8/6/2018

1

Quality Improvement Basics for Ambulatory Clinics Part Two

eCQI: A Comprehensive Approach to

MIPS

Sharon Phelps, RN, BSN, CPHIMS, CHTS-CP

Mountain-Pacific Quality Health

August 8, 2018

Goals

2

1) Review and understand key concepts of Electronic

Clinical Quality Improvement (eCQI)

2) Review and understand the eCQI process

3) Identify alignment opportunities across MIPS

categories and quality programs for identified areas of

need

4) Discuss using patient experience data within a Quality

Improvement Program.

What is eCQI?

3

Optimizing health information technology (HIT) and

standardized electronic data to achieve measurable

improvement in quality of care

Streamlining quality reporting and improving accuracy

of electronic health record (EHR) data through

improvement of data entry process and user

workflows within EHR

Incorporating data and functionality of EHR into

quality improvement projects as part of daily work

8/6/2018

2

eCQI: A Combination of…

4

EHR functionality

• Computer Provider Order Entry (CPOE)

• Clinical Decision Support (CDS)

• Patient portal/engagement

• Patient panels/tracking/risk stratification

• Health Information Exchange (HIE)

• Interfaces and registries

• Report utilities/population analytics

Evidence-based clinical best practices

Data tracking and analytics

Proven quality improvement methodologies

1

2

3

4

eCQI – The bottom line

5

It is simply a name for a consistent methodology and

approach for providers and hospitals to utilize EHR data

and technology to improve care delivery.

EHRs are now mainstream. This methodology literally

applies to EVERY PROJECT IN HEALTH CARE TODAY!

• EHRs are used to enter patient data.

• EHRs are used to mine patient data.

• EHRs are used to guide and decide the course of patient care.

• EHRs are used to share patient information.

• EHRs should be used to improve care!

As said by Dr. Allen Gee:

6

“We need to learn to use our EHRs as

tools to provide better care and

make improvements to the delivery

of care. It is not intended to simply be

a record of what we did today.”

–Dr. Allen Gee

Neurologist

8/6/2018

3

Certified

Electronic Health

Record

Technology

(CEHRT)

7

LOINCLogical observation identifiers names

and codes

ICD 10International statistical classification of

diseases and related health problems

SNOMED CTSystematized nomenclature of

medicine – clinical terms

HL7 Health language 7

NCPDP Script StandardsNational Council for Prescription Drug

Programs

STANDARDS used in CEHRT

8

Use of standardized language for certain functions:

Standard language sets the stage for standardized and efficient

national quality reporting.

What CEHRT standards do NOT mean:

9

Certification means

EHR workflows are

standardized or

accessibility is

universal. It simply

indicates software

has met basic

functional criteria to

support Meaningful

Use (MU).

The outcome =

software differs

greatly in workflow

between companies

and even between

installations.

EHR software

vendors apply their

functionality and

interpret rules (MU,

Physician Quality

Reporting System

[PQRS], MIPS, etc.)

in different ways.

8/6/2018

4

All roads lead to structured data

10

If it is not documented in a discrete field,

the system does not know it happened

and cannot trigger the next event.

• CDS rules and other functionality will not work

• Reports will be “inaccurate”

• Billing may not be accurate either

• Pertinent patient information does not get where it needs

to be

How to do

eCQI!

11

eCQI Process Cycle

12

8/6/2018

5

eCQI Project Process

13

1. Identify project and develop a project team

2. Determine project scope

3. Determine metrics (align with quality measures)

4. Identify changes and create change backlog (list of possible

changes/process measures to help improve outcome

measure)

5. Prioritize change backlog based on “value” of each change

6. Create sprint/PDSA cycle

7. Plan sprint/PDSA cycle

8. Complete PDSA cycle

9. Perform a review

10. Update and reprioritize change backlog

11. Begin new sprint

eCQI Process Steps 1-3:

14

• Identify and

develop a

project team

• Determine

project scope

• Determine

metrics

eCQI Process

Step 4:

Identify EHR

change points

“If there is no struggle, there is

no progress.”

- Frederick Douglass

15

8/6/2018

6

What is a change point?

16

Specific points or steps within the

process that could be changed to

improve data output and/or the

clinical outcome.

Change

Identification

Method 1:

Data Validation Process

17

What do we mean by data validation?

18

Using a process to ensure data pulled from

the EHR reflects the care being delivered

and documented.

(Don’t laugh, it can happen!)

8/6/2018

7

A data validation process will:

19

Help clearly

identify problem

areas in EHR

on which to

focus

Improve data

entry, because

it is now being

monitored and

used for

improvement

Build reliability

and confidence

in data output

for reporting to

external entities

Report’s generated...Now what?

20

Validate your report data by:

• Working backwards from the report to ensure data

being collected is data you want for your metric

• Getting patient level data and find the field that is

“supposed” to be populated that feeds the report

• Once you find the right fields, ensuring this is where

providers and staff are actually trained to document

• Ensuring there are not other areas where the same

item can be/is being documented

An example of a data validation process:

21

1. Run report.2. Run patient list.

Who met the denominator? Who met the numerator?

3. Review patient content.

4. Find data field.

5. Talk to staff. Do they usually

document there?

6. Does the report reflect

what you found?

8/6/2018

8

The data validation change point is key:

22

Once the opportunity for improvement has been

identified through report validation, use the rest of the

eCQI process to improve the accuracy of

information being entered and reported out.

This is a very important first change step! It results in

valid reports so your future changes are backed by

solid data.

Change

Identification

Method 2:

Workflow Reviews

23

Purpose of workflow analysis

24

Creating a visual map of workflows can increase

key stakeholder understanding of the process,

allowing further quality improvement to occur by

acting as:

• Information display

• Visual/thought stimulation

• Data collection tool

• Change management tool

• Discovery method for RCA

8/6/2018

9

When to use a workflow exercise:

25

Bad data (“garbage in, garbage out”)

Process is wasteful

Root cause analysis/problem/error prone area

New device/product/supply is added to current process

Patient/staff dissatisfied with current process

Examples:

• Data collection

and reporting for

MIPS is

burdensome, no

one believes the

data

• Patient

scheduling takes

too long

• Increase in med

errors with

bedside barcode

scanning

Layers of Workflows in eCQI

26

Includes

environmental

layout of patient

room, equipment,

devices and

supplies

How is the work

documented?

What screens and

fields are used?

Where does the

documented

information go?

Why does it go

there (triggers or

reports)?

How does it get

there (interfaces,

uploads, etc.)?

Physical Electronic Data

Analyzing

Workflows

27

8/6/2018

10

General Rules of Thumb

28

• Clearly define and understand the scope of the

process you are planning to map.

• Keep it small – you have three layers now!

• Map the REALITY not the DREAM – what is actually

occurring on a daily basis.

• Don’t solve the problem before you map it out. You may

solve the wrong problem and never solve the real one.

Staff Participation

29

Short term pains = long term gains

• Cover a few hours work = accurate flow mapping

Go to them! Get out of the conference room!

• Simply watch them work and document it

Display the mapping for staff in break room. Have them

write feedback on sticky notes and put the notes on the

map

Incentives work, too ☺

Physical Workflows

30

Environmental layout of patient room, equipment,

devices, supplies, etc.

Use floor plans if available or just sketch it out

Count physical steps between significant places:

• Number of steps from patient room to med room,

supply room and documentation stations/computers

• Steps from computer to printer

8/6/2018

11

Physical change point

analysis:

31

• How many steps is it to a documentation area?

• How many steps to a printer? How often do they have to

go to the printer?

• Are staff using the portable equipment/laptops, etc.?

– Why not? Work through barriers. Take users’ concerns about

technology seriously and help them to adapt with training, role

playing and testing equipment until they are comfortable.

– Set expectations of using equipment and monitor

performance.

• If everything else is at the bedside, how far away are

supplies and medications?

• What needs to change to support EHR use as a tool?

EHR Workflow Mapping

32

• Does the software company already have it done? DON’T

BE AFRAID TO ASK! Compare your workflow to the software company – what is

different?

• Take screenshots at each point of data entry Get multiple steps on a screenshot; just keep track of them with

a numbering system

• One step is defined as one point of data entry Where is each component entered?

Who is entering it?

Does it trigger a key next step to the process?

Where does that data go? Does it go anywhere?

• To stay focused, keep in mind your purpose for workflow

analysis

EHR workflow example (cont.)

36

8/6/2018

12

EHR Change Point Analysis

Questions

34

How many steps are staff really going through, what is

reasonable for the task?

• Be sure to multiply the steps by how many times a day staff would

be doing the task to understand the realistic data entry effect.

• Example: Patient has 12 medications to be given per shift x 20 steps

to enter each medication in the chart = 240 steps for medication

entry for that patient per shift. Is that reasonable?

Do the right staff have the right user access to enter the right

information?

What needs to change to improve EHR use as a tool?

Information/Data Flow Mapping

35

Data/information flow mapping:

• Define data type

– Text, string, date, value, formula, etc.

• Determine where each data point travels and what

function/process happens as a result of data getting there

– Example: Does it trigger a Clinical Decision Support (CDS) rule,

or need to go to an interface?

– How many different people, modules, applications or forms are

capturing the same data?

– Does duplicate information flow or does it have to be entered by

multiple different people?

• Determine if it is reportable data

?

Data Flow Analysis Questions

36

Are the key data points that should

flow ACTUALLY flowing where

they are needed? Why not?

What needs to change to support

EHR use as a tool?

8/6/2018

13

In Summary

37

All of the tools we reviewed can be used to

identify specific steps in a process, either

EHR or physical, that need to be changed

to improve data collection and outcomes.1. Data Validation

2. Physical workflow analysis

3. Electronic workflow analysis

4. Information flow analysis

Change points

have been

identified, now

what?

Let’s go back to the

eCQI process….

38

eCQI Project Process

39

1. Identify project and develop a project team

2. Determine project scope

3. Determine metrics (align with quality measures)

4. Identify changes and create change backlog (a list of possible

changes/process measures that will help improve the outcome measure)

5. Prioritize change backlog based on “value” of each change

6. Create spring/PDSA cycle

7. Plan sprint/PDSA cycle

8. Complete PDSA cycle

9. Perform a review

10. Update and reprioritize change backlog

11. Begin new sprint

8/6/2018

14

Change Backlog: Identify and

Prioritize Changes

40

• As changes are

identified, create

change backlog

(list of possible

changes/process

measures to help

improve outcome

measure)

• Prioritize change

backlog based on

“value” of each

change

Create PDSA

Sprint Cycles

41

eCQI Project Process

42

1. Identify project and develop a project team

2. Determine project scope

3. Determine metrics (align with quality measures)

4. Identify changes and create change backlog (a list of

possible changes/process measures that will help improve

the outcome measure)

5. Prioritize change backlog based on “value” of each change

6. Create sprint/PDSA cycle

7. Plan sprint/PDSA cycle

8. Complete PDSA cycle

9. Perform a review

10. Update and reprioritize change backlog

11. Begin new sprint

8/6/2018

15

PDSA Cycle Template:

43

• Create sprint/PDSA

cycle

• Plan sprint/PDSA

cycle

• Complete PDSA

cycle

• Perform a review

• Update and

reprioritize change

backlog

• Begin new sprint

MIPS: Getting

Started with

eCQILet’s apply eCQI

to MIPS…

44

eCQI Keep in Mind

45

When choosing eCQI projects:

• Focus on return on investment opportunities as well

(financial, efficiency gains, resource utilization, etc.)

• Review current quality program requirements, align

project for biggest return on investment or alignment

across programs

• For MIPS: If possible, choose an eCQI project

outcome or activity that benefits more than one MIPS

category

8/6/2018

16

MIPS eCQI Process

46

1. Run the required Quality Measures and Advancing Care

Information (ACI) reports.

2. Choose Quality Measures that align with other program

requirements (CPC+, PCMH).

3. Compare current performance to goals.

4. Complete a data validation process and review required

workflows.

5. Correct workflow entry should start to improve your

performance on measures – then utilize more accurate data to

support more quality improvement.

MIPS - Example 1

47

CQM - Diabetes Foot Exam – CMS 123/MIPS 163

1. Confirm correct data entry in EHR for CQM.

2. Set up a clinical decision support (CDS) rule to enhance your

workflow (alert for DM patients being seen who are due for a foot

exam).

3. Use eCQI process to monitor progress and continued improvement.

Benefits:

MIPS: Improve

score for Quality,

PI and IA for

primary care and

specialists

MIPS:

Receive 10%

bonus for use of

EHR in IA

Improve patient

satisfaction

(CAHPS)

Improve data and

advance use of

EHR to improve

patient safety and

quality reporting

accuracy

MIPS - Example 2

48

Align with existing community diabetes classes

1. Utilize EHR data to identify high-risk DM patient panel.

2. Utilize EHR functionality to provide patient education and establish

care plans/set goals.

3. Coordinate with existing resources to provide DM education (DEEP™

or other) to patients.

4. Utilize eCQI process to monitor progress and continued improvement.

Benefits:

MIPS:

Improve score for

Quality, PI, IA and

Cost

MIPS:

Receive 10 percent

bonus for use of

EHR in IA

Reduce burden and

cost for clinic (classes

available via QIO or

other community

resources)

8/6/2018

17

eCQI Proven Results

49

Automated data tracking for eCQI projects

and consistent/validated data

Rapid improvement gains on PDSA goals

(PDSA cycles or “sprints” average time =

30 days)

Improved

consistency on

workflows and use of

EHR

Trained staff on repeatable QI

process for ongoing use

Efficient approach;

reduces time and

resource use

Improved alignment of

QI projects and

resources

Improved clinical

outcomes for patients

MIPS eCQI Resources

50

Mountain-Pacific eCQI resources and templates

CMS MIPS Quality Measures

CMS MIPS Advancing Care Information Measures

CMS MIPS Improvement Activities Lists

CMS information on Medicare Transition of Care

Management Code

CMS Antimicrobial Stewardship/MIPS crosswalk

Resource Links

51

Health IT/electronic enabled Clinical QI (healthit.gov)• https://ecqi.healthit.gov/content/introduction-electronic-clinical-

quality-improvement

Mountain-Pacific eCQI resources• http://mpqhf.com/corporate/health-and-technology-services/hts-

services/eclinical-quality-improvement/

Certified Health IT Product List (healthit.gov)• https://chpl.healthit.gov/

8/6/2018

18

Questions or

Comments?

52

Developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for

Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern

Mariana Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and

Human Services. Contents presented do not necessarily reflect CMS policy. 11SOW-MPQHF-WY-D1-18-20

Acronyms

53

AMI – Acute Myocardial Infarction (heart attack)

CAH – critical access hospital

CART – CMS Abstraction and Reporting Tool

CEHRT – Certified Electronic Health Record Technology

CMS – Centers for Medicare and Medicaid Services

eCQI – electronic Clinical Quality Improvement

eCQM – Electronic Clinical Quality Measure

ED – Emergency Department

EDTC – Emergency Department Transfer Communication

EHR – Electronic Health Record

Acronyms (cont.)

54

HIT – Health Information Technology

HCAHPS - hospital consumer assessment of healthcare providers &

systems

HRSA – Health Resources and Services Administration

IQR – Inpatient Quality Reporting

IMM – Immunizations

IQR – inpatient quality reporting

OP – Outpatient

PDSA – Plan, Do, Study, Act

QCDR – Qualified Clinical Data Registry

QI – Quality improvement

VBP – Value Based Payment