reporting data for period 1 - practice innovation …... cqm source reporting 5 (depending on...
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Reporting Data for Period 1
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WEBINAR OBJECTIVES
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1 ABCS MeasuresCQM Source Reporting - DQIP
ENSW REPORTING REQUIREMENTS
2Updated documentationUpdated DARTNet Reporting Options TableRolling Reporting TimelineUpdated Num-Denom Instructions
ENSW DATA REPORTING METHODS
3 DISCUSSION & QUESTIONS
4 CONTACT INFO
Method Breakdown 101
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ENSW
REPORTING
REQUIREMENTS• ABCS Measures
• CQM Source Reporting – DQIP
• **Measure Specs on PIPCO site!
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ENSW CLINICAL QUALITY MEASURES
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Topic Description NQF PQRS
A: Aspirin
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period
0068 204
B: Blood Pressure Management
Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.
0018 236
C: Cholesterol Management
Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with a fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >= 190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year.
N/A N/A
S: Smoking Cessation Support
Percentage of patients aged 18 years or older who were screened about tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
0028 226
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CQM SOURCE REPORTING
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(Depending on practice determination found in Practice Survey/DQIP)
From CQM Report
Data SourceAspirin
(NQF 0068)
Blood pressure management (NQF 0018)
Cholesterol management
(New)
Smoking cessation support
(NQF 0028)
Patient-level data: Direct practice connection to DARTNet OR another organization who will capture data elements and calculate measures (e.g. HIE, NM PCA, etc.)
*Practice-level data: Numerators/Denominators from a non-EHR registry
*Practice-level data: Numerators/Denominators from EHR certified by ONC in 2014 or after
*Practice-level data: Numerators/Denominators from EHR certified by ONC prior to 2014
Patient-level data: Chart audit - using EHR data
Patient-level data: Chart audit - paper health record
*Practices that can only generate provider-level reports MUST 1) Create unique denominators and 2) Ensure that the same patient does not report for multiple providers in the practice.
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CQM SPECIFICATIONS AVAILABLE
Cholesterol
• Measure Narrative
• N/D Flowchart
• Field Specifications
Smoking Cessation
• Measure Narrative
• N/D Flowchart
• Field Specifications
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Aspirin
• Measure Narrative
• N/D Flowchart
• Field Specifications
Blood Pressure
• Measure Narrative
• N/D Flowchart
• Field Specifications
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ENSW DATA
REPORTING
METHODS• Updated documentation
• Updated DARTNet Reporting
Options Table
• Rolling Reporting Timeline
• Updated Num-Denom
Instructions
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REMEMBER RECEIVING THIS?
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UPDATED ENSW DATA REPORTING DOCUMENTATION
• DARTNet Data Reporting Options
• Created Rolling Reporting Timeline for
ENSW Cohort 1
• ENSW Instructions for Submitting Num-
Denom Data Cohort 1
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ROLLING REPORTING TIMELINE COHORT 1
ENSW Cohort 1 Rolling Reporting Timeline by Measurement Period
Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
BASELINE : (2015/01/01 - 2015/12/31)
Period 1 (Month 3): 2015/04/01 - 2016/03/31
Period 2 (Month 6): 2015/07/01 - 2016/06/30
Period 3 (Month 9): 2015/10/01 - 2016/09/30
OPTIONAL Period 4 (Month 12): 2016/01/01 - 2016/12/31
Period 5 (Month 15): 2016/04/01 - 2017/03/31
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UPDATED NUMERATOR-DENOMINATOR INSTRUCTIONS
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Discussion &
Questions• Method Breakdown 101
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METHOD BREAKDOWN: 101
• Sending Patient-Level Data via
o Direct connection to DARTNet means:
Practice or another organization will send DI flat files
for Baseline and Periods 1-3, 5 (Period 4 optional)
Use ENSW Set Up Guide
Use Set Up Guide Table Layout
o Chart Audit means:
For paper charts, contact Maggie Dunham
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How do I do this though, really…?
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METHOD BREAKDOWN: 101
• Sending Practice-Level Data (Num/Denom) via:
o Non-EHR Registry:
Use practice’s preferred format
Or follow UPDATED Num-Denom Instructions
o EHR certified before/in/after 2014:
Contact EHR Vendor
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How do I do this though, really…?
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12631 E. 17th AvenueAurora, CO [email protected]
MAGGIE DUNHAMHIT Program Manager
THANK YOUQUESTIONS?
12635 E. Montview Blvd, Suite 136Aurora, CO [email protected]
Practice Performance Registry