Michelle Pichardo, MPHInstitute for Family Health

Quality Reporting: How to Get the Data you Want?

Primary team members

CIO - Weston Willett

CMIO - Joseph Lurio MD

Sr. Applications Engineer - Jonah Piascik, Leigh Garvey

Clinical Analysts - Stephnie Cargill-Skeeling RN, Rachel Berg, Adam Szerencsy DO

Business Systems Manager - Alison Meyers

Quality Reporting Analyst - Kwame Kitson MD

Director of Billing/ AR Analyst - Kathleen Creswell

No more searching for lost charts, or waiting for

someone to return a chart, or figuring out what that says!

Endless reporting possibilities

Where to start?

Structured data can be complex

Define basic information from the EHR

Patient identification

Demographics

Insurance type

Visit information

Problem list/diagnoses

Orders, meds, procedures, labs

Meeting multiple types of reporting requests

Clinical

Financial

Operational

Local, state, and national agencies

Private Funders

Research

Developing a report specification document

Identify the specific parameters.

Share with project team

Review a test run of the report

Childhood immunization measure

Numerator: Number of children <= 2yrs of age as of 12/31/08 who

have received all of the following immunizations - 4 DTP/DTap, 3 IPV, 1 MMR,3 Hib, 3 HepB, 1 VZV, and 4 Pneumoccocal conjugate within the reporting period (1/1/08 thru 12/31/08).

Denominator: Number of all children <=2yrs of age as of 12/31/08 with at

least one medical encounter during the reporting period (1/1/08 thru 12/31/08).

Additional criteria to consider:

Were born on or after January 1, 2006 and on or before December 31 2006, and

Were first seen by the clinic prior to their second birthday, and

Were seen for a medical encounter at least once during 2008

Include all children meeting this criterion regardless of whether or not they came to the clinic specifically for vaccinations or well child care.

Children who had a contraindication for a specific vaccine should be excluded

Immunization CPT code mapping

--DTP/DTap (4 dose schedule)   ot.CPT_CODE IN ('90700','90701','90701','90720','90721','90723','90698')--IPV (3 dose schedule)or ot.CPT_CODE IN ('90712','90713','90723','90698')--MMR (1 dose schedule)or ot.CPT_CODE IN ('90707','90710')--Hib (3 dose schedule)or ot.CPT_CODE IN

('90645','90646','90647','90648','90720','90721','90737','90748','90698')--HepB (3 dose schedule) or ot.CPT_CODE IN

('90636','90723','90731','90740','90743','90744','90745','90746','90747','90748')

--VZV  (1 dose schedule)or ot.CPT_CODE IN ('90710','90716')--Pneumococcal (4 dose schedule)or ot.CPT_CODE IN ('90669','90732')

Other key points

Set reporting priorities

Participate in team member meetings

Maintain good documentation