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

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, Electronic Measurement Coordinator, RN, MHA, BJC Healthcare

Purpose & Outline 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

BJC HealthCare – St. Louis, Missouri BJC HealthCare is a non-profit health care organization based in St. Louis, Missouri. It is the St. Louis area's—and one of Missouri's— biggest employers.

BJC HealthCare by the Numbers

Preventable Harm E lectronic Measures

How it All Started - Interoperability Challenges

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 0.0% 99.0% Surgical Incision 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%

Getting Started- Interoperability Challenges- Impact on eCQMs 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.

Program Goals & Solution 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

BJC eCQM Roadmap BJC E CQM T OOL Production CMS 2016 CMS & TJC 2018.01 Submission 2017 Upgrade Submission Legacy Project 2016 2017 Retired Start Upgrade Upgrade 2015 2016 2017 2018 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Kick-off Go-Live POD 2 N EW EHR Testing POD 1 Academic ETL Build Validation, BHC

Implementation Cycle – Legacy Systems

Implementation Cycle-New E HR Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Iterative Processes CMS 2019 Submission Workflow Extract Build Value Set Mapping Pre-production Post-production Validation Identification Testing  Identify SMEs     Identify source data Map data elements Test content Validate measure results  Determine fields based on to standard terms   Test workflow Document standard workflow  workflows by Custom field  workflow and incorporate Test mapping  measure Test Extract, Transfer, mapping based on into training  Test measure  Customize EHR to Load (ETL) new workflows  Tweak ETL calculation   close known gaps Test content Tweak mappings

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.

BJC eCQM Roadmap - Ongoing BJC E CQM T OOL Upgrade Upgrade Validation Validation Workflow enhancements- CMS 2019 CMS 2018 Measure close known gaps Submission Submission management and performance TJC 2018 CQL TJC 2019 improvement 2018.01 Submission Submission Upgrade Upgrade 2018 2019 Sept Oct Nov Dec Jan Feb Mar Apr May Jun July Aug EHR Epic Optimization Upgrade EHR EHR Upgrade

Current E HR – eCQM Scorecard GOAL ID eMeasure Title 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 260 242 512 290 271 448 330 287 306 282 307 287 Median Admit Decision Time to ED-2a ED Depart Time for Admitted 52 79 194 91 55 167 121 81 75 75 94 85 Patients 93% 85% 69% 83% 77% 88% 86% 89% 87% 86% 11% VTE-1 VTE Prophylaxis 95% 95% 93% 75% 89% 73% 94% 94% 94% 97% 92% 14% VTE-2 ICU VTE Prophylaxis 95% STK-2 Discharged on Anti-thrombotic 93% 86% 88% 89% - 76% 77% 100% 50% 97% 95% Therapy STK-3 Anticoagulation Therapy for Atrial 78% 67% 54% 40% - 29% 63% - 100% 63% 95% Fibrillation/Flutter STK-5 Antithrombotic Therapy by End of 93% 91% 91% 80% - 88% 86% 50% 100% 94% 95% Hospital Day 2 81% 74% 90% 91% - 73% 73% 100% 33% 96% STK-6 Discharged on Statin Medication 95% 100% 98% 85% 79% - 83% 97% 0% 100% 85% STK-8 Stroke Education 95% STK- Assessed for Rehabilitation 82% 99% 99% 97% - 97% 94% 100% 40% 94% 95% 10 12% 13% 17% - - - 27% 38% 8% 18% PC-01 Elective Delivery 3% 54% 54% 36% - - - 50% 37% 24% 52% PC-05 Exclusive Breast Milk Feeding 50% EHDI- Hearing Screening Before 90% 96% 74% - - - 93% 87% 92% 91% 75% 95% Hospital Discharge 1a

Summary Success Factors Lessons Learned • Complexity – will not be reduced anytime • Leadership support soon • Clinical and IT partners • Required - time, talent, tools, and resources • eCQMs platform for future performance • Challenges - alignment of measures, clinical improvement work flows and EHR systems • Commitment to testing and validation (over On-going Challenges and over) • Continual State of Change-evolving national • Resisted rush to production landscape • eCQM calculation engine (flexibility & • Tight timelines (upgrade, submission, annual customization) update) • Paradigm shift- chart abstracted gold standard to optimizing and using eCQMs

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

Coming Soon to BJC eCQM… Memorial Belleville Memorial East

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

Appendix

What Makes A Good Quality Measure?

eCQM Measure Calculation E ngine