Challenges Reporting Quality Measures in Small Rural Practices: Lessons Learned from the InteGREAT Project

Challenges Reporting Quality

Measures in Small Rural Practices:

Lessons Learned from the InteGREAT

Project

James McCormack, PhD, Instructor, OHSU

Department of Medical Informatics and Clinical Epidemiology

Elizabeth Needham Waddell, PhD, Senior Study Director, ORPRN; Assistant Professor, OHSU-PSU Public Health

Learning Objectives

• What quality and performance measures are rural health providers being asked to produce?

• What specific challenges did the InteGREAT project identify in assessing of reporting capabilities for eight specific measures in four rural practices?

• How can CCOs and providers collaborate to improve their capabilities for reporting complete and accurate quality measures?

Presentation Overview

• Provide brief description of the InteGREAT project, and the importance of data reporting capacity to build a

foundation for integrated care.

• Describe 2 phases of data capacity assessment conducted during the InteGREAT project.

InteGREAT: Building Capacity for Integrated

Behavioral Health & Primary Care

(April 2014-June 2015)

1. Build partnerships among

practices that are

interested in integration.

2. Collaborate with practices

to create the foundation for integration (clinically, operationally, and

financially).

3. Provide technical

assistance as practices initiate their integrated initiatives.

• Funded by Transformation Grant from Pacific Source Community Solutions Columbia Gorge CCO

InteGREAT: Building Capacity for Integrated Behavioral

Health & Primary Care

• Implemented in 4 primary care practices and one Community Mental Health Center

• Project co-lead by Department of Family Medicine, University of Colorado (Ben Miller, PsyD) and Oregon Rural

Practice-based Research Network (Melinda Davis, PhD)

• Oversight from the Columbia Gorge Health Council and Columbia Gorge Integrated Care Work Team

Participating Practices and

Cross-Functional Implementation Teams

• Four primary care practices and one

behavioral health agency

• 24 participants on the five cross-functional

implementation teams

• MDs, Psychiatrist, RNs, MAs, LCSWs, BH

referral coordinator, Front and Back Office Leads, Practice

Managers, IT Staff,

67%

46%

66%

of adults will experience mental health illness or

substance abuse disorder at some point in

their lifetime2

of primary care providers report not being able to access outpatient behavioral

health for their patients3 Top conditions driving overall health costs:

Depression | Anxiety | Obesity | Back/Neck Pain | Arthritis When treated in harmony with mental health, chronic physical health

improves significantly, along with patient satisfaction.4,5

Definition: Behavioral Health and

Primary Care Integration

The care that results from a practice team of primary care and behavioral health clinicians, working together with

patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined

population.

This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.

Peek, C. J. and the National Integration Academy Council (2013). Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus. AHRQ Publication No.13-IP001-EF. Rockville, (MD), Agency for Healthcare Research and Quality.

Vision for Integrated Care in the Gorge

All roads lead toward interdisciplinary, team based care, with substantial variation in clinical, operational and financial

challenges.

Setting Baseline model The Vision Independent

practice

Limited referrals and consultation with specialty mental health, MD as

mental health provider

Addition of integrated BHC

Affiliated practices

Co-located mental health services (therapy)

Addition of integrated BHC

FQHC Co-located mental health services (therapy)

Addition of integrated BHC

Community Mental Health

Limited referrals and consultation with to primary care

Behavioral Health Home, with coordinated, co-located primary and specialty mental health care

Practice Facilitation for InteGREAT!

The Questions The Details

Who? • Beth Sommers

• Beth will work with a Practice Champion and a few key members of the clinic

What? • The PF and clinic team members meet in-person monthly to review data, complete assessments, and set goals.

• Team members work independently to accomplish goals (and receive email/phone support)

• Sharing progress at quarterly ICWT meetings When and

Where?

• At the practice at times agreed upon by Beth and the clinic team

How? • Baseline assessment (clinical, operational, financial) • Relationship and team development

Some tools we used to create the

foundation for successful integration

•

Practice Information Form

•

Comprehensive Primary Care Monitor

•

Health Home Monitor

•

CoACH Cost Tool

Quality Reporting Capacity Assessment for

InteGREAT

Phase 1:

• Received self-assessment spreadsheets from each participant

Phase 2:

• Reviewed self-assessments and identified possible reporting gaps

• Developed a systematic assessment process for each site

• Visited each site at least once with telephone and email conversations as needed.

• Analyzed and reported the results of the assessment and site-specific recommendations

Background: Clinical Quality Measures

(CQMs)

• Who is included in the initial population?

• Demographics (e.g., age, gender)

• Specific conditions (e.g., problem list or encounter diagnoses)

• Other patient and visit characteristics (e.g., provider, payer) • What is actually counted?

• Vitals (BP, BMI)

• Results of specific tests or procedures (lab, DI, etc.)

• Structured data in notes, assessments, plans, follow-up, etc.

• Clinical orders (medications, referrals, procedures, etc.)

• When are the start and end dates (reporting period)?

• With what exclusions, exceptions, or adjustments?

CQM Specifications and Guidelines

• There is a growing supply of CQMs sponsored by multiple stakeholders!

• Detailed specifications may vary by source and stakeholder

• Not everyone rigorously follows the “gold

standard” NQF measures

• Specifications and reporting criteria (“value

Minimal Data Set (MDS) for InteGREAT

MDS Measure (included age range) Type MDS Variations ~NQF #

A1c not done or > 9% in diabetics PH #59 LDL < 100 mg/dl in CAD PH #74 ** BP < 140/90 in Hypertension) PH #18 Age-specific BMI screening and f/u PH #421 Depression screening and f/u BH ...and improved PHQ9 #418 Substance abuse screening and f/u BH ...and improved AUDIT --Tobacco use and cessation and f/u BH #28 General anxiety screening and f/u BH ...and improved GAD7

--The InteGREAT MDS consisted of 8 measures – 4 physical health and 4 behavioral health.

Assessment Results (Phase 2)

MDS Measure (included age range) Site 1: Family Med. Site 2: FQHC Site 3, 4: Affiliated Practice Site 5: BH Center A1c not done or > 9% in diabetics Yes Yes Yes No LDL < 100 mg/dl in CAD Yes Yes Partial No BP < 140/90 in Hypertension) Yes Yes Yes No Age-specific BMI screening and f/u Yes Yes Yes No Depression screening and f/u Partial Partial Partial Partial Substance abuse screening and f/u Partial Partial Partial Partial Tobacco use and cessation and f/u Yes Yes Yes Yes General anxiety screening and f/u No No No Partial

The onsite assessment found much lower MDS capabilities than the self-assessment Phase 1.

MDS Reporting Challenges: PH CQMs

• Availability of structured results and vital signs in the EMR

• Mapping of CQM data elements (e.g., LOINC)

• Use of consistent workflows for data entry

• Useful data “lost” in notes or scanned reports

MDS Example: A1c not done or > 9% in diabetics

Percentage of 18 to 75 year olds with diabetes (all 250.xx)

AND

A1C NOT done within one year

AND

MDS Reporting Challenges: BH CQMs

MDS Example: Depression screening and follow-up

Percentage of patients age 12 years and older:

AND

Screened for depression using an age-appropriate standardized screening tool

AND

A follow-up actions/plan is documented

AND

Percentage of patients 18-75 with an improved PHQ-9 score

• Availability of structured data for screening and follow-up

• Mapping of CQM data elements (e.g., PHQ, GAD, AUDIT)

• Use of consistent workflows for clinical documentation

Data Flow Model for CQMs

CQM = numerator / (denominator - exclusions – exceptions)

Data Capture Data Selection and Retrieval Analysis and Aggregation (External Database) EMR

Findings: Key Challenges in 5 Sites

Key Challenges Examples from InteGREAT

Technical Challenges • Access to EMR reporting capabilities • Availability of structured data

• Vendor assumptions about workflow • Data quality issues

Knowledge and Resource Limitations • Expertise in using EMR reporting • Time to learn and use EMR features • Custom queries are time-intensive • Access to EMR-specific guidance

Work Practices and Local Preferences

• Data entry timing and workflows • Variation in roles and responsibility • Variation in clinical work practices

Lessons Learned

CCOs Meaningful Use (MU) PQRS(I) HEDIS UDS PCMH/PCPCH P4P ….

Recommendations for Practices

• Create a quality reporting committee or seek outside advice to inventory and prioritize CQM reporting requests and

obligations – what are YOUR quality goals?

• Assess your current reporting capabilities, resource limitations, and data quality for priority CQMs

• Seek ways to consolidate screens or forms used to capture clinical data needed for CQMs and beware of “death by a thousand clicks”

Recommendations for Stakeholders

• Recognize the challenges, competing priorities, and resource limitations facing small practices

• Develop and coordinate EMR-specific resources to assist with assessment, (re)configuration, and effective use of standard and advanced CQM reporting tools

• Leverage existing CQMs and value-based reporting programs (in addition to Meaningful Use and PQRS)

• Recognize that EMRs used in Behavioral Health are a different beast, and CEHRTs cannot be assumed

Suggested Resources (see handout)

Topic Web Resources

CQM

Specifications and Guidance

• National Quality Forum (NQF) QPS

• AHRQ National Quality Measures Clearinghouse (NQMC) • Oregon Health Authority Office of Health Analytics

• CMS.gov eCQM Library

• NLM Value Set Authority Center

• Individual CCOs and other stakeholders

EMR Vendor Capabilities

• Certified Health IT Product List (oncchpl.force.com)

• Vendor website and user communities

General Health IT Resources

• HealthIT.gov

• US Health Information Knowledgebase (USHIK) • HIMSS, AHIMA, AMIA

• Independent Practice Associations

Acknowledgements

•

Columbia Gorge Health Council

•

Columbia Gorge Integrated Care Work

Team

University of Colorado Denver,

Department of Family Medicine

Benjamin Miller, PsyD

Assistant Professor

Stephanie Kirchner

Practice Facilitation Program Manager

Emma Gilchrist, PRA

Integrated Healthcare Project Manager

OHSU/Oregon Rural Practice-based

Research Network (ORPRN) Project Team

Melinda Davis, PhD

• Director of Community Engaged Research; Research Assistant Professor, Department of Family Medicine

Beth Sommers, MPH, CPHQ

• Practice Enhancement Research Coordinator (PERC)

Elizabeth Needham Waddell, PhD

• Senior Study Director; Assistant

Professor, OHSU-PSU School of Public Health

THANK YOU!