Epic EHR workflows for CPC+
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- Russell Norris
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1 Epic EHR workflows for CPC+ Wednesday 6/13/ :30 to 1:30 - Presentation & EHR workflows 1:30 to 2:00 Review of Resources and Q & A Carl Barton & Anna Smolentzov
2 Agenda Introductions Key learning objectives Examples of Comprehensive Primary Care Plus (CPC+) Quality Improvement (QI) projects with demonstrated Epic EHR workflows Review of Resources
3 Introductions Mountain-Pacific Quality Health Carl Barton Healthcare Transformation Consultant Barry Major Practice Facilitator CPC+ Hawaii Region Hawaii Pacific Health Anna Smolentzov - Business Systems Analyst Hawaii Department of Health (DOH) Centers for Disease Control and Prevention (CDC) 1305 funding focus Improve control of diabetes and high blood pressure through support for QI, CQM reporting, use of HIT, team-based care and referral to community resources Improve identification of potential hypertension, pre-diabetes and diabetes which is not coded
4 Key Learning Objectives Navigate the Epic EHR workflows that directly align with CPC+ Care Delivery Requirements, ecqms and Quality Improvement Be able to navigate resources available to assist your practice
5 Polling Question 1 I am planning on reporting All quality measures Only the required number of quality measures
6 Components for Quality Improvement Quality Population Utilization EHR Resources Resources $ Reimbursement Method Method
7 Important Note! Utilizing the correct workflows of your EHR can ensure you get paid based on the actual quality of the care you are delivering.
8 Technical Assistance Review of resources for Hypertension, Tobacco Use Screening/Cessation and Diabetes Million Hearts resources Mountain-Pacific resources Review and support with community resources Diabetes Education and Prevention programs (DPP & DSME) Lifestyle programs Smoke Cessation programs Program Guidance for CPC+ Assessment of your practice s approach to team based care and self-management support Review methodologies like PDSA and ecqi Contact Carl Barton at cbarton@mpqhf.org or (808) if you can use additional technical assistance in the next two weeks
9 Clinical Quality Measures (CQMs) Measure CMS / MIPS ID Type BP Control 165/236 Outcome A1c Control 122/001 Outcome Nephropathy Screening 134/119 Process DM Eye Exam 131/117 Process Depression Screening 2/418 Process Utilization of PHQ-9 160/712 Process Dementia: Cognitive Assessment 149/2872 Process Screening for Falls 139/101 Process High Risk Rx in the Elderly 156/22 Process 9
10 Polling Question 2 I check my CPC+ Dashboard in Epic On a regular basis, at least monthly Approximately quarterly Infrequently I have a dashboard?
11 CPC+ Example # 1 Project: Establish care plans for high risk DM patients OR uncontrolled HTN Project Changes/Improvements Identify population with EHR Implement a care management workflow for empaneled patients to include previsit planning, establishing care plans/goals (in EHR), care coordination/follow up, self management support and enhanced patient engagement and patient education Train staff on accurate BP measurements MH - BP protocol Enhanced communication (secure messaging, phone, etc.) Implement CDS rules to support changes Group visits or another alternative visit type Increase referrals to lifestyle/self management programs
12 CPC+ Example # 1 Scoring ecqms 134 (DM nephropathy), 122 (DM A1c Poor Control), and 131 (DM eye Exam) OR 165 (controlling hypertension) Care Delivery Requirements Define at least one sub population with complex needs and provide additional support Use of care plans to establish and track goals Alternative visit types (telephone, group visits, assisted living, etc.) Utilize community resources Implement self-management support
13 EPIC EHR WORKFLOWS FOR CPC+
14 ecqms in Epic How to enter reportable data in Epic New tool to enter data: Results Console How to see if a patient is meeting a measure or not
15 CMS-134: Diabetes: Medical Attention for Nephropathy What does the measure say? Bulletins on AskIT
16 CMS-134: Diabetes: Medical Attention for Nephropathy The percentage of patients with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period. How to document: Patients with diabetes Patients with evidence of nephropathy Taking an ACE inhibitor or ARB A nephropathy screening test performed
17 CMS-134: Diabetes: Medical Attention for Nephropathy Patients with diabetes Problem List & Visit Diagnoses Patients with evidence of nephropathy Problem List & Visit Diagnoses Taking an ACE inhibitor or ARB Medication List A nephropathy screening test performed Lab orders Results Console for external lab results
18 CMS-122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) What does the measure say? Bulletins on AskIT
19 CMS-122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Inverse measure: lower score is better! How to document: Patients with diabetes Lab result
20 CMS-122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Patients with diabetes Problem List & Visit Diagnoses Hemoglobin A1c result Lab orders Results console for external results
21 ecqms Per Patient How do you see how a patient is doing? Quality Navigator Shows measures that a patient meets and does not meet
22 CMS-131: Diabetic Eye Exam Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period. How to document: Patients with diabetes: Problem List and Visit Diagnoses Eye exam performed: Results Console Eye exam result (negative): Results Console
23 CMS-165: Controlling High Blood Pressure Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. How to document: Patients with hypertension: Problem List Blood pressure: Vitals Results console necessary?: No!
24 ecqms Recap CMS-134: Diabetes: Medical Attention for Nephropathy CMS-122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) CMS-131: Diabetic Eye Exam CMS-165: Controlling High Blood Pressure
25 CPC+ Dashboard How do you see your ecqm scores in Epic?
26 CPC+ Dashboard
27 CPC+ Dashboard
28 CPC+ Dashboard: Provider Level
29 CPC+ Dashboard: Drilldown Report
30 CPC+ Dashboard: Drilldown Report
31 CPC+ Dashboard: Drilldown Report Logic
32 Patient Outreach Reports
33 Pt Outreach: Diabetes HbA1c > 9
34 Pt Outreach: Diabetes HbA1c > 9
35 Pt Outreach Encounter
36 Pt Outreach Encounter
37 Psychosocial Assessment
38 Alternative Visit Types Upcoming Features in Epic evisits with patients through MyChart (questionnairebased) Group Visits documentation tools
39 Where can you get help?
40 RESOURCES
41 Million Hearts Resources Hypertension Control: Change Package for Clinicians Hypertension Control: Action Steps for Clinicians Template - Protocol for Controlling Hypertension in Adults Tobacco Cessation Protocol Cholesterol Management Protocols
42 Diabetes and Smoking Cessation Resources Hawaii Department of Health - Patient Resources American Association of Diabetes Educators ADA-recognized and AADE-accredited DSMES Program Sites Algorithm of Care Algorithm Action Steps Hawai i Tobacco Quitline Healthcare Providers Community Programs Community Resources
43 Mountain-Pacific Resources Diabetes Tools and Resources Fitness and Blood Sugar Trackers Handout Exercise Prescription and Maintenance article eclinical Quality Improvement (ecqi) Quality Methodology ecqi Resources Cardiac Health Tools and Resources Cardiac Toolkit Blood Pressure Zone Tool Blood Pressure Poster Blood Pressure Measurement Tips and Tricks Smoking Cessation Butt Out
44 Hawaii Pacific Health Resources HealthAdvantage Connect Service Desk - Phone: (non-urgent issues): ServiceDesk@HealthAdvantageConnect.com More information about CQM Bulletins on AskIT
45 How to choose QI projects and get started using PDSA
46 Plan-Do-Study-Act (PDSA) The PDSA quality improvement methodology is an iterative, four-stage problem-solving model used for improving a process PDSA is a simple, yet powerful, tool for accelerating change Quality improvement is an ongoing cycle with strong emphasis of the use of data for decision making and to verify performance
47 PDSA, cont. Links Mountain-Pacific ecqi PDSA Worksheet template Institute for Healthcare Improvement Plan-Do-Study- Act (PDSA) Worksheet
48 Choose a QI Project 1. Choose your condition/ QI focus 2. Identify the evaluation measures (CQMs) that apply 3. Run the clinical quality measures (CQM) (or other evaluation measure) reports (min. 90-day period) to establish current performance 4. Compare current performance on measures to benchmarks or goals 5. Prioritize list of improvement projects and Identify your first QI project 6. Establish project goals or evaluation metrics/targets For example: MIPS: 1. Run CQMs chosen for quality category 2. Run Advancing Care Information reports both base and performance measures 3. Compare to benchmark/goals 4. Choose first measure to work on and establish a target goal
49 Identify Possible Improvements Answer this question: What changes can we make that will result in an improvement to the project goal selected? Brainstorm ideas for possible changes that will ultimately improve the project goal/outcome measure
50 Identify Possible Changes Identify possible EHR functionality changes How can EHR support best practices/protocols? Review staff use and workflows (based on clinical best practices for QI topic) Computer provider order entry (CPOE) Care coordination and transition of care Determine available options, decide on applicability (based on clinical best practices for QI Topic) Clinical Decision Support (CDS) Interfaces Patient Portal/eSecure messaging Etc. Patient Education materials
51 Identify Possible Changes (cont.) Review your workflows: What is the EHR vendor s recommended workflow for correct population of the CQM? (ASK YOUR VENDOR!) What process do you need to analyze further that will have the biggest impact on the measure outcome? Is it electronic, physical or a data flow? Physical - Includes environmental layout of patient room, equipment, devices, supplies, etc. Electronic - How is the work documented? What screens and fields are used? Data - Where does the information documented go? Why does it go there (triggers or reports)? How does it get there (interfaces, uploads, etc.)
52 Identify the first PDSA (improvement) Prioritize your change backlog and choose your first PDSA cycle from the list of possible changes Identify a measureable goal for the PDSA cycle Use standard data measures, easily accessible and repeatable Establish baseline data, if one is not already available (make step one of plan if needed) Determine a target goal for improvement Tasks to keep in mind for PDSA plan: Reviewing electronic, data entry and physical workflows, audit reports Leveraging EHR functionality whenever possible Implementing clinical best practices/protocols to support improvement
53 First QI PDSA Cycle Recommendation If data in CQM report is not accurate, make your first PDSA cycle about determining accurate electronic workflow, training staff on accurate workflow and validating that data That will be your immediate improvement and allow all the other functionality in the EHR to work correctly with the structured data
54 How to choose QI projects and get started using PDSA
55 CPC+ Example # 2 Project: Establish care plans for geriatric population Project Changes/Improvements Identify population with EHR Implement a care management workflow for empaneled patients to include pre-visit planning, establishing care plans/goals (in EHR), care coordination/follow up and patient education Implement CDS rules to support changes Enhanced communication (secure messaging, phone, etc.) Behavioral health integration Home visits or another alternative visit type
56 CPC+ Example # 2 Scoring ecqms 2 (Depression Screening), 166 (PHQ-9), 149 (Dementia), 139 (Screening for Falls), 156 (High Risk Rx in Elderly) Care Delivery Requirements Define at least one sub population with complex needs and provide additional support Use of care plans to establish and track goals Plan for integrating behavioral health Advanced Care Planning Alternative visit types
57 Acronyms EHR Electronic Health Record CEHRT Certified Electronic Health Record Technology QI Quality Improvement CQM/eCQM Clinical Quality Measure / electronic Clinical Quality Measure PDSA Plan-Do-Study-Act (iterative, four-stage problem-solving model) CDS Clinical Decision Support CPOE Computerized Provider Order Entry HIE Health Information Exchange ecqi - eclinical Quality Improvement Quality Methodology ecqi Resources
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