1

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

2

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.

3

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

1

2

3

4

5

6

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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

mary.burton@bjc.org

Liz Richard, MBA, MHS

Senior Director

Encore

lrichard@encorehealthresources.com