Data Quality Improvement Plan Goal This interac ve document is for Clinical Health Informa on Technology Advisors (CHITAs) to work with a prac ce to ins tute sustainable quality improvement. The Data Quality Improvement Plan (DQIP): Allows your prac ce s CHITA to understand results from your Prac ce Survey. Focuses on the data elements and clinical quality measure (CQM) reports that support care for pa ents with cardiovascular disease or those who are at high risk. Will help your CHITA to work with your prac ce team to iden fy opportuni es and barriers for implemen ng the EvidenceNOW Southwest project. Helps your CHITA to understand the prac ce dynamic. Will enhance prac ce knowledge, and ins ll autonomy and confidence in data development, data use, and data submission. By the me you complete this plan, both your prac ce and your Clinical HIT Advisor will have a clear picture of your current data quality, measure validity, and repor ng procedures, as well as iden fy priori es, barriers and opportuni- es for improvement. Your CHITA will work with you to develop processes using your electronic health record (EHR). We hope this DQIP will help your prac ce use data to improve care for pa ents, a core ac vity of all advanced primary care prac ces. Submit Online Once you have completed this plan, go here: h p://bit.ly/enswcodqip Prac ce Name: SAMPLE PRACTICE Prac ce ID: 7777 Survey Date: 05/16/2016 Questions? EvidenceNow.Southwest@ucdenver.edu 1
DATA QUALITY PROCESS: TENET ONE IDENTIFY & DOCUMENT DATA USES Build a working rela onship with the prac ce s improvement team in coopera on with the prac ce facilitator. Data Uses: Iden fy and document programs, applica ons, and measurement ac vi es where data are u lized, both at summary and individual pa ent levels. Systems and Inputs: Document systems and inputs that capture data related to uses. Impact: Determine use of data will impact the prac ce. Priori ze and stra fy data uses. EHR System ELECTRONIC Name V Y Greenway Medical 17.10.9 2010 Our prac ce change our EHR/EMR system within the next 18 months. Our prac ce s data resides in * * Our prac ce s EHR vendor help extract data and clinical quality measures. Our prac ce s current EHR/EMR system cer fied to meet Meaningful Use as defined by Health and Human Services / Office of the Na onal Coordinator for Health Informa on Technology (ONC). Our prac ce s EHR currently generate Con nuity of Care Documents (CCDs). Our prac ce share any pa ent health informa on (e.g., lab results, imaging reports, problem lists, medica on lists) electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs. Our prac ce incorporate clinical lab-test results into EHR/EMR as structured data (i.e., data recorded in discrete fields and not in text fields). During mee ngs, our prac ce discusses data or reports about clinical quality from health plans or other external enes. Data on the clinical quality of care provided by our prac ce or its clinicians publicly reported by health plans or other external enes. Our prac ce measures prac ce pa ent sa sfac on. Our prac ce recognized or accredited as a pa ent-centered medical home (PCMH). Our prac ce s clinicians have their own panel of pa ents for whom they are responsible. Our prac ce a est successfully for Meaningful Use Stage 1. Our prac ce apply for Meaningful Use Stage 2 incen ve payments. 2
Not at All (0) to Completely (4) Our prac ce has an ongoing, reliable system for empanelment and panel management within our data systems and prac ce processes. A system has been implemented for including pa ent and family input in ongoing improvement ac vi es (such as pa ent advisory groups or pa ents or family members on QI teams). A pa ent experience survey is used regularly (at least quarterly) to monitor prac ce performance. Pa ents with care or outcomes falling outside of guidelines are iden fied for more intensive care. Our prac ce uses clinical guidelines for cardiovascular disease preven on: Our prac ce uses clinical guidelines for management of pa ents at risk for cardiovascular disease (e.g., sta n use among those at risk): Within the past 12 months, our prac ce has par cipated in any of the following payment or quality demonstra on programs : ( ) : () -- ( ) () There have been the following major changes in our prac ce in the last 12 months: O: Our prac ce works with the following organiza ons/networks to support capture of EHR/Electronic Medical Record (EMR) data used to report clinical quality - Our prac ce has produced quality reports on the following clinical quality measures in the last 6 months: P 18 I V D (IVD) (NQF 0068). P 18 85 (HTN) (BP) (<140/90) (NQF 0018). P 18 24 AND - (NQF 0028). Our prac ce report the above quality measures at the prac ce level. Our prac ce report the above quality measures by clinician (MD, DO, NP, PA). 3
DATA QUALITY PROCESS: TENET TWO ESTABLISH QUALITY OF DATA Determine ENSW measures, or specific data elements within a measure to address. Retrieve relevant data. Complete an assessment of all 4 CQM reports. Validate data quality issues associated with workflow, systems uses, systems design, etc. Work with DARTNet to establish baseline. Our prac ce have someone who can configure or write quality reports from the EHR/EMR. Data on the clinical quality of care provided by our prac ce or its clinicians publicly reported by health plans or other external enes. Our prac ce is with our EHR/EMR system. Our prac ce has a registry for the following condi ons: I V D (IVD) H ( ) Our registry be configured to add new condi ons. Please indicate the status of each data element (on next page): 4
ENSW Data Elements Pa ent Linking number Billing Accounts Receivable Year of Birth Ethnicity Race Date of all visits in last 12 months Diagnos c codes linked to each visit CPT codes linked to each visit Medica ons Diagnoses/problems Height Weight Blood pressure diastolic Blood pressure systolic Smoking status Smoking cessa on referrals Total cholesterol LDL C HDL A1C Green Yellow Red Data captured in discrete fields accurately and consistently on all pa ents in prac ce Data captured in discrete fields with concern for accuracy and/or consistency Data elements not captured in discrete fields 5
Please indicate the status of ENSW Measure: : ( 0068) Numerator Pa ents who have documenta on of use of aspirin or other an thrombo c during the measurement period. Denominator Pa ents 18 y/o and older with a visit during measurement period, and an ac ve diagnosis of ischemic vascular disease (IVD) or who were discharged with myocardial infarc on (AMI), coronary artery bypass gra (CABG) or percutaneous coronary interven ons (PCI) in the 12 months prior to the measurement period. : ( 0018) Numerator Pa ents whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the measurement period. Denominator Pa ents 18 85 y/o who had a diagnosis of essen al hypertension with the first six months of the measurement period or any me prior to the measurement period. : Numerator Pa ents mee ng denominator criteria who were prescribed or are already on sta n medica on therapy during the measurement year. Denominator BLACK BLACK Select the one measure that is the most available, trusted, and usable for this project from the following list: (original harmonized denominator) Number of high risk pa ents aged >= 21 years who were previously diagnosed with or currently have an ac ve diagnosis of clinical atherosclero c cardiovascular disease (ASCVD); or with a fas ng or direct Low Density Lipoprotein Cholesterol (LDL C) level >= 190 mg/dl; or pa ents aged 40 75 years with a diagnosis of diabetes with a fas ng or direct LDL C level of 70 189 mg/dl. NOTE: Each pa ent should only be counted once. Number of pa ents diagnosed with ASCVD Number of pa ents with a fas ng or direct LDL > 190 mg/dl; Number of pa ents with a diagnosis of diabetes BLACK : ( 0028) Numerator Pa ents who were screened for tobacco use at least once within 24 months AND who received tobacco cessa on interven on if iden fied as a tobacco user. Denominator All pa ents aged 18 y/o and older seen for at least two visits or at least one preven ve visit during the measurement period. BLACK Green Yellow Red Black Already have the report, same as ENSW defini ons Have the report, but does not fully match ENSW defini ons Do not have the report, but can get it/build it No chance of ge ng report from system/vendor 6
Which method will the Prac ce use to submit data to DARTNet? (D P S /DQIP) D S Pa ent level data: Direct prac ce connec on to DARTNet OR another organiza on who will capture data elements and calculate measures (e.g., HIE, NM PCA, etc.) A (NQF 0068) F CQM R B (NQF 0018) C ( ) S (NQF 0028) Prac ce level data*: Numerators/Denominators from a non EHR registry. Prac ce level data*: Numerators/Denominators from EHR cer fied by ONC in 2014 or a er Prac ce level data*: Numerators/Denominators from EHR cer fied by ONC prior to 2014 Pa ent level data: Chart audit using EHR data Pa ent level data: Chart audit paper health record *Prac ces that can only generate provider-level reports MUST: 1) Create unique numerators and denominators 2) Ensure that the same pa ent does not report for mul ple providers in the prac ce 7
DATA QUALITY PROCESS: TENET THREE DATA QUALITY IMPROVEMENT GOALS Institute improvement team and feedback and regular check-ins. Include those who are involved in creating and using the data. Identify goals for data quality improvement related to identified uses and issues. Establish measures of success. Please list your three goals for improving data quality in your prac ce: Make the goals SMART (specific, measurable, a ainable, realis c, mely). Think of your data elements. Consider how to consistently pull reports and validate informa on relevant to each clinical quality measure (CQM). With each goal, be sure to include measures of success. GOAL 1: GOAL 2: GOAL 3: 8
Who will lead the Prac ce s HIT efforts? Name Email Phone Number What will you make happen in the next 10 working days to begin your progress? 9
DATA QUALITY PROCESS: TENET FOUR MONITOR PROGRESS AND ADJUST GOALS Are there processes or technology that can help improve and monitor data quality? Compare progress to benchmarks. Alter plan as needed to accommodate issues, emergent needs, and other changes. Not at All (0) to Completely (4) Our prac ce has a QI team that meets regularly. The QI team has a sustainable, reflec ve QI process that deals effec vely with challenges and conflict. 10
DATA QUALITY PROCESS: TENET FIVE DEVELOP DATA SUSTAINABILITY PLAN Create plan that provides ongoing feedback and monitoring of continuous data quality improvement. Consider who else can be brought to the table with an investment in patient/provider/practice data. Implement data quality processes that can bring about additional transformation opportunities. 9 MONTH PRACTICE GOAL for EvidenceNow Southwest FUTURE GOALS for a er EvidenceNow Southwest ends Once you have completed this plan, go here: h p://bit.ly/enswcodqip 11