Using your Electronic Medical Record for Quality Reporting and Better Patient Care Developed by HealthInsight with funding from the U.S. Centers for Disease Control and Prevention through the Utah Department of Health.
Welcome to Quality Data for Beginners: Using your Electronic Medical Record for Quality Reporting and Better Patient Care. This guide is for small clinics in a private practice and will cover three main topics: 1) basic quality reports and how to get them from your electronic health record (EHR), 2) creation of patient lists, and 3) how to use reports and patient lists for quality improvement. But, first let s start with some reasons you may want to look at the quality data for your clinic. Why get quality data from your EHR? You want to report measures to a quality program, such as the Centers for Medicare & Medicaid Services (CMS), Quality Payment Program (QPP), the Healthcare Effectiveness Data and Information Set (HEDIS), to get incentives and quality recognition. You want to improve a measure or meet a benchmark. You want to ensure excellent care for patients with diabetes, hypertension, or other conditions. You can do this! You are used to entering data into your EHR, but what about getting data out? Getting quality data takes some practice and patience, but it is worth the effort. Where do I start? Most EHRs have a few pre-made reports. If you feel uncomfortable exploring your EHR alone, request help from your EHR vendor (Eclinicalworks, Greenway, or Athena). Have them take you on a tour of your EHR and show you popular features and common quality measure reports. Also, consider reaching out to another practice that uses the same EHR as your practice. HealthInsight may be able to connect you with a practice that uses the same EHR. Contact HealthInsight at 801-892-0155. Once you feel comfortable, explore menu tabs and drop downs boxes, and look for key words such as Reports, Meaningful Use, PQRS, QPP, Quality, or MIPS. Generating these pre-made reports requires filling in different fields, such as dates. These pre-made reports have useful clinical measures such as screening rates for diabetes, cervical cancer, colorectal cancer, vaccines, depression, blood pressure control, and tobacco use. This chart explains some of the measures most popular with payers and quality programs. Please reach out to HealthInsight for guidance on what quality measures may be best for your practice. 2
Quality Measure For more quality measures visit qpp.cms.gov and ncqa.org A1C Patients aged 18-75 Diabetes Type 1 and 2 with A1C greater than 9 (poor control) or missing annual A1C Blood Pressure Control Patients with diagnosis of hypertension whose most recent reading was <140/90 Lipids Patients with diagnosis of vascular disease whose most recent LDL-C was <100 Aspirin Patients 18 years and older with diagnosis coronary artery disease prescribed aspirin or clopidogrel in the last 12 months Tobacco Use Screening and Cessation Intervention Patients 18 years and older who were screened for tobacco use one or more times within the last 24 months AND who receive smoking cessation counseling if a tobacco user Depression Screening Patients 12 years and older who were screened for depression on the date of the encounter using a screening tool such as PHQ-2 and if positive, a follow-up plan was documented on the same day as the positive screen Influenza Immunization Patients six months and older who were seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization NQF Measure QPP Medicare Measure 0059 Yes Yes 0018 Yes Yes 0075 Yes Yes 0068 Yes Yes 0028 Yes Yes 0418 Yes Yes 0041 Yes Yes HEDIS Commercial Measure 3
Troubleshooting Data You may run these reports, look at the data and say, This data seems wrong, I know we do way more X s than this. If this is the case, you will need to troubleshoot and verify the data. Put on your investigator hat, because you can get to the bottom of this. Consider pulling five to 10 patient charts and see where data is recorded, this can be very instructive. Common Problem Possible Error Solution Percentages seem abnormally low or high Lab values seem wrong Other issue Troubleshooting Ideas Report is getting data from wrong field or staff data entry not standard. Lab data not interfacing well with EHR, not being added in structured data field, or staff data entry not standard. Ask where data is coming from. Staff? Other? Call vendor, ask which fields are used to calculate measure and how to get correct field added to report. Standardize staff data entry. Call lab, verify lab results entered in EHR are in correct, structured data field. Standardize staff data entry. Talk with staff, lab, and vendor about issue and find solution. Examine individual patient charts and pull a cross-section of individual patient charts. Does this small sample indicate the data is likely accurate, or not? 1. Check with your EHR vendor s website, manual or submit a help request ticket to your EHR vendor. 2. Compare your EHR report to a payer report. 3. Search YouTube or Google for solutions. 4. Reach out to HealthInsight for a master user and other ideas for troubleshooting. 5. Start your own EHR help group with other office managers who use the same EHR as you. Use group text and phone calls to help each other. 6. Visit HealthIT.gov for ideas. 4
Patient Lists Manage the care of patients with diabetes, hypertension or other conditions Did you know you can sort patients by diagnosis code? This will give you a list of patients who could benefit from closely managed care. The most popular patients to manage include those with diabetes, hypertension, asthma, or depression. Each condition has different items to track, such as lab results, last seen, foot exam, etc. For help on what tests and information would be useful for these different patient groups, talk to the provider at your clinic. There are also examples of patient registries online. Some EHRs allow you to manage the patient names and information you are tracking on those patients; however, some do not have the functionality. If your EHR does not have this option, you can put the information into an Excel spreadsheet (HIPAA compliant of course), or purchase an add-on software that works with your EHR to help you optimally manage the information and care of these patient groups. By closely following this select group of patients, you can quickly improve quality measures. In fact, this is the single best way to improve a quality measure. Learning to create a patient list can be a little more advanced; however, with a call to your EHR vendor and a few diagnosis codes in hand, you can create a patient list. Here are some diagnosis codes to get you started. For a sample of a patient registry, see the appendix at the back of this guide. Diagnosis Codes to Create a Patient List Aspirin for those who need it - This information is usually pulled from either the patient s medication list or, in some cases, the patient s problem list. Keeping the medication list current is necessary to generate accurate reports. Example ICD-10 diagnosis codes for conditions where aspirin may be indicated include: I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris I25.82 Chronic total occlusion of coronary artery I25.90 Chronic ischemic heart disease, unspecified Z86.74 Personal history of sudden cardiac arrest I65.29 Occlusion and stenosis of unspecified carotid artery Blood pressure control - This information is pulled from the patient s vital sign fields and the problem list. The problem list must be up-to-date with correct and current diagnoses. Frequently used ICD-10 diagnosis codes for hypertension include: I10 Essential (primary) hypertension R03.0 Elevated blood-pressure reading, without diagnosis of hypertension I11 Hypertensive heart disease I12 Hypertensive chronic kidney disease I13 Hypertensive heart and chronic kidney disease 5
Cholesterol management - This information is pulled from the problem list and claims reporting data regarding labs or from a lab interface importing structured data. The problem list must be up-to-date with correct and current diagnoses. Frequently used ICD-10 diagnosis codes for hyperlipidemia include: E78.0 Pure hypercholesterolemia E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E78.5 Hyperlipidemia, unspecified Quitting smoking - This information will be pulled from the structured smoking status fields within your social or health histories. The problem list and medication list must be in a structured format. Diabetes - The denominator information is usually pulled from a patient s problem list, with a diagnosis code of diabetes mellitus. Many of the control measures, including NQF 0059, correlate the diabetes diagnosis with an HbA1c value that should be less than one year old. It is important to have the HbA1c lab value mapped appropriately for these measures to function. Frequently used ICD-10 diagnosis codes for diabetes mellitus include: E11.9 Type II diabetes mellitus without complications E10.9 Type I diabetes mellitus without complications E11.65 Type II diabetes mellitus with hyperglycemia E10.65 Type I diabetes mellitus with hyperglycemia Prediabetes - Quality improvement with respect to prediabetes is heavily dependent on identification. The main indication is impaired glucose tolerance. Other frequently used ICD-10 diagnosis codes include: E66.0 Obesity due to excess calories Z83.3 Family history; diabetes mellitus (situation) R73.02 Impaired glucose tolerance R73.09 Other abnormal glucose Z86.32 Personal history of gestational diabetes O99.810 Abnormal glucose complicating pregnancy R03.0 Elevated blood pressure I10 Essential (primary) hypertension E78.5 Hyperlipidemia, unspecified E28.2 Polycystic ovarian syndrome L83 Acanthosis nigricans 120-25 Codes for coronary disease 6
How to Improve Measures You now have accurate quality reports, and you even created a list of patients with diabetes, high blood pressure, or another condition. Great job, your new EHR skills are going to benefit the clinic and patient care. In fact, you have already completed the first step for a quality improvement project because you have accurate data and you can run it again at regular intervals. This will help you to see progress from any changes you make in clinic workflows. Changes in workflows? Yes, to get better results in clinic measures, there is a good chance some changes will need to be made. To get started on your quality improvement project, you ll need to write down a plan, and then do something called a PDSA cycle (Plan-Do-Study-Act). This method allows you to test a little change and see if it works before it goes clinic-wide. Many clinics just like yours have successfully made changes and improved measures using the PDSA cycle. For success stories, tool kits, and to get ideas from other clinics, look at the resources section of this guide and talk to HealthInsight about your goals. PDSA in Action: Blood Pressure Control Set the goal Sample goal: Improve our blood pressure control rate to 70 percent to win the HealthInsight Quality Award in 2018 and the Utah Million Hearts Coalition Award. Establish measures Sample measures: The latest measure report indicates blood pressure control is 50 percent or 200 out of 400 patients have a blood pressure higher than 140/90. We will increase blood pressure control in 88 patients, to reach our goal of 70 percent control rate by June 2018. Create a plan for the change Sample plan: The quality manager will identify 20 patients from our registry that are not at goal and conduct a chart audit with the provider to see why they are not at goal. We will identify three reasons most patients are not at goal. We will set the audit for Monday afternoon and the quality manager will provide the list and tally sheet for the provider. We will send out the results the same day for the quality improvement team to review and come back with our plans for our next intervention. Testing changes and evaluating results Sample evaluation: Results of the chart audit show 10 out of 20 patients had their blood pressure reading recorded in the incorrect field in the EHR. The next two out of 20 patients didn t go to their scheduled education visit with their pharmacist. The remaining eight out of 20 are being seen by the provider and just seem to be not at goal. The audit was done by the quality manager, it took 45 minutes, and the results were emailed to the provider. All team members decided they need to do a training on blood pressure entry at the next staff meeting. The training was scheduled. 7
The next PDSA was planned by the team. Blood pressure data being entered in the correct place will increase our control rate by 30 patients. We will have the quality manager review the patient list for all patients not at goal and share the list with the provider to see which patients to schedule for a visit. She will ask the front desk to schedule these patients. We will check our control rates and see which patients have come in from the list and also who had their blood pressure recorded correctly. Conclusion Don t get overwhelmed when it comes to PDSA and making changes. Remember, work on your biggest priority and when you are meeting your goal, move on to the next goal as you can. Projects do not need to be huge; little changes over time will make a big difference. Include your entire team on these projects and you will find this is a wonderful opportunity to cultivate leadership, team building, and growth/learning mindset within your clinic. As you and your team work together and get even better at what you do, you will find your efforts paying off in quality awards, meeting national benchmarks, and pride in knowing you are saving lives and improving the quality of life for your patients through outstanding medical care. Special thanks to Utah Department of Health and the U.S. Centers for Disease Control and Prevention for making this guide possible. Please see the appendix for PDSA cycle detail, example of a diabetic patient registry and resources for diabetes, high blood pressure, tobacco use, and pre-diabetes. Thank you for reading the Quality Data for Beginners: Using your Electronic Medical Record for Quality Reporting and Better Patient Care. Has this guide helped your clinic improve care? Do you have a success story to share? Please contact HealthInsight at 801-892-0155 to share your story. Published December 2017 by HealthInsight 8
Appendix: PDSA Cycle in Detail Step 1: Setting the aim, or what are we trying to accomplish? State the aim clearly (SMART: specific, measurable, achievable, results-focused, and time- bound) Include numerical goal and time frame that require fundamental system change Set stretch goals - A "stretch" goal is one to reach for within a certain time Avoid aim drift - Once the aim has been set, the team needs to be careful not to back away from it deliberately or "drift" away from it unconsciously Be prepared to refocus the aim Step 2: Establishing measures, or how will we know that a change is an improvement? Plot data over time Seek usefulness, not perfection Use sampling Integrate measurement into the daily routine Use qualitative and quantitative data Step 3: Create an overall plan for improvement or selecting change. Resources The following resources may be helpful in using the Model for Improvement: Avoid the same responses such as throwing more money and people at the problem Implement recommended practices guidelines Think processes and systems of work: simplify processes, reduce waste or unnecessary redundancies, strengthen hand-offs Creative thinking Appropriate use of new or existing technology Describe change (strategies) Predict outcome List steps needed Plan for collection of data o o Institute for Healthcare Improvement website: http://www.ihi.org Langley G.J., Nolan K.M., Nolan T.W., Norman C.L., Provost L.P. (2009). The Improvement Guide. New York, NY: John Wiley and Sons. The Improvement Guide is viewable online at http://books.google.com/ Type the title of the book into the search field and locate the most recent edition. 9
Appendix: Registry Summary Report Patients Diabetes 10
Appendix: Resources Diabetes www.choosehealth.utah.gov Connects patients with diabetes to free diabetes education www.livingwell.utah.gov Connects patients with diabetes to self-management class High Blood Pressure http://healthinsight.org/bloodpressure Medical assistant blood pressure technique training video, patient medication algorithm, Utah Million Hearts Coalition Award application and more http://millionhearts.hhs.gov/ Treatment protocols, research, patient education Pre-diabetes www.livingwell.utah.gov Connects patients with prediabetes to a free or low-cost lifestyle change program. Utah Tobacco Quit Line www.waytoquit.org and 1.800.QUIT.NOW Free resources including counseling and nicotine replacement therapy Acronym Dictionary CMS: Centers for Medicare & Medicaid Services Quality Payment Program EHR: Electronic Health Record HEDIS: Healthcare Effectiveness Data and Information Set MIPS: Merit-based Incentive Payment System NQF: National Quality Forum PDSA: Plan, Do, Study, Act PQRS: Physician Quality Reporting System QPP: Medicare Quality Payment Program 11