Michelle Pichardo, MPH September 30, 2010 Quality Reporting and Quality Improvement.

Michel le P ichardo, MPH

September 30 , 2010

Quality Reporting and Quality Improvement

Learning Objectives

How can electronic health record systems accelerate data collection for monitoring and improving quality?

Who are the key members that assist in monitoring quality data/reports and how is the information shared throughout the organization?

Now that your organization has access to data for quality reporting, how do you translate that into meaningful use?

HIE

EpicCare Link

Patient Portal

Quality Reporting/Improvemen

t

Clinical Decision Support

Goal of Quality Improvement

To reach the state of TQM (Total Quality Management).

Where all aspects of the organization are working towards improving quality.

Get to Know Your Data

Build a Data Dictionary

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Define All Key Elements Captured by the EHR

Patient AddressRace / Age / GenderMedical history Social history

Provider LocationReason for visitProblem list

TemperatureBlood pressureHeight/weightRespirations

ProceduresMedicationsLab resultsDiagnoses

Take the Time to QA the Data

Document and Define the Measures and Metrics

Identify the specific parameters.

Share with project team.

Review a test run of the report.

Decide how often the report with run.

A mountain full of data yet a finite amount of resources to handle it.

Target measures and target resources in the most efficient ways possible.

Quality Improvement Team

President & CEO – Neil Calman, MD

CIO - Weston Willett

CMIO - Joseph Lurio MD

Sr. Vice President – Robert Schiller, MD

VP Clinical Affairs- Nicole Nurse, RN

Quality Reporting Analyst - Kwame Kitson MD

Quality Reporting Examples

TCNY reports

UDS and IDS reporting

Diabetes and HIV disease registries

Risk stratification system

Site lead quality improvement initiatives

0

10

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30

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50

60

70

80

90

100

ALL

Percentage

BMI Screening

Depression Screening

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10

20

30

40

50

60

70

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90

100

ALL

Percentage

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20

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ALL

Percentage

Colon Cancer Screening

86.8%

13.2%

Patients with HTN controlledPatients without HTN controlled

Hypertension Control

0.9% 0.0% 0.2%

21.7%

0.2%

49.8%

3.0%

23.5%

Asian

Native Hawaiian

Other Pacific Islander

Black/African Descent

Native American/AlaskanWhite (Non-Hispanic)

More than one race

Unknown/Unreported

Hypertension Control by Race1

1 UDS Measure, 2009

20.1%

79.9%

Hispanic patients with HTN controlledNon-Hispanic Patients without HTN con-trolled

Hypertension Control by Ethnicity

Disseminating the results

Other key points

Set reporting priorities

Participate in team member meetings

Maintain good documentation

Thank You

Contact Information:

Michelle PichardoEmail: [email protected]

Phone: 212-633-0800 ext.1279