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Use of Clinical Dashboards to DrivePerformance Improvement for eCQMsJuly 31, 2019

SpeakersRose Almonte, MS, RNPrincipal Clinical Informatics, MITREDenise Garcia Egan, MPHDirector of Clinical Business Intelligence, Open Door Family Medical CentersDebbie Krauss, MS, RNNurse Consultant, Center for Clinical Standards & Quality, CMSHolly McNary, BSN, RNClinical Outcomes Specialist, Quality Measurement & Reporting, Texas Health ResourcesBarbara Ray, RHIADirector of Quality Measurement & Reporting, Texas Health ResourcesModeratorArtrina Sturges, EdDAlignment of Electronic Clinical Quality Measures (eCQMs) LeadInpatient Value, Incentives, and Quality ReportingOutreach and Education Support Contractor07/31/20196

PurposeThis event will provide an overview of hospital andprovider organization initiatives and activities thatuse clinical dashboards to display eCQMperformance to drive improved patient care andpatient outcomes.An acute care hospital and a provider organizationwill share their experiences using clinicaldashboards to track quality performance andclose care gaps.07/31/20197

ObjectivesParticipants will be able to: Describe how clinical dashboards can beused to achieve quality measurement goals. Apply clinical dashboard initiatives to increasevalue of eCQMs in improving patient careand outcomes. Understand change management processinvolved in implementing and supportingclinical dashboards.07/31/20198

Debbie Krauss, MS, RN, Nurse Consultant, Center for Clinical Standards & Quality, CMSeCQM Strategy Background07/31/20199

BackgroundeCQM Strategy Project Goals Reduce Burden Increase Value Increase Stakeholder InvolvementProblem Statement Providers participating in CMS quality and value-based purchasing programs haveshared challenges they experience related to the complexity and high burden ofeCQM implementation, data capture, and reporting.Project Scope Measure Development process from concept to the Measures Under Consideration(MUC) list Electronic Clinical Quality Reporting requirements and processes from eCQMimplementation to submission Tools for Development and Reporting07/31/201910

eCQM Strategy Recommendations07/31/201911

Holly McNary, BSN, RNClinical Outcomes Specialist, Quality Measurement & ReportingBarbara Ray, RHIADirector of Quality Measurement & ReportingTexas Health ResourcesThe Wave of the Future:eCQMs, Clinical Dashboards, and Quality07/31/201912

Texas Health ResourcesCONSUMER FOCUS Texas Health Resources is afaith-based, nonprofit systemthat cares for more patients inNorth Texas than any other provider. Texas Health Resources has morethan 25,000 employees and 6,200physicians with active staff privileges. The health system includes TexasHealth Physicians Group andhospitals under the banners ofTexas Health Presbyterian, TexasHealth Arlington Memorial, TexasHealth Harris Methodist, and TexasHealth Huguley. Texas Health Resources comprises27 hospital locations.CULTURE OF EXCELLENCEEXCEPTIONAL CARETRANSFORMATIVE GROWTHVALUE CREATION07/31/201913

Texas Health ResourcesPutting quality on the map: The many roads that lead to Texas HealthCONSUMER FOCUSCULTURE OF EXCELLENCEEXCEPTIONAL CARETRANSFORMATIVE GROWTH07/31/201914

Texas Health Resources:Vision 2026CONSUMER FOCUSCULTURE OF EXCELLENCEEXCEPTIONAL CARETRANSFORMATIVE GROWTH07/31/201915

Meaningful Use eCQM TeamProject ManagerAmy Crow, Meaningful Use Program Manager, Clinical Decision SupportQuality Measurement & Reporting TeamBarbara Ray, RHIA, DirectorDonna Harkreader, MBA, BSN, RN, CPHQ, ManagerHolly McNary, BSN, RN, Clinical Outcomes SpecialistElectronic Health Record (EHR)Clinical Documentation TeamSamir Babar, System Analyst ILance Skaar, System Analyst IIIAaron Gillespie, BSN, RN, LSSYB, System Analyst II07/31/201916

Meaningful Use eCQM Team07/31/201917

Innovative Epic eCQM ToolsMeaningful Use (MU) eCQM - CMS Dashboard Implemented in July 2017 Two dashboard views: Personal (standard) and ComprehensiveoPersonal (standard) view includes VTE, Stroke, and ED measures –Intended for entity-based personneloComprehensive view includes all 13 mapped measures –Intended for eCQM Team and Quality/Leadership Displays updated eCQM performance each time the Quality Reporting DocumentArchitecture (QRDA) is run (weekly) Initial and ongoing extensive education (including live demonstrations and tip sheetdispersed for use of the dashboard) Enhancements and upgrades to functionality and aesthetics, since implementationincludes color coded performance data and ability to run workbench reports directlyfrom dashboard for further drill downs End users encouraged to review eCQM Dashboard performance data and notepotential measure population inaccuracies Monitored weekly by eCQM Team for accuracy of data and technical issues07/31/201918

Measure Mapping and Successful Self-SubmissionMeasure Mapping andSuccessful Self-SubmissionAll currently mapped measures are displayed on the Dashboard Comprehensive View. ED-1 (CMS 55) Median Time from ED Arrival to ED Departure for Admitted ED PatientsED-2 (CMS 111) Median Admit Decision Time to ED Departure Time for Admitted PatientsVTE-1 (CMS 108) Venous Thromboembolism ProphylaxisVTE-2 (CMS 190) Intensive Care Unit Venous Thromboembolism ProphylaxisSTK-2 (CMS 104) Discharged on Antithrombotic TherapySTK-6 (CMS 105) Discharged on Statin Medication STK-3 (CMS 71) Anticoagulation Therapy for Atrial Fibrillation/FlutterSTK-5 (CMS 72) Antithrombotic Therapy By End of Hospital Day 2STK-8 (CMS 107) Stroke EducationSTK-10 (CMS 102) Assessed for RehabilitationPC-01 (CMS 113) Elective DeliveryPC-05 (CMS 9) Exclusive Breast Milk FeedingCMS 31 Hearing Screening Prior to Hospital Discharge07/31/2019Mapped &SubmittedforQ3 2016Q2 2017Q1 2018Mapped Q4201619

MU eCQM - CMS Dashboard –Personal in EpicThe MU eCQM – CMS Dashboard (standard view) is intended for all users including entity QualityDirectors/staff and includes VTE, Stroke, and ED data only. It does NOT include Mother/Baby measures.This material contains confidential and copyrighted information of Epic Systems Corporation and Texas Health Resources.07/31/201920

MU eCQM – CMS Dashboard –Comprehensive in EpicThe MU eCQM – CMS Dashboard – Comprehensive is the MU/eCQM Team view andincludes all 13 mapped measures: VTE, Stroke, ED, and Mother/Baby measures.This material contains confidential and copyrighted information of Epic Systems Corporation and Texas Health Resources.07/31/201921

eCQM Reporting WorkbenchReports in EpicEnhancements to functionality as a result of an Epic upgrade now allow generation of a workbench reportdirectly from link within dashboard for further review/patient specific drill down.This material contains confidential and copyrighted information of Epic Systems Corporation and Texas Health Resources.Information shown does not represent actual clinical data. Reporting Workbench results and measure statusdetails from ORYX WEBINAR presented by Epic on January 20, 2017.07/31/201922

Dashboard Tip SheetThis material contains confidential and copyrighted information of Epic Systems Corporation andTexas Health Resources. Information shown does not represent actual clinical data.07/31/201923

eCQM Process Evolvement:eCQM Dashboard a Key ComponentRun QRDARun QRDAReview APTT2016–2017eCQM ReviewProcessReview theQRDA I XMLfiles07/31/2019Run ClarityDetail andSummaryReportsReview in EpicReview eCQMQuality SummaryReport in Epic2017–2018eCQM ReviewProcess(V17 Upgrade)Review MeasureStatus Details,QRDA ClinicalData Elements inEpicReview MUeCQM - CMSDashboard inEpicRun eCQMWorkbenchReport in Epic orClarity DetailReport24

Dashboard Data:Pedal to the Metal on PerformanceAchieving and sustaining improvement with focused efforts on mapping accuracy and education2016–2019 YTD Texas Health Resources Overall eCQM Performance100%99.00%97.64%98.61%98.56% 98.90%96.07% 95.99% 82019 YTD*Graph includes performance for measures utilized for annual submission.07/31/201925

Utilizing eCQM Dashboard Data for Performance ImprovementUtilizing eCQM Dashboard Datafor Performance Improvement2018 Selected STK-8 (Stroke Education) as focus area based upon eCQM Dashboardperformance data Selected entity for participation based upon performance data and resource availability Deployed comprehensive educational program Weekly review of fallouts with entity liaison Tracking of actions taken and education provided to staff2019 Selected entity for participation based upon eCQM Dashboard performance data andresource availability Broad focus at request by entity to include VTE-1, VTE-2 and STK-2, STK-3, STK-5, STK-6 Detailed fallout review provided to entity with staff information for 1:1 follow up Education plan developed Performance Improvement initiatives in progress07/31/201926

Utilizing eCQM Dashboard Datafor Performance Improvement Selected STK-8 (Stroke Education) for focuso Lowest compliance, and no known build or mapping issues Deployed comprehensive education, encouraged use of Epic tools, weekly review of fallouts with entity2018 STK-8 Entity Measure PerformancePI ProjectWeekly reviewof fallouts71.4%66.6%TRANSFORMATIVE GROWTHEducation53.1%54.1%48.0%Baseline period:January-March13.3%9.0%07/31/2019Mean post PI performance 53%.42% improvement from yJuneJulyAugSeptOctNovDec27

Thank YouTexas Health ResourcesHolly McNary, BSN, RNClinical Outcomes Specialist, Quality Measurement & ReportingBarbara Ray, RHIADirector Quality Measurement & Reporting07/31/201928

Denise Garcia Egan, MPH, Director of Clinical Business IntelligenceOpen Door Family Medical Centers07/31/201929

History of Open DoorOpen Door was founded as a free clinic in 1972 to address health inequities in Ossining, NY.1985 – Open Door Sleepy Hollow1994 – Open Door Foundation1995 – Open Door Port Chester2003 – School-Based Health Centers2006 – Open Door Mount Kisco2007 – eClinicalWorks Implementation2013 – Open Door Brewster2015 – Mobile Dental Unit (K–12) Family MedicineResidency Program2016 – Relevant adoption2017 – Open Door Mamaroneck2018 – Brand new Open Door Sleepy HollowDental Residency Program2019 – Brand new Open Door Saugerties Dental07/31/201930

Open Door Locations07/31/201931

Open Door Care Delivery Sites07/31/201932

Open Door Scope of Services07/31/201933

Open Door Dashboard UseClinicians P4pClinicalReport CardMeasures Visit Planning Productivity Loop ClosureReports07/31/2019Care Team Visit Planning PopulationHealth –Outreach Care Planning Loop ClosureAdministrators InfectionControl ClinicalPerformance RiskManagement BusinessReview34

Open Door 2018 Highlights07/31/201935

Open Door NationalRecognition/External Accreditation07/31/201936

Dashboard Implementationand AdoptionEvaluation Reviewedinformationmanagementsystems Interviewedstakeholders Assesseddata needs07/31/2019Mapping Built datawarehouse anddashboardsbased onmeasurespecifications Mapped toeClinicalWorksValidationEducationAccountability Compared newdashboards toprevious usedreports System forreporting andtrackingdiscrepancies Trainedcliniciansfirst andthen rolledout to careteams Onboardingfor all newclinicians UsageReports Tied toClinicianBonus –P4P andProductivity37

Relevant Dashboards07/31/201938