampling of our Improved Quality Scores Value Derived 56

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

2016 NOMS Healthcare Bacterial Pneumonia Hospital Rate Value Derived 58

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People Process 60 Technology

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