Pioneers in Quality: eCQM National Data Trends and Statistics – … · 2019-06-03 · the ePC-01 data to The Joint Commission − An additional 56 hospitals submitted ePC-01 data

Pioneers in Quality: eCQM National Data Trends and Statistics – Understanding your organization’s performance

Tricia Elliott, MBA, CPHQStephen Schmaltz, MS, MPH, PhD

May 21, 2019

2© 2019 The Joint Commission. All Rights Reserved.

Agenda:1. Overall eCQM reporting statistics 2. Results by measure3. Exceptions and exclusions4. PC-01 comparison of eCQM to chart5. Resources available6. Final Comments


Overall eCQM Results2017 Data


Joint Commission eCQMsMeasure ID eCQM eCQM Name

16420 eED-1a Median Time from ED Arrival to ED Departure for Admitted ED Patients – Overall Rate

16424 eED-2a Median Admit Decision Time to ED Departure Time for Admitted Patients – Overall Rate

16441 eSTK-02 Discharged on Antithrombotic Therapy

16442 eSTK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter

16444 eSTK-05 Antithrombotic Therapy by End of Hospital Day 2

16445 eSTK-06 Discharged on Statin Medication

16460 eVTE-1 VTE Prophylaxis

16461 eVTE-2 Intensive Care Unit (ICU) VTE Prophylaxis

16544 ePC-01 Elective Delivery

16580 eCAC-3 Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver

16581 ePC-05 Exclusive Breast Milk Feeding During the Newborn’s Entire Hospitalization

16606 eAMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival

16607 eEHDI-1a Hearing Screening Prior to Hospital Discharge


2017 eCQMs Record and Hospital Counts by Measure

Measure Name Hospitals Records

eAMI-8a: Primary PCI Received Within 90 Minutes 3 0eCAC-3: Home Management Plan of Care 18 224ePC-01: Elective Delivery 190 3,740eSTK-03: Anticoagulation Therapy for Atrial Fibrillation/Flutter 531 4,211eSTK-05: Antithrombotic Therapy by End of Hospital Day 2 918 31,374ePC-05: Exclusive breast milk feeding 120 38,077eSTK-06: Discharged on Statin Medication 1,190 38,279eSTK-02: Discharged on Antithrombotic Therapy 1,405 53,258eEHDI-1a: Hearing Screening Prior To Hospital Discharge 289 107,378eVTE-2: Intensive Care Unit (ICU) VTE Prophylaxis 1,200 379,358eVTE-1: VTE Prophylaxis 1,375 1,619,710eED-2a: Median Admit Decision Time to ED Departure Time for Admitted Patients 1,468 1,766,646

eED-1a: Median Time from ED Arrival to ED Departure for Admitted ED Patients 1,583 2,230,046


Hospitals Reporting by eCQM40

3

354

52

262

234

74 54 18 12 43 16 4

1,58

3

1,46

8

1,40

5

1,37

5

1,20

0

1,19

0

918

531

289

190

120

18

1594

1490 15

29

1384

1224 13

14

935

530

298

190

138

24

0

200

400

600

800

1000

1200

1400

1600

1800

eED-1a eED-2a eSTK-02 eVTE-1 eVTE-2 eSTK-06 eSTK-05 eSTK-03 eEHDI-1a ePC-01 ePC-05 eCAC-3

2016 2017 2018


Volume of Records Reported by eCQM66

0,74

0

502,

642

332,

217

88,6

68

5,22

6

2,38

6

2,47

3

4,55

8

1,60

0

328

912

154

2,23

0,04

6

1,76

6,64

6

1,61

9,71

0

379,

358

107,

378

53,2

58

38,2

79

38,0

77

31,3

74

4,21

1

3,74

0

224

2,13

9,41

7

1,74

1,91

3

1,58

0,88

7

384,

957

112,

034

57,8

04

40,1

83

35,3

50

33,4

40

5,04

2

3,28

0

399

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

eED-1a eED-2a eSTK-02 eVTE-1 eVTE-2 eSTK-06 eSTK-05 eSTK-03 eEHDI-1a ePC-01 ePC-05 eCAC-3

2016 2017 2018


Individual eCQM results2017 Data


− Results: 2017 eCQM distribution compared to the corresponding distribution of the chart-based measure

− Exclusions: there are clinical reasons that would suggest the case should not be included in the measure population

− Exceptions: the case is eligible for the measure population and fails the numerator criteria, but there clinical reasons that the case didn’t pass these criteria

DefinitionseCQM Data

10© 2018, The Joint Commission

ED MeasureseED1a and eED2a


Mean Performance by eCQM

270.

2

60.5

309.

5

132.

9

341.

9

140.

5

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

eED-1a eED-2a

Min

utes

2016 2017 2018

ED eCQMs (Time Values)




Stroke MeasuresSTK-2, STK-3, STK-5, STK-6


Aggregate Performance by eCQM

88.2

%

82.6

%

86.8

%

72.4

%

90.8

%

68.0

%

89.7

%

85.5

%92.9

%

69.8

%

89.7

%

89.1

%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

eSTK-02 eSTK-03 eSTK-05 eSTK-06

Min

utes

2016 2017 2018

eCQMs (Percentage Values)


Symbols represent National Aggregate Rates








VTE MeasuresVTE-1 and VTE-2



88.2

%

94.3

%

81.4

%

92.7

%

86.8

%

93.6

%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

eVTE-1 eVTE-2

Min

utes

2016 2017 2018







PC MeasuresPC-01, PC-05



43.0

%

32.7

%

26.1

%

53.6

%

18.8

%

54.6

%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

ePC-01 ePC-05

Min

utes

2016 2017 2018







Home Management Plan of Care Given to Patient/Caregiver (Children’s Asthma Care)

eCAC-3



91.6

%

80.4

%

66.2

%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

eCAC-3

Min

utes

2016 2017 2018





EHDI MeasuresEHDI-1a



76.3

%

75.9

%

84.4

%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

eEHDI-1a

Min

utes

2016 2017 2018





Reasons for exclusions and exceptions2017 eCQM Data


eCQM exclusions % exclusions exceptions % exceptions

eSTK-02 8522 13.7 329 0.5eSTK-03 1031 19.0 181 3.3eSTK-05 7420 18.8 589 1.5eSTK-06 16031 29.2 573 1.0eVTE-1 1047858 39.2 0 0.0eVTE-2 56577 12.8 4549 1.0ePC-01 6146 62.2 0 0.0ePC-05 1795 4.5 0 0.0eEHDI-1a 228 0.2 0 0.0

Summary of Exclusions and Exceptions by Measure2017 eCQM Data


− Total of 5836 exclusions for this measure

− 14% of the number of cases potentially eligible for the measure

− Most common reasons for exclusion from the measure - (% of exclusions):− Patients who expired, left against medical advice, or were discharged other than home: 90%− Patients with comfort measures documented: 31%

STK-02 Exclusions2017 eCQM Data




− Most common reasons for exclusion from the measure - (% of exclusions):− Patients who expired, left against medical advice, or were discharged other than home: 88%− Patients with comfort measures documented: 38%





− Most common reasons for exclusion from the measure - (% of exclusions):− Patients who have a duration of stay of less than 2 days - 58%− Patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy administered within 24

hours prior to arrival or anytime during hospitalization – 38%− Patients with comfort measures documented –9%



− Total of 414 exceptions for this measure


− Most common reasons for exceptions from the measure - (% of exceptions):− Patient refusal – 69%− Statin allergy – 37%

STK-06 Exceptions2017 eCQM Data


Hospital-specific comparisons of eCQM results to most recent chart review results




− Hospitals reporting low eCQM results in 2016 tend to improve results in 2017

− eCQM results are more variable compared to chart review results

− As noted on prior slides, eCQM results are generally moving closer to those obtained through chart review

− Hospital-specific comparisons of eCQM and chart review results indicate that the eCQM results are generally less favorable, but that the gap between the two is decreasing

Hospital-specific comparison observationseCQMs


Comparison of PC-01 eCQM Results to chart review


− Initial Population - Patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care to undergo a delivery procedure and had a length of stay <= 120 days

− Denominator - Patients delivering newborns with >= 37 and < 39 weeks of gestation completed

− Denominator Exclusion - Patients with conditions possibly justifying elective delivery prior to 39 weeks gestation

− Numerator – Patients with elective deliveries by either:

− Medical induction of labor while not in labor prior to the procedure− Cesarean birth while not in labor and with no history of a prior uterine surgery

PC-01 and ePC-01: Elective Delivery definition


− The ePC-01 measure hospital rates tend to disagree the most with results obtained through chart review, compared to other eCQM measures, so an analysis was undertaken to compare these two data sources at the record level

− Submission of chart-based PC-01 data to The Joint Commission is required for all accredited hospitals with obstetric services and an average daily census of 10 or more

− Of the 2121 hospitals submitting PC-01 data based on 2017 discharges, 131 also submitted the ePC-01 data to The Joint Commission

− An additional 56 hospitals submitted ePC-01 data through the Apervita direct submission platform, but these data were not available for analysis

− eCQM and chart data records from these 131 hospitals were then matched to compare the measure outcome at the individual record level

− There were 18,169 matched records included in the analysis

Comparison of PC-01 eCQM Data to Chart Data2017 matched eCQM and Chart Data


− The eCQM under-identifies records that belong in the denominator compared to chart review

− Cases identified as being in the denominator by chart review were also identified as being in the denominator by the eCQM

− Most of these cases were misidentified as not being in the measure population

Comparison of PC-01 eCQM Data to Chart Data: Denominators2017 matched eCQM and Chart Data


− Reasons for misidentification:

− Missed denominator records have no gestational age recorded in the eCQM which automatically throws the case out of the measure

− The gestational age may have been captured, but the timing of assessment did not meet the timing requirement for the measure which requires assessment of gestational age within 24 hours before delivery

− Other reasons include mismatches between the eCQM and chart on the gestational age and conditions possibly justifying an elective delivery not being captured in the eCQM

Comparison of PC-01 eCQM Data to Chart Data: Denominators2017 matched eCQM and Chart Data


− The eCQM over-identifies numerator status compared to chart review

− Of the records identified as being a numerator by the eCQM, only a few were also identified as a numerator by chart review

− Records were identified as being in the denominator and not being in the measure through chart review

− Of the records identified as being a numerator by chart review− Only a few Records identified by the eCQM as not being in the measure and fewer

were identified as being in the denominator

Comparison of PC-01 eCQM Data to Chart Data: Numerator2017 matched eCQM and Chart Data


− Reasons for eCQM failing to identify as a denominator case:

− C-Section with prior uterine surgery identified in chart but not in eCQM − Medical Induction with Active Labor identified in chart but not in eCQM − Planned C-Section in Labor identified in chart but not in eCQM− C-Section with active labor identified in chart but not in eCQM − C-Section identified in eCQM but not in chart, no labor− Medical Induction identified in eCQM but not in chart, no labor

− Reasons for eCQM failing to identify as a numerator case:

− No gestational age in eCQM− Disagreement on gestational age (eCQM gest age is 39 weeks)− Timing of gestational age at or after delivery

Numerator Discrepancy Reasons2017 matched eCQM and Chart Data


− Reasons for eCQM failing to identify as not being in the measure:− Denominator exclusions are identified in chart but not in eCQM− Chart says gestational age not 37 or 38 but eCQM says they are − History of stillbirth identified by chart but not in eCQM

Failure of eCQM to identify record as being in the measure 2017 matched eCQM and Chart Data


− The combination of under-identifying numerators and over-identifying denominators results in inflation of ePC-01 rates compared to PC-01 chart-based rates

− TJC is evaluating methods regarding the capture of gestational age to improve the agreement between the eCQM and chart results for this measure

− Accurately capturing prior uterine surgery, planned C-Section in labor, medical induction with active labor, C-Section with active labor, and labor in the eCQM would avoid the miss-identification of records as a numerator

− More work needs to be done to resolve the gestational age discrepancies found in some records between the eCQM and chart to determine the most accurate capture of these data

Comparison Study Conclusions2017 matched eCQM and Chart Data


Resources for evaluating eCQMs


Resources:

• eCQM Flows (Overview of Population Criteria Requirements)

• Direct Data Submission: Quality Improvement Tab/Process

• Additional Resources


From eCQI Resource Center

These were made available for hospital measures starting with the 2019 reporting year.



https://ecqi.healthit.gov/eligible-hospital/critical-access-hospital-ecqms?field_year_value=2

https://ecqi.healthit.gov/eligible-hospital/critical-access-hospital-ecqms?field_year_value=2




The Joint Commission – Direct Data Submission Platform

− Hospitals with ADC>10 use the Platform for submission of CY 2019 data due March 16, 2020

− Minimum of 4 measures for one self-selected quarter are submitted to the Joint Commission

− Platform is OPEN now

− Use DDSP early and often to address your eCQM data− All 13 eCQMs can be uploaded onto the platform, and the

available tools can be used to evaluate the eCQM results


Navigate to “Verify Data” – Quality Improvement Tab

(1) Select Verify Data

(2) Select “Quality Improvement” Tab


(3) Select ePC-01

Measure

(4) Select appropriate

quarter

(5) Select Data bar

“Does not Meet”

(6) Click on the magnifying glass for

any one of the “Active Documents”

Make selections, Launch ‘Source Viewer”

This will launch the “Source

Viewer/Logic Explorer”


Select Logic Explorer and run against PC-01

(7) Select Logic

Explorer

(8) Choose “PC01”

measure

(9) Click Generate

Clicking on “Generate” will run the file through CQL

measure definition for the “PC01” measure

This will switch the mode to “Logic

Explorer”


Select episode of care

(10) Select Episode of Care

This will highlight the measure definitions with

green indicator dot. A green dot means that the EOC passed that definition.


Investigate using Logic Explorer

(10) Select Denominator and keep selecting in respective

sub-columns(don’t click checkbox)

(11) Click on check box “Gestational Age Near

Term” to see CQL definition

No green indicator dot on “Denominator” indicating that the EOC did not meet denominator definition.


Pioneers In Quality – Joint Commission Website


Pioneers In Quality – CQL Education Expert to Expert Series


Thank you for joining us…− Three Takeaways

1. The gap between chart abstracted measures and eCQMs is shrinking.

2. Use aggregated results of the 2017 and 2018 eCQMs to identify opportunities for improvement in your HCO’s eCQM results.

3. Use the available resources on the DDSP platform and on the Joint Commission website.
