From Meaningful Use to TransformationXavier University Cintas Center

May 20, 2011

Breakout Session T2

Getting Better All the Time: An Applied Guide to Quality Reporting

and Performance Measurement

PanelistsBarb Reagan, RN

Director of Quality Improvement

HealthBridge

Mark WitteChief Executive Officer

The Family Medical Group

Mark Wess, MD, MScAssociate Professor, UC GIM

Director, UC Center for Health Informatics

Multiple Quality Initiatives

• Bridges to Excellence (BTE)• RWJ Aligning Forces for Quality (AF4Q)• CMS Physician Quality Reporting System (PQRS)• ARRA, HITECH, Meaningful Use• NCQA Patient Centered Medical Home (PCMH) or

Neighborhood (PCMN)• Accountable Care Organizations (ACO)• Payers – P4P• and others

http://www.allhealth.org/community-initiatives.asp

Common Themes• Accountability• Action• Alignment

– recognition – funding

Data management and measurement assisting

change process

Quality Reportingfor Improving Outcomes

Barb Regan, RN

Cincinnati Initiatives- the beginning of quality reporting

Aligning Forces for Quality (AF4Q)• Initiative through the RWJF that focuses of a full

continuum of health care delivery (2007)• Multiple phases of the initiative-HealthBridge focused on

quality reporting for Management of Chronic Illness and Patient Centered Medical Home pilot

• As part of these 2 pilots, HealthBridge realized:– Most EHRs could not produce quality reporting– Free text data hard to captured and report on– Multiple ways to enter the same information in EHR – Most EHR are not designed to manage a full patient population

with chronic disease

Shared Experiences• Providers all thought they scored higher

– Sure there was a problem with the report– Review of data against chart (ehr or paper)– Wanted to score better next year

• Beneficial for staff members review the data before submission– Especially true when one staff member assigned to provider– Blanks make a great visual– Awareness of data needed for quality reporting– Realized they played a role in quality improvement

• All providers wanted a better way to track their patient with chronic conditions– More frequent reporting and monitoring of data

Key Lessons Learned- The 3 C’s

• Codified– Data in codified fields can be queried – Work with your EHR to build as many reportable fields as

possible templates flow charts medication lists- NDC codes, RxNorm codes

Medication ListAspirin 81mg Once a dayASA 81 DailyAspirn

• Consistent– Train staff and providers to enter data in reportable fields

if implementing a new EHR, the time to start is now have provider and staff review progress Correct bad data-give credit where credit is due

Height Weight6 ft 3 in 175.25

75 inches 175 ¼ lbs.

6’ 3” 175..25

Diabetic Foot Exam Date

Diabetic Foot Exam Value

05-01-2010 normal

05-07-2010 nl

05-10-2010 .

Key Lessons Learned- The 3 C’s

• Connected– Interface with your HIE (Health Information Exchange)

one connection to receive community results data placed in discrete fields PDF or scanned results cannot captured easily for quality reporting gateway for your EHR to securely send and receive data

Hemoglobin A1C Value Reference RangeHbA1c 6.5 4.3-5.6 A1C 8.2% 4.3-5.6hb 7.2 Normal Range

12.0-15.5 G/DL

Key Lessons Learned- The 3 C’s

Meaningful Use

“The key to Meaningful Use is to know how to measure performance and give feedback to providers.”

Dr. David Blumenthal, Former National Coordinator for Health IT

• Quality reporting is needed for Meaningful Use– Attestation process requires documentation to meet the

thresholds (ex. 40% eRx)– Providers experiencing the same problems attesting to

meaningful use – Certified EHRs still struggle producing documentation– Minimalist approach to quality reporting

HealthBridge realized practices needed assistance with quality reporting

Greater Cincinnati Beacon Community• Cooperative agreement with the government to achieve

measurable improvements in health care quality, safety and efficiency

• 30 month strategy to improver outcomes and manage population health

• Aim: Wed HIT-HIE-QI• Uses HIT tools to link health providers and other community–

wide resources in new and innovative ways• Each community developed and submitted their own health IT

related strategies and will work as a collaboration to implement and track performances

• 3 part strategy: decrease cost per capita, improve healthcare quality and manage and improve population health

• **BEACON IS A COMMUNITY**

13

Registry- Tool for Quality Improvement

Why Use a Registry?• All patient, all-payer, all disease registry• Provides a comprehensive preventive care, chronic disease

management system that looks for GAPS IN CARE• Emphasis on interoperability, integration and interfacing• Comprehensive and versatile reporting capabilities• Customizable alerts and decision support• Real-time graphical clinical dashboard• Patient Portal• Patient report card• Patient reminders• Patient outreach• Integrated PQRI module• CMS certified registry and sit on the National PCMH Committee

Outcome Manager- collects administrative and clinical data for total snapshot of your patient

Alert Summary provides real-time evidence based protocol to find gaps in patient care

Generate patient reminders from your alert lists. Letters or voice over IP phone messages

Patient Report Card

Dashboard- real-time reporting on clinical measures by provider and group

In Summary

Quality is not an act, it is a habit.

Aristotle

Barb Regan, RNHealthBridge513-247-5256

bregan@healthbridge.org

Getting Better All the Time: An Applied Guide to Quality Reporting

and Performance Measurement

The Family Medical GroupA doctor’s story

Mark Witte, MD

You are who your record says you are.

Bill Parcells

The Family Medical Group• 11 physicians – largest independent Family Practice

Group in Greater Cincinnati.• 5 mid level providers• 3 locations• 31,000 patients in our EMR• 85 employees• Level 3 certification as a patient centered Medical home.• Top workplaces in Greater Cincinnati, Enquirer Media• Best Doctor Group, CityBeat Magazine

The Family Medical Group-61,151 encounters in 201-Handle 12,000 phone calls a month.-50,000 + hits on our website-Social Media presence – Facebook/TwitterParticipants in the following community initiatives

– Patient Centered Medical Pilot– Primary Care Innovation Group– WE Thrive Collaborative on Childhood Obesity– REC enrollee with HealthBridge– Your Health Matters– OHIO KePro’s Quality Measurements– Case Management project with Anthem– Care Coordination Project with Good Sam Hospital– Childhood immunization initiative with the Hamilton County

Board of Health– Part of a local effort to establish a health center for the

uninsured in Price Hill

Intro to the Family Medical Group

Who are we?

A system of patient care.

Every system is perfectly designed to get the results that it gets. Paul Battalden, Clinical Microsystems

Important Foundations• Patient Centered Medical Home is not about the

doctor doing more, but the organization becoming more effective.

• PCMH teaches us that effective/outcome driven/patient centered Healthcare requires a commitment to data management

• PCMH challenges us to find a common language. A language that providers, staff and, most importantly, patients speak.

A case study• Regina A. Kohls, MD• 2700 hundred patients in her panel.• TFMG Physician profile. We have created a

profile of every providers practice that includes the following:– Demographic information ( gender, ages, etc.)– Clinical data (diagnostic codes, quality scores, etc.)– Financial data – Practice utilization of services– Community involvement– Patient feedback– Staffing feedback

Your Health Matters

• Public reported on 5 diabetes measures-– A1C– LDL– Blood Pressure– Aspirin use– Smoking cessation

– Her score for the first submission -9%

Lessons of Public Reporting • Humility• All are measured on the same criteria• Outside view that addresses internal issues• Forced us to look at how we were

documenting data• Some challenges to the criteria (aspirin)• Improvement process must begin with a plan• Long term commitment

Dr. Kohls’ plan• Helped create a new template/flowsheet in our

EMR. Leader on our EPIC optimization team. (Not about the doctor doing more)

• Created her own sheet to engage with patients. Every person with diabetes is given a sheet with the explanation of the measures. (Language)

• We want it to be the score of the doctor and patient.

• We created a patient information center on facebook.

What are some of the results

• We are waiting for the final audit, but we know there is at least a 30 percent increase in our score. (Data management)

• In the DRP (NCQA) submission, Dr. Kohls scored 100%.

What are the recommendations

• “Be not afraid.”• Use it as a tool for practice transformation.• We dedicate physician meeting time to

this.• Use it as an opportunity to train staff.• Engage MA’s in auditing process so that

they see how they are impacting the doctor/patient score.

One EMR – Multiple Practices

Mark Wess, MD

Islands of Transformation

UHGMCRes

UC-PCN 1UC-PCN 2

UHMed-Peds

Certified

UHGMCFac UC-PCN 3

UC-PCN 4UC-PCN 5

UC-PCN 6UC-PCN 6

UC-PCN 7 UC-PCN 6

Pending

Starting

Legend

PCMHUC-PCN 7

Team Approach = Success

• Provider• Office staff• EMR staff• Data extract and reporting staff• Office champion(s)• Patients

UC EMR Positives• Improved PCP capture• Location of care captured• Improved disparate data capture

– Templates– Cues for documentation– HealthBridge results– Improved awareness of prior

documentation and gaps– Flow sheet views

UC EMR Limitations

• Limitations of functionality supporting reporting needs

• Lack of interoperability between fields• Free text allowed in high value fields• Multiple fields and locations for the same

type of information • Unintended use of field, decreased data

quality• Variations in design and use by individuals

Data Analysis and ReportingInfrastructure for data extraction and analysis

– Hardware, software, individuals– Consistent data “cleansing”– “Combine” data into one parameter– Number at goal for each parameter– Percent at goal– Ranking within practice– Process and outcome ranking scores within groups

Reporting– Monthly reporting by provider– Entire practice sees results– Raw patient data for providers to see and use

Action Steps on Reporting: Improving Documentation of Care• Simplify number of locations• Structured data

– Radio buttons, Yes-No, limited text choices, date format consistent (select from calendar)

• Coded data– Especially diagnoses, medications, allergies

• Field edits or staff education on correct data entry (do not use %, mg/dL, etc.)

• Add EMR fields for missing data• Educate staff on correct documentation

– Feedback on data quality

Action Steps on Reporting

• Provider or office action steps for improvement– Targeted

• missing ASA, LDL

– Global• mail merge letter to patients

– Patient activation• diabetes day, focused office visit on barriers

to DM goals and interventions planned

Major Lessons Learned• Engaged team members including patients• Capture data in a consist and reportable

manner• Consistently report to team members• “Office” needs to take action to improve

documentation and optimal care• Outcomes matter (D5), but also consider

process adherence (foot exam)• Metrics reflect the team

Results

• Improving scores – patients and providers• NCQA PCMH designations• AF4Q public reporting with BTE payments• Beacon participation• P4P

Ongoing and continued efforts for improvement

Transformed culture and care processes

We thank you for your time and attention

Questions Welcome