ecqm Implementation and Submission Insights Cerner Corporation Nebraska Methodist Health System

ecqm Implementation and Submission Insights Cerner Corporation Nebraska Methodist Health System

Agenda: 2015 Pilot Program Overview Client Perspective Questions 1

2015 ecqm Pilot Program

Overview of 2015 ecqm esubmission Pilot File generation using data discretely captured in Cerner Millennium EHR 33 facilities submitted through Cerner Quality Clearinghouse 26 facilities submitted to CMS 29 facilities submitted to TJC TJC had 34 total facilities submitted The Joint Commission submission 3% 3% 3% 3% 3% 85% Cerner vendor a vendor b vendor c vendor d vendor e 3

2015 ecqm submission by measure 4

Timeline of the 2015 ecqms submission April 1 CMS 2014 specifications released August IPPS 2015 Final Rule Published 2014 2015 2016 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Oct requirements for 2015 submission to engineering April thru October Client configuration, validation of outcomes Feb code with validation partners March code generally available Nov thru Dec - submission to CMS & TJC 5

Mapping When deciphering the specifications, we determine the required data elements for each measure We look at the specification and compare it to our EHR in terms of workflow and how we would pull data out of our system For every qualifying attribute, we determine where that would be captured in our EHR Based on that workflow, is it naturally codified (i.e. Final Dx) or does it need to be mapped because the qualifying attribute may differ between facilities (i.e. order)? Each client then has to define where in their system they capture those discrete data elements They will map their Millennium discrete data elements to the ecqm data elements Example: Emergency Department Visit is a value set in the ecqm and the client needs to define which encounter/visit type they use in their database to denote and ED Visit 6

Lessons Learned & Ongoing Challenges Understanding the success criteria for submission This wasn t clearly understood by us or our clients early in the development/validation process While we want to confirm/validate the numerator/denominator values, the value that has the submission deadline is the IPP Keeping up to date with webinars and changes to the programs The updates across EH ecqms, Core Measures, EP ecqms can be challenging to keep current Validate earlier Instead of validating the quarter s data at the end of the quarter, validate each month on a rolling cycle Identifying issues and troubleshooting is more time consuming than Core Measures TJC Mismatch report is very helpful in identifying discrepancies 7

Donna Hubbell, Vice President of Quality and Patient Safety Marie Kozel, Director Clinical Informatics Rhonda Post-Seip, Internal Auditor Linda Brown, Data Management Analyst Beth Edwards, Clinical Quality Specialist Dan Pulcifer, Systems Analyst Stacy Hug, Systems Analyst 2015 ecqm submission & 2016 ecqm plan Nebraska Methodist Health System

Nebraska Methodist Health System Fully Integrated Health System At a Glance: Hospitals 3 Clinics - 50 Licensed beds - 740 Active Medical Staff - 603 Physicians - 275 Discharges - 21,525 OR volume - 35,829 ED Visits 53,843 Births 4,837 Full Suite of Cerner software services Ambulatory, Inpatient, Revenue Cycle, Lab, Pharmacy, Imaging, Maternity 9

2015 ecqm submission motivators Previous experience with eligible provider side with a registry Wanted submission experience Desire to get the information Decided to dip their toe with the Joint Commission option 10

2015 ecqm Project All 3 facilities submitted ED1, ED2 to The Joint Commission Cerner consulting services engaged Meet weekly with Cerner counterparts Data validation of 10% random patient sample Workflow re-designed Committee structure of team members Quality IT analyst Informatics Internal Auditing Executive Sponsor 11

2015 esubmission Project Team Donna Hubbell Vice President of Quality & Patient Safety Marie Kozel Director Clinical Informatics Rhonda Post-Seip Internal Auditor Linda Brown Data Management Analyst Beth Edwards Clinical Quality Specialist Dan Pulcifer Systems Analyst Stacy Hug Systems Analyst Zach Moosa Cerner Quality Reporting Consulting Parady Sengsay Cerner Quality Clearinghouse 12

Lessons Learned Committee structure Consensus on Bedrock filter settings Report Validation Right documentation for auditing Specification differences Trust the relationship with Cerner Quality Clearinghouse Access to InfoView business object reports Validate early and often 13