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Health Care Quality Improvement
for Meaningful Use
Adrienne Mims, MD MPHMedical Director for Medicare Quality Improvement
GMCF
Health Care Quality Improvement for Meaningful Use
AGENDA
• What is meaningful use? Why is it relevant for TeleHealth?
• The quality improvement process
• Resources
Meaningful Use
The American Recovery and Reinvestment Act of 2009 authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR).
Meaningful Use is using certified EHR technology to…
• Improve quality, safety, efficiency, and reduce health disparities
• Engage patients and families in their health care
• Improve care coordination
• Improve population and public health
• All the while maintaining privacy and security
Relevant for TeleHealthcare?
Three components – Use of certified EHR• in a meaningful manner• for electronic exchange of health information to
improve quality of health care• to submit clinical quality measures
Meaningful Use
Established 3 stages of meaningful use: 2011, 2013 and 2015
Meaningful Use
Stage 1 Objectives and Measures Reporting
Must complete: 15 core objectives
5 objectives out of 10 from menu set
6 total Clinical Quality Measures (out of 38)
Meaningful Use 15 Core Objectives
1. Computerized physician order entry2. E-Prescribing3. Report ambulatory clinical quality measures to
CMS/States4. Implement one clinical decision support rule5. Provide patients with an electronic copy of their health
information, upon request6. Provide clinical summaries for patients for each office
visit7. Drug-drug and drug-allergy interaction checks8. Record demographics
9. Maintain an up-to-date problem list of current and active diagnoses
10. Maintain active medication list
11. Maintain active medication allergy list
12. Record and chart changes in vital signs
13. Record smoking status for patients 13 years or older
14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
15. Protect electronic health information
Meaningful Use 15 Core Objectives
Meaningful Use 5 out of 10 Menu Objectives
• Incorporate clinical lab test results as structured data
• Generate lists of patients by specific conditions• Send reminders to patients per patient preference
for preventive/follow up care• Provide patients with timely electronic access to
their health information• Use certified EHR technology to identify patient-
specific education resources and provide to patient, if appropriate
• Medication reconciliation
• Summary of care record for each transition of care/referrals
• Capability to submit electronic data to immunization registries/systems
• Capability to provide electronic syndromic surveillance data to public health agencies
• Drug-formulary checks
Meaningful Use 5 out of 10 Menu Objectives
How can you evolve into a system of meaningful use?
A structured methodology is needed
Quality Improvement is a formal approach to the
analysis of performance and systematic efforts to
improve it.
Quality Improvement - Methods
FADE = focus, analyze, develop, execute, evaluate
PDSA = plan, do, study, act
Six Sigma = (define, measure, analyze, improve,
control)
CQI = Continuous Quality Improvement
TQM = Total Quality Management
Utilize an approach that matches employees and company’s culture.
Support for Quality Improvement
• Leadership Team *− Executive sponsor− Project sponsor− Improvement leader
• Design team• Additional stakeholders
* Upper management must be on board Realistic expectations of ROI
Did you develop a project charter or set definitive goals?
Examples:– Foster better communication
between providers
– Implement e-prescribing
– Achieve meaningful use
– Reduce 30-day readmission rate
Fundamental Questions for Improvement
• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?
To improve, you must make changes.
But…
Not all changes lead to improvement
Model for Improvement
What are we trying to accomplish?
How will we know a change is an improvement?
What change can we make that will result in Improvement?
Aim
Measures
Ideas
PLAN DO
ACT STUDY
Why an Aim Statement?
• Answers and clarifies “What we are trying to accomplish?”
• Creates a shared language to communicate the project to others.
Aim Statement
S = pecificM = easureable
A = ttainable
R = elevant/realistic
T = imely
Defining the Measures
A good aim statement helps define the measures.• Measurement should not slow things down
• Seek usefulness, not perfection
• Use sampling
• Use accessible measures (don’t wait for IT)
AIM Statement
To increase the number of patients with diabetes who have urine kidney tests performed from 25% to 50% by June 2011
Did you collect baseline measurement?
Measurement defines expectations and values• Evaluate compliance
− Compare to benchmarks− Track improvements− Identify opportunities
• Used by stakeholders− Improve care− Provider selection− Align incentives
Data drives decision making
Types of Data
• Patient self-reported data− HRA− Productivity− Satisfaction surveys
• Demographic • Plan design• Medical claims• Pharmacy claims• Laboratory data• Biometric screening• Disability data
Measure Caveats
• Measure types Structure: physical equipment and facilities
Process: how the system works/demonstrates compliance
with the current process
Outcome: demonstrates the overall impact of the new
process/the final product or results
• Data collection is resource-intensive
• Robust IT systems enable more efficient, timely reporting
• Use of case studies to clarify through examples
“Data collection and analysis is a journey,
one that must be taken carefully and with
significant deliberation, but one that has the
potential to bring great value”
~ Jan Berger, MD
• Get buy-in and agreement across the organization• Create partnerships• Identify data sources• Convene a data summit• Collect and analyze data
What does our process look like?
Process Mapping
• What are the steps that you would go through as a patient for an office visit in primary care?
• Procedure– Identify who is involved in the process– Identify the starting and end points– Draw swim lines and post the steps in the
process over time– Map the process using sticky notes– Use 2 words for the process (noun + verb)
Swim Lanes Receptionist
Nurse
Physician
Lab
Health Education
Pharmacy
Check out
What is the root of the problem?
Was a root cause analysis performed?
Pick one area to focus on for improvement at a time
PDSA Cycle for Process Improvement
• What changes are to be made?
• Next cycle?
• Objective• Questions and predictions• Plan to carry out the cycle
(who, what, where, when)• Plan for data collection
PLAN
• Carry out the plan• Document the problems
and unexpected observations
• Begin analysis of the data
DO• Complete the analysis
of the data• Compare data to
predictions• Summarize what is
learned
STUDY
ACT
PDSA Pitfalls
• Plan, Plan, Plan, Panic
• The Nike Model “Just do it”
• The research model – Plan-do-study-publish
• Neglecting to follow up on previous changes introduced (leaving out the “s”)
• Piloting on a large scale – more than just a test
• “Do” and “Act” are NOT a PDSA cycle
Was an action plan created?
Action PlanItem Person (Who) Action (What)
Target Date (When) Follow Up
After visit/discharge
Summary Lead MD Consider adding
diagnosis and medication 11/21/10 Pending
Registry of patients on Warfarin Analyst
Determine the volume and distribution of patients on Warfarin 1/15/11
Wallet card evaluation
Lab assistant Hand each patient with survey 10/1/10 Complete
How are projects steps tracked?
Internal Quality Control Measures
Indicator Name Patient Satisfaction Days without staff call outs
Measure Frequency Quarterly Monthly
Data Source Survey Daily Schedule
Numerator 50 10
Denominator 100 20
Final Goal 80% 10%
Most Recent Measurement Period Fall 2010 December
Most Recent Measure 50% 50%
Interim Goal 75% 20%
Variance 5% 30%
RCA Needed? Yes Yes
Were interim measures defined? If so, are they tracked on a dashboard?
What is the reporting mechanism for informing others of the project?
www.gmcf.org
Summary
Obtaining Meaningful Use
certification is a goal that can
be accomplished through a
well-planned quality
improvement process.
Resources
Get information, tip sheets and more at CMS’ official website for the
EHR incentive programs: www.cms.gov/EHRIncentivePrograms
Learn about certification and certified EHRs, as well as other ONC
programs: http://healthit.hhs.gov
Learn about Georgia’s Regional Extension Center Institute for
Healthcare Improvement: http://www.ihi.org/IHI/
GMCF – The Medicare Quality Improvement Organization for Georgia:
www.gmcf.org [email protected]
This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-PRV-11-03