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Managing eCQM Reporting
Through a System EHR TransitionSession 217, March 8, 2018
Mary Burton, RN, PhD, Group Manager, Clinical Quality
BJC Healthcare
Liz Richard, Senior Director, MBA, MHS, Encore
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Conflict of Interest
• Mary Burton, RN, PhD
Has no real or apparent conflicts of interest to report.
• Liz Richard, MBA/MHS
Receives a salary from Encore, an emids Company.
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Agenda
• BJC Healthcare Overview
• Electronic Clinical Quality (eCQMs) Measures
• eCQM Development, Implementation, and Reporting
• BJC eCQMs and the eMeasure Calculation Engine Journey
• BJC eCQM Future State
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Learning Objectives
• Describe the challenges associated with managing electronic
clinical quality measures (CQMs) across multiple electronic
health record (EHR) platforms
• List the alternatives for eCQM reporting while transitioning to a
new EHR platform
• Explain the challenges of eCQM reporting while transitioning to a
new EHR platform
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Polling Question #1
How would your organization be classified?
1. Hospital/System/Provider
2. Consulting Firm/Vendor
3. Governmental Organization
4. Other
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BJC HealthCare by the Numbers
Hospitals 15
Employees 31,000+
Physicians 4,350
Staffed Beds 3,524
Hospital Admissions 154,129
Home Health Visits 175,420
Emergency Department Visits 563,124
Net Revenue $4.8 billion
Charity and Unreimbursed Care $284.8 million
Community Health Programs $12.9 million
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BJC Service Area
Partner institutions
Washington University Physicians and
allied health providers serve as the
medical staff of
Barnes-Jewish Hospital and St. Louis
Children’s Hospital – both nationally
recognized, world-class teaching
hospitals – on the campus of
Washington University Medical
Center.
The Alvin J. Siteman Cancer Center at
Barnes-Jewish Hospital and
Washington University School of
Medicine is an international leader in
cancer treatment, research,
prevention, education and community
outreach.
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Preventable Harm Electronic Measures
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eCQMs
eCQMs are quality measures with electronic specifications.
The specifications include data elements, logic, value sets and definitions that
are captured, stored and calculated in Certified EHR Technology (CEHRT).
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What Makes A Good Quality Measure?
Transparency: the evaluation criteria are clear
Measure validity: evidence-based and validated by appropriate organizations
(e.g., National Quality Forum or professional societies)
Data validity: data used are from objective sources
Risk adjustment: appropriate risk adjustment is incorporated in the measures
Timeframe: data used reflect current performance
Volume (for comparison between facilities): a sufficient number of hospitals
and patients are evaluated for meaningful comparisons
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2
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4
5
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eCQMs
eCQM Description NQF
AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival
N/A
CAC-3 Home Management Plan of Care Document Given to Patient/Caregiver
N/A
ED-1Median Time from ED Arrival to ED Departure for Admitted ED Patients
495
ED-2Admit Decision Time to ED Departure Time for Admitted Patients
497
EHDI-1aHearing Screening Prior to Hospital Discharge
1354
PC-01 Elective Delivery 469
PC-05 Exclusive Breast Milk Feeding 480
eCQM Description NQF
STK-02 Discharged on Antithrombotic Therapy 435
STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter
436
STK-05 Antithrombotic Therapy by the End of Hospital Day Two
438
STK-06 Discharged on Statin Medication 439
STK-08 Stroke Education N/A
STK-10 Assessed for Rehabilitation 441
VTE-1 Venous Thromboembolism Prophylaxis 371
VTE-2Intensive Care Unit Venous Thromboembolism Prophylaxis
372
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Polling Question #2
What is your involvement in eCQM development and reporting at
your organization?
1. Program Leader or team member
2. Technical Support
3. Report Recipient
4. Other
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BJC IT Landscape
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BJC eCQMs 2014
Measure
ED-2 STK-2 STK-3 STK-6 VTE-1 VTE-2
Faci
lity
A
eCQM 227 95% 68% 95% 73% 100%
Abstracted CQM 192 100% 94% 97% 99% 92%
Faci
lity
B
eCQM 61% 0% 62% 50% 45%
Abstracted CQM 100% 92% 100% 100% 100%
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Assessment Findings - eCQMs
Workflows resulting in missing or incomplete data
Variation in documentation to support data capture
Deficiencies in adoption of recommended workflows
Missing interfaces to support data capture
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Assessment Findings - Reporting
Extensive maintenance concerns
for vendor #1
Limited flexibility of tool
configuration for vendor #2
Multiple tools to calculate and report, with concerns about accuracy
No single source of truth for measure definitions
May not support the expansion of
eMeasure programs
Inability to support the complexity of eMeasure reporting as BJC transitions from multiple EHRs to the new EHR
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eCQM Reporting Tool Alternatives
Consideration
Consideration EHR-Vended Self-Certified Non-EHR Vended
Flexibility in Content
Flexibility in Workflow
Report Customization Capability
Extract-Transform-Load Not Needed
Mai
nte
nan
ce No eCQM Specification Updates
No Calculation Engine Updates
No Report/Dashboard Updates
Support of eCQM Continuity
Level of Effort Low High Medium
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Advantages of Using a Measure Calculation Engine
• Flexibility in sourcing data elements and associated workflows
• Standardized eCQM calculations across Integrated Delivery Network (IDN), even
with disparate EHRs
• Data guide facilitated documentation of data sources promoting transparency,
problem-solving and process improvement
• Exposed data quality and data gap issues
• Ability to map organizational data element terminology to eCQM-required
terminology
• Supporting tools for eCQM improvement (data guide, risk assessment, measure
resource library, measure drill down, and value set library)
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Polling Question #3
Is your organization transitioning to a new EHR ?
1. Yes
2. No
3. N/A
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Timeline
2015 2016 2017 2018
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
Project Start
Production
2016 Upgrade
CMS 2016 Submission
2017 Upgrade
CMS/TJC 2017 Submission
2018 Upgrade
Legacy Retired
Kick-off
ETL Build
Testing
Go-Live
Validation
Hospital #1
POD 1
POD 2
POD 3
LEGACY
NEW EHR
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Implementation Cycle - Legacy
Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
WorkflowIdentification
Data Analysis
Value SetMapping
Pre-production Testing
Post-production Validation
Identify SMEs
Identify all workflows by measure
Identify and document workflow gaps
Identify source data fields based on workflow
Profile source data to determine data quality
Identify and document data gaps
Determine value set gaps
Map data elements to standard terms
Engage users in testing
Test ETL
Test content
Test workflow
Test mapping
Test measure calculation
Validate measure results
Engage users in validation
Communicate, communicate, communicate
Iterative Processes
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Implementation Cycle-New EHR
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov
WorkflowIdentification
ETL BuildValue SetMapping
Pre-production Testing
Post-production Validation
Identify SMEs
Determine workflows by measure
Customize EHR to close known gaps
Identify source data fields based on workflow
Test 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
• Validate measure results
• Document standard
workflow and incorporate
into training
• Tweak ETL
• Tweak mappings
Iterative Processes
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eMeasure Calculation: Legacy
Security & AuthenticationHIPAA Compliance
Client ETL(Informatica, DataStage, other)
AnalyticsDataHome
Landing
AnalyticsEngine
Inte
grat
ion
&
Co
nfo
rma
nce
Pro
cess
or
IntakeSchema
Value Set MappingTranslations
Source Systems Data Acquisition Layer
eCQMCompliance &
Reporting
Meaningful UseCompliance &
Reporting
Client Custom MeasuresReporting
PresentationIntegrated Information PlatformHealth Data Core
Consolidatedata for
ETL
Raw Data sftp
EHR EHR
EHR ED
ED OB
Pt Reg Pt Reg
Pt Reg Meds
Claims Allergy
Data transformation
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eMeasure Calculation: New EHR
Security & AuthenticationHIPAA Compliance
Client ETL(Informatica, DataStage, other)
AnalyticsDataHome
Landing
AnalyticsEngine
Inte
grat
ion
&
Co
nfo
rma
nce
Pro
cess
or
IntakeSchema
Minimal Value Set Mapping
Translations
Source Systems Data Acquisition Layer
eCQMCompliance &
Reporting
Meaningful UseCompliance &
Reporting
Client Custom MeasuresReporting
PresentationIntegrated Information PlatformHealth Data Core
Consolidatedata for
ETL
Raw Data sftp
EHR
Pt Reg
Claims
Data transformation
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Challenges – eCQM Specifications
• eCQM Logic
• Date/Time
• Value Set Mapping
• Validation
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Challenges–New EHR Implementation and eCQM Calculation
• Maintain and upgrade legacy systems while building new EHR
• Unidentified/developing workflows
• Value set mapping
• Content testing – test data
• Applying lessons learned from legacy EHRs to build of new EHR
• Technical unfamiliarity with new EHR
• Customization of new EHR for eCQMs
• Continue mandatory reporting of eCQMs from legacy systems
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Reporting to CMS for IQR and MU:eCQM Data
Den Score Den Score Den Score Den Score Den Score Den Score Den Score Den Score Den Score Den Score Den Score
ED-1a
Median Time from ED Arrival to ED Departure for
Admitted ED Patients - Non-Mental Health Patients 792 239 693 280 3786 415 111 247 2072 417 2052 257 152 231 169 274 404 266 151 223
ED-1b
Median Time from ED Arrival to ED Departure for
Admitted ED Patients - Mental Health Patients 792 379 693 315 3786 591 111 236 2072 488 2052 323 152 228 169 313 404 230 0 0
ED-2a
Median Admit Decision Time to ED Departure Time
for Admitted Patients - Non-Mental Health Patients 783 57 677 76 3655 223 109 40 2033 161 2024 91 152 53 168 60 402 67 134 65
ED-2b
Median Admit Decision Time to ED Departure Time
for Admitted Patients - Mental Health Patients 783 60 677 77 3655 314 109 42 2033 205 2024 109 152 72 168 80 402 30 0 0
VTE-1 VTE Prophylaxis 725 89% 1477 87% 647 85% 6182 93% 193 94% 1783 90% 2156 89% 105 87% 342 93% 330 85%
VTE-2 ICU VTE Prophylaxis 194 91% 592 93% 178 92% 2014 97% 33 97% 402 97% 689 96% 69 90% 115 97%
STK-2 Discharged on Anti-thrombotic Therapy 11 100% 80 91% 36 97% 241 89% 1 0% 63 97% 74 99% 3 100% 2 100% 15 100% 37 77%
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter 3 33% 21 62% 6 67% 54 65% 1 0% 10 60% 15 80% 0 0% 1 0% 2 100%
STK-5 Antithrombotic Therapy by End of Hospital Day 2 11 91% 88 88% 26 88% 196 93% 1 100% 61 95% 65 95% 3 67% 2 100% 10 100% 37 92%
STK-6 Discharged on Statin Medication 7 100% 28 96% 31 94% 109 88% 1 0% 41 88% 57 93% 3 67% 1 100% 8 100%
STK-8 Stroke Education 5 40% 39 85% 26 88% 182 78% 1 0% 38 97% 46 93% 1 0% 0 0% 11 73%
STK-10 Assessed for Rehabilitation 13 15% 92 75% 37 14% 353 97% 1 100% 63 78% 80 60% 3 0% 2 0% 15 40%
PC-01
Elective Delivery Prior to 39 Completed Weeks
Gestation 0 0% 1 0 0 0% 0 0% 0 0% 1 100% 0 0%
PC-05 Exclusive Breast Milk Feeding 250 50% 480 63% 754 37% 1072 56% 72 31% 170 21% 266 56%
EHDI-1a Hearing Screening Before Hospital Discharge 185 92% 399 96% 1091 61% 937 94% 63 95% 156 83% 203 97%
BJSP BJH Memorial
BJC 4th Quarter 2016 eCQM DataOctober 3, 2016 - December 31, 2016
PWHeCQM
AMH BHC PHC BJWC CH MBMC MBSH eMeasure Title
eCQMBHC BJWC MBSH Memorial
Den Score Den Score Den Score Den Score
VTE-1 1477 87% 193 94% 105 87%
STK-2 80 91% 1 0% 3 100% 37 77%
STK-5 88 88% 1 100% 3 67% 37 92%
EHR 1 EHR 2EHR 3 EHR 4
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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
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
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Current State 2018
ID eMeasure Title GOAL AMH BHC BJH BJSPH BJWCH CH MBMC MBSH PHC PWH SLCH
ED-1aMedian Time from ED Arrival to ED Depart for Admitted ED Patients 287 227 435 304 257 453 261 256 268 276 304
ED-2aMedian Admit Decision Time to ED Depart Time for Admitted Patients 85 49 218 83 40 191 90 61 70 78 140
ED-3aMedian Time from ED Arrival to ED Depart for Discharged ED Patients 171 216 349 231 187 253 229 192 286 206 201
VTE-1 VTE Prophylaxis 95% 86% 82% 90% 85% 90% 87% 88% 81% 90% 70%
VTE-2 ICU VTE Prophylaxis 95% 95% 90% 97% 95% 100% 97% 97% 92% 96% 93%
STK-2Discharged on Anti-thrombotic Therapy 95% 92% 97% 89% 94% 100% 97% 96% 100% 80% 100%
STK-3Anticoagulation Therapy for Atrial Fibrillation/Flutter 95% 80% 67% 74% 67% - 91% 74% - 50% 50%
STK-5Antithrombotic Therapy by End of Hospital Day 2 95% 100% 87% 94% 100% 100% 94% 91% 100% 80% 100%
STK-6 Discharged on Statin Medication 95% 79% 100% 87% 82% 100% 97% 80% 100% 0% 100%
STK-8 Stroke Education 95% 26% 62% 60% 100% - 97% 88% 0% 50% 100%
STK-10 Assessed for Rehabilitation 95% 8% 83% 99% 35% 100% 67% 62% 0% 40% 17%
PC-05 Exclusive Breast Milk Feeding 50% 49% 64% 37% 55% 45% 26% 57%
EHDI-1aHearing Screening Before Hospital Discharge 95% 87% 90% 53% - - - 86% 85% 83% 84%
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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 for
internal performance
improvement
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Questions
Please complete the online evaluation for this session.
Mary Burton, RN, MSN, APRN(R), PhD,
Group Manager Clinical Quality
BJC Healthcare
Liz Richard, MBA, MHS
Senior Director
Encore