Clinical Quality and PolicyA DEEP DIVE BEFORE AN AERIAL VIEW

Our Mission

1. Understand the technical framework

2. Testing

3. Programs and performance

4. Governance

5. Data- and Workflow

6. Integration and Interoperability

7. Making Quality Meaningful

Understanding the Technical Framework

1. QDM to CQL

2. CDA to FHIR, Smart on FHIR apps

3. Terminology

4. VSAC

5. Cimi on FHIR

Understanding a Measure: (Example title and number)

eMeasure (or eCQM)

The electronic format for quality measures using:

• the Quality Data Model to define clinical concepts (Lego brick specifications) and

• the Healthcare Quality Measure Format to define quality measures (instructions constraining the use of Lego blocks to create meaningful structures).

8Barnes I. Making the Move to Electronic Clinical Quality Measurement. Epic 2015 Expert User Group Meeting. Verona, WI. March 17, 2015

The Quality Data ModelAn information model intended to clearly and consistently define concepts used in quality measures in a standardized format.

The QDM includes:

➢ criteria for data elements,

➢ relationships for relating data element criteria to each other, and

➢ functions for filtering criteria to the subset of data elements that are of interest.

Quality Data Model (QDM)

9Barnes I. Making the Move to Electronic Clinical Quality Measurement. Epic 2015 Expert User Group Meeting. Verona, WI. March 17, 2015

HOW DO WE DESCRIBE A PROBLEM FOR ELECTRONIC QUALITY MEASUREMENT?

QUALITY DATA ELEMENT Category: consists of a single clinical concept identified by a value set

‘Medication’, ‘Laboratory Test’

Data Type: The context in which each category is used to describe a part of the clinical care process

‘Laboratory Test, Order’ ‘Laboratory Test, Performed’

Attribute: provides specific detail about a QDM element

‘Laboratory Test, Performed: (result)’

Value Set: used to define the set of codes that can possibly be found in a patient record for a particular concept.

Barnes I. Making the Move to Electronic Clinical Quality Measurement. Epic 2015 Expert User Group Meeting. Verona, WI. March 17, 2015

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Health Quality Measures Format (HQMF)

A Health Level Seven International (HL7) standard for documenting the content and structure of a quality measure.

It includes:

• Metadata

describing the

quality measure

• Human readable

narrative

description, data

criteria, and

measure

population

• Machine readable

translation of the

measure.

Barnes I. Making the Move to Electronic Clinical Quality Measurement. Epic 2015 Expert User Group Meeting. Verona, WI. March 17, 2015

11

2018 Standards Evolution for CMS eCQM Specifications

10

Public comment on eCQMs open until Nov. 10!

Expression Logical Model (ELM)

Clinical Quality Language (CQL)

NativeJava

ScriptDrools SQL

Authors use CQL to produce libraries containing human-readable yet precise logic.

ELM XML documents contain machine-friendly rendering of the CQL logic. This is the intended mechanism for distribution of libraries.

Implementation environments will either directly execute the ELM, or perform translation from ELM to their target environment language.

Future Standards Need to be Interoperable Across Each Other to Allow Flexibility

Evolving eCQM Standards

Now

Definitions:

HQMF – Health Quality Measure Format

CQL – Clinical Quality Language QDM – Quality Data Model

Near Term

HQMF (Metadata, Population Structure

QDM (Logic)

QDM (Data

Model)

HQMF (Metadata, Population Structure)

CQL (Logic)

QDM (Data Model)

Differences Between the Quality Data Model (QDM) Now and When using Clinical Quality Language (CQL)

QDM Now

• Data Model and Logic are both in the QDM

QDM with CQL

• The Data Model will continue to exist as the QDM

• CQL will provide the logic expressions and will replace that function currently in the QDM

Clinical Quality LanguageOriginated from need to harmonize decision support and quality measurement

Author-friendly and human-readable language

Computable and implementable

Standard for Trial Use (STU)

CQL provides the ability to express logic that is human readable yet structured enough for processing a query electronically

Limitations of a QDM Logic Model QDM can’t express comparisons needed to evaluate outcomes of care

◦ e.g., change in depression scale (PHQ-9) results over time for a single patient, or for each patient in a cohort

QDM can’t use mathematical expressions to derive results◦ e.g., patients who have a PHQ-9 Follow-Up Score = ½(Baseline PHQ-9 Score)

QDM can’t identify components of an assessment, examination or test procedure

◦ e.g., assure the systolic and diastolic blood pressure results are from the same blood pressure reading

QDM logic model only works with QDM data model

Benefits of CQL

**

Measure Authoring Tool

Narrative Measure Specification

Measure Authoring Tool Measure Package

MAT Measure Package Export

1. Human Readable HTML

2. CQL Library information

3. ELM (machine-friendly representation of XML)

4. HQMF XML file consumable by an EHR

Measures encoded and packaged in the MAT output 4 measure artifacts

Measure Authoring Tool: Clause Library

Standards Improvement and Harmonization:Clinical Quality Measurement and Clinical Decision Support

CQM

Specific

Standards

HQMF

QRDA

Category-1

QRDA

Category-3

QDM

CDS

Specific

Standards

HeD

vMR

Common

Metadata

Standard

Common Data

Model Standard

(QI

Core/FHIR)*

Common

Expression

Logic Standard

(CQL)**

* Quality Improvement and Clinical Knowledge

** Clinical Quality Language

Common

Expression

Logic Standard

(CQL)**

Common

Clinical Data

Elements

(CIMI/FHIR)

Advanced Next Generation Standards for Clinical Quality Improvement

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Allowed in QPP now– proposed support in future QPP reporting API

Next Generation Standards for Clinical Quality: FHIR Clinical Reasoning: FHIRhttps://hl7-fhir.github.io/clinicalreasoning-module.html

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HSPC: Healthcare Services Platform Consortium“The iPhone Approach”

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Terminology

The problem

• Huge amounts of clinical data being generated both within and outside clinical care settings

• Tremendous potential• Primary use – i.e., clinical care

• Secondary use – e.g., quality measures, public health, rare diseases research

• But potential can only be realized if the data are stored and exchanged using common data and messaging standards

Data versus messaging standards

• Data standards – provide a consistent definition for a given concept across systems

• Messaging standards – provide a common structure by which to exchange data between systems

Data vs messaging standards

• Need both common data and messaging standards for successful interoperability

iOS AndroidiOS Messaging standardMessaging standard

Data standard

Data standards

• LOINC – laboratory and clinical observations• Urine sodium, Systolic blood pressure, Ankle MRI

• SNOMED CT – findings/values• Hypernatremia, Hypotension, Streptococcus pneumoniae bacteremia

• RxNORM – clinical drugs• Penicillin, Infliximab

• IEEE – observables for medical devices• Ventilator breath rate setting, EEG burst rate

• ICD-10-CM – diagnoses (for billing)

• CPT – procedures (for billing)

Messaging standards

• HL7 (Health Level 7)• Version 2

• Version 3/CDA

• FHIR

• DICOM (Digital Imaging and Communications in Medicine)

LOINC in an HL7 message

MSH|^~\&|||||19981105131523||ORU^R01|

PID|||100928782^9^M11||Smith^John^J|

OBR||||55417-0^Blood pressure panel^LN|

OBX||CE|8361-8^Body position^LN| |33586001^Sitting^SCT|

OBX||NM|8479-8^Systolic blood pressure^LN||138|mmHg|

OBX||NM|8462-4^Diastolic blood pressure^LN||85|mmHg|

LOINC in XML message (e.g., HL7 CDA)

<Observation> ...

<component> <code>

<coding> <system value="http://loinc.org" /> <code value= "1975-2" /> <display value="Bilirubin.total [Mass/volume] in Serum or Plasma" />

</coding> </code> <valueQuantity>

<value value="0.8" /> <unit value="mg/dL" /> <system value="http://unitsofmeasure.org" /> <code value="mg/dL" />

</valueQuantity> </component>

Data vs messaging standards

• Need both common data and messaging standards for successful interoperability

Hospital

EHRCMS

Personal

health

record

Messaging standard

OBX|1|Data type|Test code||Result|Units|…

Messaging standard

OBX|1|Data type|Test code||Result|Units|…

8479-8 Systolic blood pressure 138 mmHg18816-9 Medication name + identifier 2193 Ceftriaxone RxCUI8361-8 Body position with respect to gravity 33586001 Sitting SNOMED CT

Data standards

LOINC basics

Logical Observation Identifiers Names and Codes

• Standard terminology to identify lab tests, clinical measurements, documents, surveys, and more

• Used in 170+ countries, mandated in nearly 30

• Maintained by Regenstrief Institute, Inc.

• Supported by the National Library of Medicine

And it’s free!

Brief history of LOINC

• Organized in 1994 by Clement McDonald, MD

• Needed a universal language for observation identifiers

• Began with laboratory observations

• Expanded to clinical observations in 1996

• Currently includes 4 major categories• Laboratory LOINC

• Clinical LOINC

• HIPAA attachments

• Standardized survey instruments

LOINC grows because you ask

How to access LOINC

• Twice-yearly releases in June and December

• June 2017 (v2.61) release had >85,000 terms

• Find codes using• Regenstrief LOINC mapping assistant (RELMA) – desktop application

• https://search.loinc.org

• Multiple download formats

• New files in v2.61, including LOINC Parts, Answers, and Groups

Value Set Authority Center (VSAC)

The Value Set Authority Center (VSAC) publishes updated eCQM value sets annually.

The Downloadable Resource Table provides prepackaged downloads for the most recently updated and released eCQM value sets, as well as for previously released versions.

Where can I find value sets?

https://vsac.nlm.nih.gov

Download value sets by measure, value

set name, or quality data model category

VSAC Value Sets: Downloadables

Value Set Authority Center (VSAC)

Clinical Information Interoperability Council

CIIC is a broad stakeholder-based group of clinical and technical stakeholder organizations who are seeking to fill in the gaps needed to reach a shared set of interoperability data elements for clinical care

Has adopted the CIMI detailed clinical model approach with the physical CDEs translated to FHIR

Targets gaps including: clinician organization engagement and education, governance processes, resourcing, and tooling

https://healthservices.atlassian.net/wiki/spaces/CIIC/overview

Graphic of a CIMI Detailed Clinical Model

data 138 mmHg

SystolicBPSystolicBPObs

quals

data Right Arm

BodyLocationBodyLocation

data Sitting

PatientPositionPatientPositionSNOMED CT

LOINC

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FHIR Data Element Resourcehttps://www.hl7.org/fhir/dataelement.html

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Discussion: Standards

Why MACRA?Medicare Access and CHIP Reauthorization Act of 2015

Beginning in 2019, all current Medicare payment, including incentive programs, will be combined into one Merit-Based Incentive Payment System (MIPS), replacing all Medicare reimbursement for eligible professionals.

The MIPS program will use four performance measures to determine reimbursement, which will begin in 2019:

Quality;

Resource use;

Clinical practice improvement activities; and

Meaningful use of certified EHR technology (Advancing Care Information)

Privacy and security including HIPAA are also requirements and failure to adhere to required standards results in penalties

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Now just “Improvement Activities (IA)”

CMS prefers term “QPP”

Program started 2017, timelines continue to shift and payment adjustments lag by 2 years

Still on hold

QPP Builds on Prior Existing CMS Programs and Requirements

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• Many providers say that the expansion of quality programs has distracted from, rather than added to the focus on providing quality care

• Need for alignment with non-federal programs has been recognized but not addressed

APMs & MIPSPaying for Performance

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Clinicians who receive a substantial portion of their revenues (at least 25% of Medicare

revenue in 2018-2019 but threshold will increase over time) from qualifying

alternative payment mechanisms will not be subject to MIPS.

While the definition of a qualifying APM has yet to be determined, MACRA outlines

criteria which includes but is not limited to:

Alternative Payment Model

(APM)

Merit-Based Incentive Payment System (MIPS)

Quality

(60% of MIPS score 1st year)

Clinical Practice Improvement

Activities(15%)

Resource Use

(0% 1st year)

Advancing Care Information

(25%)

Quality Measures

Advancing Care Information

Risk-sharing

Adjustments based on the composite performance score of each eligible physician or other health professional on a 0-100 point scale based on the following performance measures. All scores noted below are for the first MIPS year and are subject to adjustment. Additional positive adjustment available for exceptional performance.

MIPS/QPP Weighting: 2017 and 2018

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Majority of program weight lies on quality measures with contributions from Improvement Activities and Advancing Care Information; aligning all three of these activities allows a reporter to maximize value and staff engagement while minimizing investment.

In 2018, the proposed rule does not change the mix of weighted activities. Cost will be measured and feedback will be provided in 2018; however, it will not be used to calculate performance. Therefore, considering cost starting in 2018 will position reporters ideally for future years in which cost will begin to take on greater weight for scoring.

Cost (AKA ”Resource Use”)

50

• CMS will calculate the Medicare Spending Per Beneficiary (MSPB) and total per capita cost measures for feedback purposes.

• Do not include previous episode-based measures but new ones are in development.

• Improvement scoring will be based on statistically significant changes at the measure level.

Why think about cost now?• Improvement scoring with CMS • Future episode-based cost measures• Move to APM or other cost-sharing arrangement (not

just with CMS)• Your own bottom line (+ making the C-suite happy)

More on QPP Scoring…

51SOURCE: CMS, HTTPS://QPP.CMS.GOV/DOCS/QPP_PROPOSED_RULE_SLIDE_PRESENTATION.PDF

More on QPP Scoring…

52SOURCE: CMS, HTTPS://QPP.CMS.GOV/DOCS/QPP_PROPOSED_RULE_SLIDE_PRESENTATION.PDF

Really,

0-14?

HEDIS

About HEDIS It all starts with HEDIS®

Health care’s

most-used tool

for improving

performance

Asks how often

insurers provide

evidence-based

care to support

more than 70

aspects of health

54

H

E

D

I

S

ealthcare

ffectiveness

ata

nformation

et

55

184 million 57% of population

HEDIS shines a light on health plans' quality

About HEDISIt all starts with HEDIS®

Administrative/Claims

Data

57

About HEDIS

Medical Record

Data

Survey

Data

HEDIS in LOINC

• Since 2009, NCQA and Regenstrief have worked together to maintain HEDIS value sets in LOINC

• Updated every fall for the following year

• For value sets that have not changed, dates are updated

• Otherwise new panels are created

TJC

2017/2018 ORYX Performance Measurement Reporting Requirements Updated: 8/15/2017

2017/2018 ORYX Performance Measurement Reporting Requirements Updated: 8/15/2017

Discussion

LUNCH

Understanding the Big Picture

Governance and Strategy• Start by aligning your quality strategy to your business goals• Build a team of multidisciplinary experts and thought leaders• Create an overview of all your programmatic and regulatory requirements• Develop a coherent approach that minimizes rework, mapping, and validation• Automate and test test test• Celebrate your successes and build on them

Infrastructure for Successful eCQM Implementation

Successful eCQMs

Health IT/Data

Governance

Team Effort

Quality

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/

Gap

analysis

Data capture

and workflow

design

Data extraction

and eCQM

calculation

Validation

Downstream

uses of

eCQM

results

Get

content

Overview: eCQM Implementation Process

A Study of the Impact of Meaningful Use Clinical Quality Measures. Eisenberg et al., 2013. http://www.aha.org/content/13/13ehrchallenges-report.pdf

eCQM Implementation is Iterative and Collaborative

A Study of the Impact of Meaningful Use Clinical Quality Measures. Eisenberg et al., 2013. http://www.aha.org/content/13/13ehrchallenges-report.pdf

Workflow Analysis

Definitions of workflow vary:◦ The flow of work through space and time, where work is comprised

of three components: inputs are transformed into outputs.[1]

◦ The activities, tools, and processes needed to produce or modify work, products, or services. More specifically, clinical workflow encompasses all of the 1) activities, 2) technologies, 3) environments, 4) people, and 5) organizations engaged in providing and promoting health care.[2]

1. Carayon P, Karsh, BT. Workflow toolkit and lessons in user-centered design. Paper presented at the AHRQ Annual Health IT Grantee and Contractor Meeting; 2010 June 2-4; Washington, DC.

2. Niazkhani Z, van der Sijs H, Pirnejad H, Redekop W, Aarts J. Same system, different outcomes: Comparing the transitions from two paper-based systems to the same computerized physician order entry system. International Journal of Medical Informatics 2009; 78(3): 170-181.

Agency for Healthcare Research and Quality. What Is Workflow. Rockville MD. October 2010.http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Dataflow: What is it?

Dataflow and Workflow Redesign

Data Capture◦ New query build

◦ Interface to bring data from disparate application into certified electronic health record technology (CEHRT)

◦ Deploy alerts, reminders, and order sets judiciously

Workflow redesign◦ Work with subject matter experts to determine where/how data should be captured

(e.g., cardiovascular services)

◦ Evaluate aspects of care coordination or transitions of care

Step 1: Decide what processes to examine

Step 2: Create a preliminary flowchart

Step 3: Add detail to the flowchart

Step 4: Determine who you need to observe and interview

Step 5: Do the observations and interviews

Workflow Analysis Process

Is workflow just the sequence of steps of a process?

Not exactly

Workflow is the sequence of physical and mental tasks performed by various people over time and through space

◦ It can occur at different and/or multiple levels (e.g., one person, between people, or across organizations)

◦ It can occur sequentially or simultaneously

Agency for Healthcare Research and Quality. What Is Workflow. Rockville MD. October 2010.http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Shows how processes really happen, as opposed to how they are supposed to happen or how we expect they will happen

Allows a better understanding of what contributes to different types of flows for the same processes

Helps to identify ways to improve the flows

Can illustrate ways that health IT will affect workflows

Goals of a flowchart

Agency for Healthcare Research and Quality. What Is Workflow. Rockville MD. October 2010.http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Both flowcharts show the workflow of “patient check-in”

Both are accurate descriptions of the same process at a particular clinic, but only the figure on the right (#2) shows the details of what the workflow really is

The details of the workflow will change when you implement health IT

◦ If you don’t understand the details, you cannot plan for the changes that will come.

Example: Detailed Flowcharts

Agency for Healthcare Research and Quality. What Is Workflow. Rockville MD. October 2010.http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Implementing Shared Formulary and E-based Medication Order Review to Create "Closed Loop" Medication Process in Critical Access Hospitals (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.

http://archive.ahrq.gov/news/events/conference/2009/wakefield/index.html

Example: Swim Lane Diagram, Before Population

Example: Swim Lane Diagram, After Population

Implementing Shared Formulary and E-based Medication Order Review to Create "Closed Loop" Medication Process in Critical Access Hospitals (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2009/wakefield/index.html

Clinic-level workflow: the flow of information, in paper or electronic formats, among people at a practice or clinic.

Intra-visit workflow: workflow during a patient visit

Inter-organizational workflow: workflow between healthcare organizations

Cognitive workflow: the workflow in the mind

The Layers of Workflow Interactions

Agency for Healthcare Research and Quality. What Is Workflow. Rockville MD. October 2010.http://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Compare measures

Consider reporting modification or quality improvement

Challenges to data identification and collection:

◦ Unstructured data

◦ Data latency

◦ Discordant data

Data and Workflow Process for Updates

Data Extraction and eCQM Calculation

Once data are available, move forward with data extraction and calculation

Continue iterative process of validation

Additional tweaks to data capture and/or workflow may be necessary after validation

Remember to modify tracking documentation

http://blog.bersin.com/mit-symposium-focuses-on-data-quality/

Workflow Assessment:

Capturing Data as Part of WorkflowDepression Care Example

Patient with DepressionHas current depression diagnosis

Taking antidepressant

Receiving psychotherapy

Care team includes PCP, nurse case manager, consulting psychiatrist, pharmacist

Symptoms routinely assessed using PHQ-9 Health Questionnaire (recent score indicates moderate depression)

Goes to visit with PCP

Historical Data

◦ Patient history in PCP’s EHR◦ Diagnoses

◦ Visits

◦ Referrals

◦ Medications

◦ Patient completes PHQ-9 on patient portal mobile app and at visits

Workflow for Patient Visit

• Updates personal info

• Completes PHQ-9 on tablet

Patient Check-in

• RN assessment

• Weight

• Blood PressureRooming

• PCP assessment

• Adjusts treatment

• Follow-up with RN Case Manager

PCP Exam

Data Capture in Real Time

• Updates personal info

• Completes PHQ-9 on tablet

Patient Check-in

• RN assessment

• Weight

• Blood PressureRooming

• PCP assessment

• Adjusts treatment

• Follow-up with RN Case Manager

PCP Exam

Data for Quality MeasurementStructured

By-product of workflow

Captured and used in real time (supports measurement-based care)

In this example:

Denominator = Patient with active depression diagnosis and visit

Numerator = PHQ-9 administered to monitor symptoms

Common Clinical DataSet (CCDS)Required for transitions of care in 2014 and 2015 Editions of Certification

Describes a minimum set of data with variable level of specification– generally minimum requirement is a terminology binding

Alone does not guarantee interoperability because metadata and other form and manner vary

However, it is a good starting place to look for requirements that will be widely available

Common Clinical Data Set

Renamed the “Common MU Data Set.” This does not impact 2014 Edition certification.Includes key health data that should be accessible and available for exchange.Data must conform with specified vocabulary standards and code sets, as applicable.

91

Patient name Lab tests

Sex Lab values/results

Date of birth Vital signs (changed from proposed rule)

Race Procedures

Ethnicity Care team members

Preferred language Immunizations

Problems Unique device identifiers for implantabledevices

Smoking Status Assessment and plan of treatment

Medications Goals

Medication allergies Health concerns

2015-2017

Send, receive, find and use priority data domains to improve health and health quality

ONC Interoperability Roadmap Goal

Red = New data added to data set (+ standards for immunizations)Blue = Only new standards for data

Data Mapping:

Mapping

• Mapping is the process of matching a concept in one system to the equivalent concept in another system

• For example, laboratory code to LOINC

• ICD-10-CM code to SNOMED CT

• NDC code to RxNorm

• Best to assign the standard code as close to the origin of the data as possible to prevent loss of information

• The more times the data is mapped from one system to another, the higher the chance for errors

Mapping principles

• Map to the most specific code based on the available information

• Do not overspecify, i.e., do not map to a concept that has more information than what you have available by making assumptions about your data

Choose codes to fit your purpose

• Laboratory – in most cases a single LOINC represents a single assay

• Acute clinical care – need granular codes that accurately reflect what is being measured

• 76215-3 Invasive Systolic blood pressure

• 76534-7 Noninvasive Systolic blood pressure

Choose codes to fit your purpose (cont.)

• If comparing two methodologies for measuring an analyte, need to find the exact LOINC codes that represent those two assays

• Example – comparing Zika IgM immunoassay to Zika IgM immunofluorescence assay

80824-6 Zika virus IgM Ab [Presence] in Serum by Immunoassay

82731-1 Zika virus IgM Ab [Presence] in Serum by Immunofluorescence

• If doing a study on how many pregnant women were tested for Zikavirus infection over a certain time period, need to use all Zika LOINC codes to find the correct data

Searching principles

• Searches should be tailored for the purpose – i.e., looking for very specific data (Zika IgM by IF or IA) versus broader use

• For specific searches, use all available information to narrow down the results

• Searching for Zika IgM IF returns 1 LOINC code

• Searching for Zika CSF returns 8 codes

• For broad use, keep the search broad• Searching for Zika returns 30 records

Mapping examples

• Major laboratories have LOINC mappings published on their websites• https://www.labcorp.com/test-menu/30451/lipid-panel-with-total-

cholesterolhdl-ratio

Mapping examples

• https://www.mayomedicallaboratories.com/test-catalog/Fees+and+Coding/82047

Mapping examples

• http://www.questdiagnostics.com/testcenter/eGFR

Customizing a HIT Installation: Impacts

Often EHR and HIT systems will allow the implementer to make many customizations to the system being implemented

The level of effectiveness of a customization varies based on the:◦ Guidance offered by the developer

◦ Knowledge of the informatics team involved in the implementation

◦ Data already available in the system

◦ Knowledge and alignment of the existing system database

◦ Knowledge and alignment of export requirements for reporting and exchange

The Impact of Customization: Pro/Con

Pros:Allows the system to reflect specialized requirements

Gives local terms and providers a place in the system

Cons:Generally the more customization the bigger the barrier to interoperability

The more customization the more the cost of mapping and maintenance

The more customization the more likely things are to break

How to Position Yourself on the Leading Edge: Clinical Quality Programs:

1. Look at scoring and bonus point opportunities

2. Consider reorienting your practice into groups. Or “practice groups”

3. Consider creating or using measures that are more meaningful:1. Outcomes and risk adjustment2. Special populations*, specialty measures3. Multidimensional interventions

4. Integrating workflow and process changes– thinking about cost1. Care plans and coordination (count for IA)2. Sophisticated risk assessment* and targeted intervention

5. Evaluate changes in reporting options

6. New standards and technology

103

Discussion