Managing ecqm Reporting Through a System EHR Transition

Transcription

1 The Joint Commission Pioneers in Quality 2018 ecqm Proven Practices Webinar Series August 23, 2018 Managing ecqm Reporting Through a System EHR Transition Mary Burton, RN, PhD, Group Manager, Clinical Quality BJC Healthcare Liz Greiner, Electronic Measurement Coordinator, RN, MHA, BJC Healthcare

2 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

3 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.

4 BJC HealthCare by the Numbers

5 Preventable Harm Electronic Measures

6 How it All Started - Interoperability Challenges

7 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%

8 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.

9 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

10 BJC ecqm Roadmap BJC ECQM TOOL Production CMS 2016 Submission CMS & TJC 2017 Submission Upgrade Project Start 2016 Upgrade 2017 Upgrade Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Kick-off Go-Live POD 2 Legacy Retired NEW EHR Testing POD 1 Academic ETL Build Validation, BHC

11 Implementation Cycle Legacy Systems

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

13 Example: Stroke Education 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.

14 BJC ecqm Roadmap - Ongoing BJC ECQM TOOL Upgrade Upgrade Validation CMS 2018 Submission TJC 2018 Submission Workflow enhancementsclose known gaps CQL Upgrade Upgrade Validation CMS 2019 Submission TJC 2019 Submission Measure management and performance improvement Sept Oct Nov Dec Jan Feb Mar Apr May Jun July Aug EHR Epic Optimization EHR Upgrade EHR Upgrade

15 Current EHR ecqm Scorecard ID emeasure Title GOAL AMH BHC BJH BJSPH BJWC CH MBMC MBSH PHC PWH SLCH Median Time from ED Arrival to ED ED-1a Depart for Admitted ED Patients Median Admit Decision Time to ED-2a ED Depart Time for Admitted Patients VTE-1 VTE Prophylaxis 95% 93% 85% 69% 83% 77% 88% 86% 89% 87% 86% VTE-2 ICU VTE Prophylaxis 95% 95% 93% 75% 89% 73% 94% 94% 94% 97% 92% STK-2 STK-3 Discharged on Anti-thrombotic Therapy 95% 93% 86% 88% 89% - 76% 77% 100% 50% 97% Anticoagulation Therapy for Atrial Fibrillation/Flutter 95% 78% 67% 54% 40% - 29% 63% - 100% 63% Antithrombotic Therapy by End of STK-5 Hospital Day 2 95% 93% 91% 91% 80% - 88% 86% 50% 100% 94% STK-6 Discharged on Statin Medication 95% 81% 74% 90% 91% - 73% 73% 100% 33% 96% STK-8 Stroke Education 95% 100% 98% 85% 79% - 83% 97% 0% 100% 85% STK- 10 Assessed for Rehabilitation 95% 82% 99% 99% 97% - 97% 94% 100% 40% 94% PC-01 Elective Delivery 3% 12% 13% 17% % 38% 8% 18% PC-05 Exclusive Breast Milk Feeding 50% 54% 54% 36% % 37% 24% 52% EHDI- 1a Hearing Screening Before Hospital Discharge 95% 90% 96% 74% % 87% 92% 91% 75%

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

17 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

18 Coming Soon to BJC ecqm Memorial Belleville Memorial East

19 Thank you! Mary Burton, RN, MSN, APRN(R), PhD, Group Manager Clinical Quality BJC Healthcare Liz O Neil-Greiner, RN, MHA Electronic Measurement Coordinator-Healthcare Informatics BJC Healthcare elizabeth.oneilgreiner@bjc.org

20 Appendix

21 What Makes A Good Quality Measure?

22 ecqm Measure Calculation Engine