ENSW PTO Training Clinical Quality Measures Kyle Knierim, MD Using DARTNet to Improve Practice Wilson Pace, MD Kyle Knierim, MD 1

Overview of Session 2 Review ENSW clinical quality measures Go over CQM reporting options Explain steps for most common way to report your CQM’s Highlight DARTNet reports that can be used for practice improvement Answer your questions

ENSW CLINICAL QUALITY MEASURES 3 TopicDescription NQFPQRS A: AspirinAspirin Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period B: Blood Pressure ManagementBlood Pressure Management Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year C: Cholesterol ManagementCholesterol Management Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with a fasting or direct Low-Density Lipoprotein Cholesterol (LDL-C) level >= 190 mg/dL; OR patients aged years with a diagnosis of diabetes with a fasting or direct LDL-C level of mg/dL; who were prescribed or are already on statin medication therapy during the measurement year. N/A S: Smoking Cessation SupportSmoking Cessation Support Percentage of patients aged 18 years or older who were screened about tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

ENSW CQM REPORTING 4 ENSW CQM Reporting Required to report all 4 measures 5 times: –Baseline –Month 3 Post-Baseline –Month 6 Post-Baseline –Month 9 Post-Baseline –Month 15 Post-Baseline Required: Numerators and Denominators must be reported for all 4 measures at a practice level

ENSW CQM REPORTING 5 Reporting Options DARTNet supports several reporting options –Standard approach Upload of structured excel spreadsheet with numerators and denominators –OPTIONAL approaches Direct extraction of patient-level data elements – many options through DARTNet and possibly other vendors Automates reporting Gain access to richer, more in depth performance reports beyond ENSW core measures Practice fees may apply that are NOT covered by ENSW

ENSW CQM REPORTING 6 Chart Audits Last resort – not sustainable For practices unable to create numerator and denominator reports from their EHR Practice will submit billing data to DARTNet to identify patients Auditor collects information on 30 patients per measure per time period Retrospective – either at months 0, 6, 15 or just month 15. Will either contract with clinic staff or have external contractor do the audit. Alert ENSW team early if this is an issue for your practice.

ENSW CQM REPORTING 7 STEPS FOR STANDARD APPROACH DARTNet will use Egnyte to transfer files securely Person responsible for reporting sends to: DARTNet replies with a link to a secure folder and another with the time limited password. –Overkill, but keeps it consistent for all types of file transfers for ENSW, even those that contain PHI

ENSW CQM REPORTING 8 STEPS FOR STANDARD APPROACH DARTNet will use Egnyte to transfer files securely Person responsible for reporting sends to: DARTNet replies with a link to a secure folder and another with the time limited password. Practice clicks on this link and downloads spreadsheet –Overkill, but keeps it consistent for all types of file transfers for ENSW, even those that contain PHI Practice enters information into spreadsheet and then saves it back into the same Egnyte folder

ENSW CQM REPORTING 9 STEPS FOR STANDARD APPROACH The link only works for 48 hours –If the process happens in <48 hours the same link and password can be used. –If the original file is not picked up or replaced within the 48 hour window just again and they will send a new link and new DARTNet is notified when the file is replaced and will get the spreadsheet and delete the practice’s copy on Egnyte.

What can you do with once data is in DARTNet? ENSW Report: No Filters Selected; showing ALL Characteristic options Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Choose clinical category from Category List Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Characteristic Name will determine Characteristic Value options Example: PTO Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Characteristic Name will determine Characteristic Value options Example: STATE Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Another Report View Option – Multiple measures at once Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Choose specific Organization (bar graph) to see that organization’s trend over time (line graph) Practice Performance Reports

What can you do with once data is in DARTNet? ENSW Report: Table report option available. Will display all ENSW Metric results for a specific organization on one screen Practice Performance Reports

ENSW MORE INFORMATION 17 Where to find more information Check out a detailed list of measures and their eCQM standards and reporting instructions on the ENSW website under Learning Community Resources DARTNet training information is also available at the website. Collection of vendor-specific instructions on the ideal/preferred documentation and reporting workflows to support the measures. These will be on the ENSW website soon.

ENSW Q&A 18 Questions and Discussion

19 Assistant Professor KYLE KNIERIM, MD THANK YOU CEO DARTNet Institute Professor of Family Medicine WILSON PACE, MD