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									Launching Quality: HIT Enabled and Practical
       “Quality is the degree of excellence of our processes, performance, decisions,
       and human interactions.”
                                  Benson*




                                            NACHC Annual F.O.M.I.T. Conference
                                              Tuesday, November 10, 2009




                                              “HIT does not stand on its own.
                                               It is used by people to perform a process.”
I. What is the right time to launch an HIT enabled quality initiative?


    II. What goes in must come out. Data Quality Assurance


          III. Which HIT enabled quality targets?


                IV. The Silence of Quality in the Data – Report, Review, Respond


                      V. The Key Question: Is it Quality Yet?
               1. Answers to 5 questions

               2. Data Quality Assurance

              3. Decision making about
What you will
                 Quality
learn
               4. The relationship between
                  Quality and HIT

               5. What others have done or
                  recommend
    About Primary Care Development Corporation

•    Nonprofit founded in 1993


•    Mission: Ensure excellent healthcare in every neighborhood


•    Work with organizations in five programs areas:

      –   Capital Financing (CDFI)
      –   Performance Improvement
      –   Healthcare Information Technology (HIT)
      –   Emergency Preparedness
      –   Policy Leadership

•    Work with hospital-based clinics, FQHCs, DTCs in NYS and throughout U.S.


•    Learn more and contact us at www.pcdcny.org
          AHRQ Grant – 2008-2010
          Study: EMR/CDSS/Hypertension
          CHC Upstate NY

          Altman/Elebash Grant – ’08-’09
Sources   Study: HIT Adoption/Quality
          CHC New York City

          HEAL 5 Grant – 2008-2010
          Study: HIT Adoption/Quality/HIE
          9 CHCs Brooklyn
I. What is the Right Time to Launch Your HIT Enabled Quality Initiative



   When                            Pros                                           Cons
               • Establishes culture of quality                 • Risks forcing technology into quality
 Before HIT
               • Quality dictates technology selection            workflows
               • Prioritizes integrating technology into        • Identifies initiatives that HIT may be
                 quality improvement processes                    unable to enhance
               • Quality drives and defines technology
                 use
               • Starts with a team that identifies
                 opportunities for clinical process change
               • Kills two birds with one stone                 • High impact on resources
 During HIT
               • Incorporates HIT embrace with quality          • Lowers the range, depth of initiatives
               • Balances objectives of both initiatives        • Forcing the reach for low hanging fruit
               • Allows time to learn quality capabilities of   • Risks high probability of complete
 After HIT
                 HIT                                              workflow redesign
               • Aligns with HIT capabilities                   • Risks forcing an HIT driven agenda
      Building a Culture of Effective EMR use and HIT Enabled Quality




                                                                                                                       PHR
                                                                                                                       P4P
                                                                                                                      PCMH
                                                                                                                      TCNY
                                                                                                                       QAR
                                                                                                                       UDS
Selection   Readiness   Prep    Install   Testing   Appl Set-up   Training   GO LIVE   Sustainability   Integration    B2E
                                                                                                                       MU
                                                                                                                       AQA
                                                                                                                       NQF
                                                                                                                      PQRI
                                                                                                                      HRSA
                                                                                                                      HEDIS
                               Begin with the end in mind
                                                        Jim Collins
                         Recommendation
                          x

                               Implement technology
                               and HIT enabled
                               Quality based upon an
                               Established Value
            Which choice
                               Proposition
            is right for me?




Technology’s greatest impact is on written communications and data
II. What Goes in Will Come Out / Data Quality Assurance




           Just how good is my data?/ Or how bad is it?

           How “good” does it have to be?

           Who is going to know how good my data is?

           Who does good data effect?
Your vendor wants good data…its in the contract…


          1. Practice shall meet all requirements applicable to a
          practice in the VENDORs Service Description, including
          without limitation
               1. proper use of the VENDORS Services,
                             appropriate data capture and input of
               2.Practice’s appropriate data capture and input of
                          data
               required data, and technical and other requirements.

          2. Practice shall meet all requirements for participation
          in the HITECH Medicare incentive program that are
          imposed by HITECH, including without limitation:
               1. complying with all privacy and security and other
               compliance requirements required by HITECH.
               2. Practice shall be responsible for obtaining and
               entering in the VENDOR System all clinical and
               demographic information,
               3. and for meeting any clinical quality or outcomes
               criteria and patient outreach criteria, required by
               HITECH to receive Incentive Payments.
                                                           Data
                                                         Customers
                                                                     Payers
NHIN
                                                                          Medicare
             State Database SHIN-NY
                                                                                Medicaid
                                                                                       PQRI

                                                                                               HEDIS
                   Referrals/Specialists
                                                                                                       FED/MU
                                                             RHIO
                                                                                              NCQA PCC-PCMH
                                             Hospitals
PHR
                                                                                               UDS
       Consults
                                                                                 B2E
           Education                   eRx

                  Results                        Labs
                                                                                        P4P
                                                           DOH
                         Scheduling

CHC
                                              Updates      of Data
          Pre registration             HPI          Orders            Tx Plan     Reports               Clinical
                       Registration                 Results            Notes     Registries             Advisory
                                                     Lab                          Panels                Committee
                                                     eRx
               Sources of Data Challenges

  Systematic Errors               Random Errors
    Programming mistakes            Data entry mistakes (most

    Bad definitions, rules           mistakes happen here!)
    Sloppy data collection          Data transcription
                                      problems, illegible
    Integrating various data
                                      handwriting
     sources
                                     Misrepresentation by
    Presentation
                                      patient or other
 Interpretation Errors            Specific Data Errors
   What it reveals                  Duplicates
   What it conceals                 Active vs. inactive
   What you’re looking for vs.      Count accuracy
    what it shows                    Correct Code
   Unrealistic HIT
    expectations
                   Consistent, complete, comparable
                   Reliable, relevant
We CRAVE good
data and HIT can   Accurate, available
help

                   Valid, verifiable
                   Exportable
First Move: Establishing trustworthy static baseline* data




  First Total Patient/pop. Count          First Total Clinical Condition Count
      - Inactive Patients                      - Incorrect Dx
      - Duplicate Patients                     + Corrected dx
    adj Merged Data                         adj Data elements
     Other adjustments                      Other adjustments
       = True Denominator                     = True Numerator


                    Clinical Condition Count/Total Count


*Note – static baseline aka “benchmark”
11/10/2009                     134/84




             134/84
                      134/84
11/10/2009




             400
11/10/2009                                         150/80 right a




             150/80 right arm   150/80 right arm
                                   134/84
Simply finding missing data
If a performance bonus were being paid data QA makes a difference…

                                                               Duplicates
                                                               Inactive


               QUALITY METRICS                    BEFORE             AFTER
   # of patients in Diabetes registry              2505              1996
   % of patients with a visit in last year         69%                87%
   % of patients with an HbA1c in last year        67%                84%
   # of patients in hypertension registry              3517          2779
   % of patients with HTN and HbA1c                    16%           37%
   controlled in last year
                                                        Duplicates
                                                        Inactive
                                                        ? Data
      …but what kind of HIT enabled quality is this?
                  Recommendation
                   x

                        1. Remove inactive patients

                        2. Remove duplicate patients
Approaching
     Which choice
     is right for me?   3. Verifying patients are assigned
your Data QA               correct codes at diagnosis,
Ensurance                  encounter
Policy                  4. Ensure accountability for
                           data quality……………… by…

                        5. MONTH END DATA QA PROGRAM
III. Which Quality Targets?



 • Compared to non-recognized physicians, physicians with PPC
   Recognition
    – significantly fewer episodes per patient (0.13; 95% CI = 0.13, 0.15)
    – lower resource use per episode ($130; 95% CI = $119, $140)
                                      (Source: Rosenthal, AJMC, October 2008)


 Practices can be systematic without an EMR, but practices with fully
 functional EMR’s achieve highest scores on PPC
                                      (Solberg, 2005)

  Clinical practice systems are associated with decreased use of inpatient
  and emergency care…                  (Flottemesch, in preparation)
IV. The Silence of Quality in the Data – Report, Review, Respond




 Provider Name         # of HTN         # of HTN          % of HTN
                       Patients         Patients          Patients
                                       Controlled        Controlled
 Provider 1                41              22               54%
 Provider 2                27              17               63%
 Provider 3                1                0                0%
 Provider 4                52              39               75%
Example PPC3D - NCQA Medical Record Review Worksheet
                             Recommendation
                              x
                                      1. Go for usefulness not perfection
When picking                          2. Use a balanced set of measures
HIT enabled
quality targets                       3. Keep it simple; start small think
                                         big
              Patient
            Satisfaction
                                      4. Use qualitative and quantitative

                                      5. Define everything
Financial                  Clinical
Viability                  Quality


                                      6. Measure representative samples
               Staff
            Satisfaction
            Competence
                                      7. Build quality measures into “daily”
                                         work
V. The Key Question: Is it Quality Yet? Is it HIT Enabled?




            Hypertension Control              Blood Pressure Control in
                                                  Diabetic patients

                           Controlled,                           Controlled,
                            44.77%                                36.61%
      Not Controlled ,
          55.33%
                                              Not Controlled ,
                                                  63.39%
V. The Key Question: Is it Quality Yet? Is it HIT Enabled?




 EMR             CDSS
Launch           Launch
                (reminders)
                Recommendation
                 x

                      1. Reliably informs decisions

                      2. Not a process on automatic pilot
   Which choice
   is right for me?
                      3. Silent in the data but lives in the
Quality                  response/intervention

                      4. Evolves with each interpretive iteration

                      5. HIT is a catalyst and a vehicle only
  “Technology doesn’t always make things easier.
  Sometimes it just makes more things possible.”
                                                  Peter Cucchiara
                                                  Director PI/HIT




                          22 Cortlandt St.
                          New York, NY 10007
                          212-437-3921
                          pcucchiara@pcdcny.org




                               http://www.pcdcny.org/

Thank You

								
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