MIPS; Improving Your Score with eCQIPatty Kosednar, PMP, CPEHR, CPHIMSHIT Project Manager

HealthInsight

Our business is redesigning health care systems for the better

HealthInsight is a private, non-profit, community based organization dedicated to improving health and health care in the

western United States.

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Mountain-Pacific Quality Health

We are the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for• Montana• Wyoming• Hawaii• Alaska

• Guam• American Samoa• The Commonwealth of the

Northern Mariana Islands

Recent MIPS Presentations

• MIPS Submission and Scoring – 6/27• 9 Steps to MIPS Reporting – 6/20• MIPS Advancing Care Information/Cost Categories – 5/23• MIPS Quality and Improvement Activities Categories –

5/16• Quality Payment Program Overview – 5/9

• Link to all previous webinar materials (both slides and recordings: http://healthinsight.org/qpp#webinars

Today’s Objectives

• Review and demonstrate the fundamentals of electronic clinical quality improvement (eCQI)– eCQI overview and benefits– E.H.R functionality and eCQI– eCQI methodology, process and templates

• Combine information from past MIPS webinars to illustrate possible strategies to use eCQI for MIPS score improvement

• Discuss how to get started with eCQI

OVERVIEW OF ECQI

• The introduction of electronic health records (EHRs) and other health information technology has changed the need for technical assistance for health care organizations (especially rural/small)

• No longer are clinical best practices and clinical expertise enough to successfully drive quality improvement and improved outcomes

• Clinical quality improvement now requires both clinical and health information technology expertise

• As a result we have created an approach that combines clinical best practices and technology expertise

• Electronic clinical quality improvement eCQI

The Need for a New Approach

eCQI: Electronic Clinical Quality Improvement

• Optimizing health information technology (HIT) and standardized electronic data to achieve measureable improvement in quality of care

• Incorporating the data and functionality of your EHR into your quality improvement projects

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

eCQI – A Combination Of:

• 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

Benefits of eCQI

• Align quality improvement efforts for greatest ROI and efficiency gains

• Reduce burden and duplication of effort between quality reporting/requirements

• Leverage EHR for advanced functionality and data tracking to improve outcomes and reduce manual tracking/chart abstraction

• Standardize processes and consistency through workflow analysis and staff education/training

• Focuses on achieving value added changes quickly and efficiently

• Our eCQI methodology can be applied to all quality improvement initiatives (is not quality program specific)

EHR Functionality for eCQI

• Clinical Decision Support (CDS)– Target conditions and standardize treatments

• Data Display: Flow sheets, patient data reports and graphic displays

• Workflow Assistance: Task lists, patient status lists, integrated clinical and financial tools

• Data Entry: Templates to guide documentation and structured data collection

• Decision Making: Access to resources rule based alerts, clinical guidelines or pathways, patient/family preferences, and diagnostic decision support

EHR Functionality for eCQI Cont.

• CPOE– Data points can be retrieved from CPOE to effect care

improvement– CPOE enhances use of clinical decision support rules or guidelines

at the point of care

• Patient education/discharge instructions– Provide credible source of information– Encourage patient engagement– Assist with transition of care

• Patient reminders– Proactive preventative care– Follow up and care coordination

EHR Functionality for eCQI Cont.

• Lab interfaces (or lab results as structured data)– Data points retrieved from lab results– Lab results (structured data) enhances use of clinical decision

support rules or guidelines at the point of care

• Patient Panels/Risk Stratification– Track and monitor high risk patients– Use patient panels or risk scores to identify care coordination

priorities– Track performance based on panels/risk scores

EHR Functionality for eCQI Cont.

• HIE/Transition of Care/Discharge Info/Public Health Registries– Improve communication between providers and/or facilities– Provide and enhance continuity of care delivery– Data collection and analytics– Population health data

• Structured Data: If it is not documented in a discrete field, the system does not know it happened and cannot trigger the next event or report!

• You must use the recommended workflows and data entry points for the CQM reports from your EHR Vendor

• Structured and standardized data is the foundation to interoperability– Improve care coordination– Improve transition of care– Assist with risk stratification and reduction in total cost of care

Focus on Structured Data

Utilizing the correct workflows of your EHR can ensure you get paid based on the actual quality of the care you are delivering

Important Note!!!

Our eCQI Process Includes:

• Leveraging EHR functionality• Using evidence based clinical best practices• Standardizing data tracking and analytics• Performing workflow analysis/review• Incorporating the Agile (SCRUM) iterative delivery model

combined with proven quality improvement methodologies (PDSA)

• Managing the process with a certified project management structure (“lite”)

• Focuses on achieving value added changes quickly and efficiently using “sprints”

eCQI Tasks

• Identify Project Scope and Team • Create (or update) and prioritize Change Backlog• Create Sprint/PDSA• Perform/complete Sprint= PDSA cycle(s) • Perform sprint review and update Change Backlog• Repeat

Streamlined eCQI Process Model

Choose an eCQI Project

1. Run the required clinical quality measures (CQM) (or other evaluation measure) reports (min 90 day period) to establish current performance

2. Compare current performance on measures to benchmarks or goals

3. Prioritize list of improvement projects and Identify your first eCQI project

4. For MIPS:a. Run CQMs chosen for quality category b. Run Advancing Care Information reports both base and performance

measuresc. Choose first measure to work on for eCQId. Identify eCQI project scope

Create a Project Scope

• Answer this question: What are we trying to accomplish:• Establish a goal (make it a SMART Goal)

– S – specific– M – measureable– A – actionable– R- relevant– T – time bound

• Define evaluation measures • Identify project constraints

Project Scope Example

• Improve CMS 165 (HTN Blood Pressure Control) above 76 percent by 12/31/17

• For all payers, all patients, all clinic locations

• Link to MP eCQI Scope/Change Backlog template

Create a Change Backlog - Identify Possible Changes

• Answer this question: “What changes can we make that will result in an improvement” to the project goal selected

• Brainstorm ideas for possible changes that will ultimately improve the project goal/outcome measure

Identify Possible Changes

• Identify possible EHR functionality changes– How can EHR support best practices/protocols?– Review staff use and workflows (based on clinical best

practices for QI topic)• Computer provider order entry (CPOE)• Care coordination and transition of care

– Determine available options, decide on applicability (based on clinical best practices for QI Topic)

• Clinical Decision Support (CDS) • Patient Portal/eSecure messaging• Patient Education materials• Care Coordination• Interfaces• Etc.

Identify Possible Changes Cont.

Review your workflows:• What is the EHR vendor’s recommended workflow for correct

population of the CQM (ASK YOUR VENDOR!!!)• What process do you need to analyze further that will have the

biggest impact on the measure outcome?• Is it electronic, physical or a data flow?

– Physical - Includes environmental layout of patient room, equipment, devices, supplies, etc

– Electronic - How is the work documented? What screens and fields are used?– Data -

• Where does the information documented go? • Why does it go there (triggers or reports)?• How does it get there (interfaces, uploads, etc)

Create Change Backlog

• Prioritize your Changes and Choose first Sprint (PDSA cycle)

Change Backlog Example

• Train all staff on correct electronic workflow for CMS 165

• Train staff on accurate BP measurements• Implement HTN protocol• Make sure HTN is addressed at each patient visit• See HTN patients with BP >140/90 every six months

• Link to MP eCQI Scope/Change Backlog template

Sample Change Backlog

Identify the Sprint/PDSA Plan

• Prioritize your change backlog and choose your first sprint from the list of possible changes

• Identify a measureable goal for the sprint– Use standard data measures, easily accessible and repeatable

• Establish baseline data, if one is not already available (make step one of plan if needed)

• Determine a target goal for improvement• Tasks to keep in mind for PDSA plan:

– Reviewing electronic, data entry and physical workflows– Leveraging EHR functionality whenever possible– Implementing clinical best practices/protocols to support

improvement

First Sprint (PDSA) Recommendation

• If data in CQM report is not “accurate”, make your first sprint (PDSA cycle) all about determining accurate electronic workflow, training staff on accurate workflow and validating that data.

• That will be your immediate “improvement” and allow all the other functionality in the EHR to work correctly with the structured data

• Link to MP eCQI PDSA Worksheet template

Sprint/PDSA Example

Sprint/PDSA Example Cont.

Streamlined eCQI Process Model

eCQI Tasks

• Identify Project Scope and Team • Create (or update) and prioritize Change Backlog• Create Sprint/PDSA• Perform/complete Sprint= PDSA cycle(s) • Perform sprint review and update Change Backlog• Repeat

eCQI Proven Results

• Efficient approach; reduces time and resource use• Rapid improvement gains on PDSA goals (PDSA cycles or

“sprints” average time 30 days)• Improves consistency on workflows and use of EHR• Automates data tracking for eCQI projects, reduced resource

use and consistent/validated data• Improves alignment of QI projects and resources• Trained staff on a repeatable QI process for ongoing use in

hospitals/clinics• Improves clinical outcomes for patients

eCQI Proven Results

MIPS; GETTING STARTED WITH ECQI

eCQI Keep in Mind

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 ROI or alignment across programs (CPC+, PCMH, Payer, etc)

• For MIPS: If possible, choose an eCQI project outcome or activity that benefits more than one MIPS category

The MIPS Pie

Quality 60%ACI 25%

I A 15%2017

The MIPS Pie

Quality 50%

ACI 25%

I A 15%

Cost 10%2018

MIPS eCQI Basic

1. Run the required Quality Measures and Advancing Care Information (ACI) reports (min 90 day period) to establish current performance

2. If possible, choose Quality Measures that align with other program requirements (CPC+, PCMH, etc)

3. Compare current performance to benchmarks or goals4. Review required workflows and data entry requirements for

each measure remind/retrain staff5. Correct workflow entry should improve your performance

on measures – improving your score for both quality and ACI

MIPS: More Bang for the Buck

1. Perform steps identified in MIPS basic slides for Quality Measures and Advancing Care Information (ACI) measures

2. Choose Quality Measures that align with other program requirements (CPC+, PCMH, etc)

3. Identify and eCQI project and follow the eCQI process4. Choose a project that will improve Quality

Measures, possibly get you bonus points for ACI and meets the Improvement Activity category requirements

MIPS; More Bang for Your Buck –Example 1

• Choose to report clinical quality measure CMS 50/ID 374 (closing the referral loop) for one of your Quality measures (it is a high priority measure)

• Use eCQI to improve your performance score (10th decile is 72% - EHR submission*)

• Can attest to Improvement Activity – medium activity (care coordination IA_CC_1 )

• Qualifies for a 10 percent ACI bonus

*check for current benchmark/submission methods

MIPS: More Bang for Your Buck –Example 2

• Choose to report clinical quality measure CMS123 /ID 163(DM foot exams) for one of your Quality measures

• Use eCQI to improve your performance score (10th decile is 98% – registry, 76% for EHR*)

• 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)

• Improvement Activity – Medium – Use of clinical decision support ( IA_PSPA_16)

• Counts for ACI 10 percent bonus

*check for current benchmark/submission methods

MIPS: Adventurous – Examples• eCQI project – Improve Care Coordination

– Implement Medicare Transition of Care Management (TCM) billing code

• Improve revenue• MIPS Quality – Closing the referral loop• Advancing Care Information – Summary of care, clinical information

reconciliation• Improvement Activity – Care coordination, medication reconciliation, closing

the referral loop, etc

• eCQI – project – Antimicrobial Stewardship Program (ASP)– Work with HealthInsight/Mountain Pacific (QIN/QIOs) on ASP

implementation• Several quality measures align• Advancing Care Information – patient education, clinical decision support• Improvement Activities – Working with QIN/QIO, clinical decision support,

medication reconciliation, patient education

MIPS eCQI Resources

• Mountain Pacific eCQI Resources and templates• CMS MIPS Quality Measures• CMS MIPS Advancing Care Information Measures• CMS MIPS Improvement Activities Lists• Link to CMS information on Medicare Transition of

Care Management Code• Link to CMS Antimicrobial Stewardship/MIPS

crosswalk

eCQI and Programs

• eCQI can improve tracking and performance quality reporting requirements for:–Merit Based Incentive Payment System (MIPS)–Comprehensive Primary Care Plus (CPC+)–Inpatient Quality Reporting (IQR)–Antimicrobial Stewardship Programs (ASP)–ACO or other payment models–NCQA PCMH Certification

eCQI Resources

• ONC- Healthit.gov: https://ecqi.healthit.gov/• Mountain-Pacific:eCQI Resources and Toolkit:

http://mpqhf.com/corporate/health-and-technology-services/hts-services/eclinical-quality-improvement/

• Patty Kosednar, eCQI Consultant; pkosednar@mpqhf.org

Questions

This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-D1-17-50

For More Information Contact a QPP Expert in Your State

Mountain-Pacific Quality Health

QualityPaymentHelp@mpqhf.org

Please contact us for assistance!

MontanaAmber Rogersarogers@mpqhf.org(406) 544-0817

WyomingBrandi Wahlenbwahlen@mpqhf.org(307) 472-0507

Hawaii and TerritoriesCathy Nelsoncnelson@mpqhf.org(808) 545-2550

AlaskaPreston Grooganpgroogan@mpqhf.org(907) 561-3202

Region/Senior Account ManagerSharon Phelpssphelps@mpqhf.org(307) 271-1913

Visit us online at www.mpqhf.org.

For More Information Contact a QPP Expert in Your State HealthInsight QPP Support

Call: 801-892-6623Email: qpp@healthinsight.org

Web: www.healthinsight.org/qpp

NevadaAaron HubbardCall: 702-948-0306Email: ahubbard@healthinsight.org

OregonDavid Smith Call: 503-382-2962Email: dsmith@healthinsight.org

Utah Brock StonerCall: 801-892-6602Email: bstoner@healthinsight.org

New Mexico Ryan Harmon or Danielle PickettCall: 505-998-9752 or 505-998-9768Email: rharmon@healthinsight.orgor dpickett@healthinsight.org