Managing eCQM Reporting Through a System E HR Transition Mary - - PowerPoint PPT Presentation

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Managing eCQM Reporting Through a System E HR Transition Mary - - PowerPoint PPT Presentation

Aug 07, 2023 152 likes •393 views

The Joint Commission Pioneers in Quality 2018 eCQM Proven Practices Webinar Series August 23, 2018 Managing eCQM Reporting Through a System E HR Transition Mary Burton, RN, PhD, Group Manager, Clinical Quality BJC Healthcare Liz Greiner,

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Managing eCQM Reporting Through a System E HR Transition

Mary Burton, RN, PhD, Group Manager, Clinical Quality BJC Healthcare Liz Greiner, Electronic Measurement Coordinator, RN, MHA, BJC Healthcare The Joint Commission Pioneers in Quality 2018 eCQM Proven Practices Webinar Series August 23, 2018

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Purpose: Describe the challenges associated with managing electronic clinical quality measures (CQMs) across multiple electronic health record (EHR) platforms, while transitioning to a single platform. Outline: 1. Background

1. BJC – who we are 2. Interoperability challenges 3. Program goals & solution

2. Process

1. Timeline 2. Implementation cycle-legacy and new EHR 3. Example of sourcing/mapping i.e. stroke education

3. Current scorecard 4. Summary, challenges and lessons learned

Purpose & Outline

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BJC HealthCare – St. Louis, Missouri

BJC HealthCare is a non-profit health care

  • rganization based in St. Louis, Missouri.

It is the St. Louis area's—and one of Missouri's— biggest employers.

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BJC HealthCare by the Numbers

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Preventable Harm E lectronic Measures

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How it All Started - Interoperability Challenges

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Interoperability Challenges- eCQM and Chart Abstraction

Measure Description Hospital Legacy eCQM Chart Abstracted CQM 10/14 - 1/15 4/14 - 6/14 AMI-2 Aspirin Prescribed at Discharge 88% 100% PC-01 Elective Delivery 100.0% 4.3% SCIP-1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision 0.0% 99.0% STK-2 Discharged on Antithrombotic Therapy 61.0% 100.0% STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter 0.0% 92.3% STK-4 Thrombolytic Therapy 0.0% 100.0% STK-6 Discharged on Statin Medication 61.5% 100.0% VTE-1 Venous Thromboembolism Prophylaxis 49.6% 100.0% VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis 45.1% 100.0%

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Findings from discovery sessions:

  • Variation in workflows resulting in missing or incomplete data
  • Variation in documentation to support data capture
  • Missing interfaces to support data capture
  • Multiple tools for calculation and reporting

– No single source of truth

  • Inability of legacy systems to support expansion of eCQM program and

transition from multiple EHRs to new EHR.

Getting Started- Interoperability Challenges- Impact on eCQMs

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Goals:

  • Utilize eCQMs to drive clinical quality improvement
  • Provide accurate and trusted performance results with single source of truth
  • Ease burden of documentation by capturing data to support eCQMs within

existing clinical workflows

  • Be leaders in clinical quality by submitting all eCQMs to TJC and CMS

Solution:

  • Implement more flexible non-EHR vendor for e-measure calculations driven

through multidisciplinary team approach

Program Goals & Solution

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BJC eCQM Roadmap

2015 2016 2017 2018 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

Project Start Production 2016 Upgrade CMS 2016 Submission 2017 Upgrade CMS & TJC 2017 Submission 2018.01 Upgrade Legacy Retired

Kick-off ETL Build Testing Go-Live Validation, BHC POD 1 POD 2 Academic

BJC ECQM TOOL NEW EHR

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Implementation Cycle – Legacy Systems

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Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Iterative Processes

CMS 2019 Submission

Implementation Cycle-New E HR

Workflow Identification Extract Build Value Set Mapping Pre-production Testing Post-production Validation

  • Identify SMEs
  • Determine

workflows by measure

  • Customize EHR to

close known gaps

  • Identify source data

fields based on workflow

  • Test Extract, Transfer,

Load (ETL)

  • Test content
  • Map data elements

to standard terms

  • Custom field

mapping based on new workflows

  • Test content
  • Test workflow
  • Test mapping
  • Test measure

calculation

  • Validate measure results
  • Document standard

workflow and incorporate into training

  • Tweak ETL
  • Tweak mappings
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E xample: Stroke E ducation

Stk-8 Stroke Education: Workflow discovery sessions found the stroke booklet given to patients meets measure criteria. Mapped “written information given” field to all six education criteria. Decreases documentation burden and aligns to current workflow.

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BJC eCQM Roadmap - Ongoing

2018 2019 Sept Oct Nov Dec Jan Feb Mar Apr May Jun July Aug

CMS 2018 Submission TJC 2018 Submission CQL Upgrade

BJC ECQM TOOL EHR

2018.01 Upgrade

CMS 2019 Submission TJC 2019 Submission

Upgrade Validation Upgrade Validation EHR Upgrade EHR Upgrade Workflow enhancements- close known gaps Epic Optimization

Measure management and performance improvement

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Current E HR – eCQM Scorecard

ID eMeasure Title GOAL AMH BHC BJH BJSPH BJWC CH MBMC MBSH PHC PWH SLCH ED-1a Median Time from ED Arrival to ED

Depart for Admitted ED Patients

287

260 242 512 290 271 448 330 287 306 282 307

ED-2a

Median Admit Decision Time to ED Depart Time for Admitted Patients

85

52 79 194 91 55 167 121 81 75 75 94

VTE-1 VTE Prophylaxis 95%

93% 85% 69% 83% 77% 88% 86% 89% 87% 86% 11%

VTE-2 ICU VTE Prophylaxis 95%

95% 93% 75% 89% 73% 94% 94% 94% 97% 92% 14%

STK-2 Discharged on Anti-thrombotic

Therapy

95%

93% 86% 88% 89%

  • 76%

77% 100% 50% 97%

STK-3 Anticoagulation Therapy for Atrial

Fibrillation/Flutter

95%

78% 67% 54% 40%

  • 29%

63%

  • 100%

63%

STK-5 Antithrombotic Therapy by End of

Hospital Day 2

95%

93% 91% 91% 80%

  • 88%

86% 50% 100% 94%

STK-6 Discharged on Statin Medication 95%

81% 74% 90% 91%

  • 73%

73% 100% 33% 96%

STK-8 Stroke Education 95%

100% 98% 85% 79%

  • 83%

97% 0% 100% 85%

STK- 10

Assessed for Rehabilitation

95%

82% 99% 99% 97%

  • 97%

94% 100% 40% 94%

PC-01 Elective Delivery 3%

12% 13% 17%

  • 27%

38% 8% 18%

PC-05 Exclusive Breast Milk Feeding 50%

54% 54% 36%

  • 50%

37% 24% 52%

EHDI- 1a

Hearing Screening Before Hospital Discharge

95%

90% 96% 74%

  • 93%

87% 92% 91% 75%

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Success Factors

  • Leadership support
  • Clinical and IT partners
  • eCQMs platform for future performance

improvement

  • Commitment to testing and validation (over

and over)

  • Resisted rush to production
  • eCQM calculation engine (flexibility &

customization)

Lessons Learned

  • Complexity – will not be reduced anytime

soon

  • Required - time, talent, tools, and resources
  • Challenges - alignment of measures, clinical

work flows and EHR systems

Summary

On-going Challenges

  • Continual State of Change-evolving national

landscape

  • Tight timelines (upgrade, submission, annual

update)

  • Paradigm shift- chart abstracted gold standard to
  • ptimizing and using eCQMs
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What’s next?

  • Well positioned to be a leader in

eCQM and regulatory measures nationally

  • Contributor on future proposed

measures

  • Continue to develop custom

measures

  • Optimize the use of electronic

measures for performance improvement initiatives

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Coming Soon to BJC eCQM…

Memorial East Memorial Belleville

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Thank you!

Mary Burton, RN, MSN, APRN(R), PhD, Group Manager Clinical Quality BJC Healthcare mary.burton@ bjc.org Liz O’Neil-Greiner, RN, MHA Electronic Measurement Coordinator-Healthcare Informatics BJC Healthcare elizabeth.oneilgreiner@ bjc.org

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Appendix

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What Makes A Good Quality Measure?

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eCQM Measure Calculation E ngine