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 CQMs 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 (= 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 sendsto: DARTNet replies with a link to a secure folder and anotherwith 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 sendsto:DARTNet replies with a link to a secure folder and anotherwith 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