Tracking Clinical
Quality Measures
Missouri’s Federally-designated
Regional Extension Center
University of Missouri:
Department of Health Management and Informatics
Center for Health Policy
Department of Family and Community Medicine
Missouri School of Journalism
Partners:
Hospital Industry Data Institute (Critical Access Hospitals)
Missouri Primary Care Association
Missouri Telehealth Network
Primaris
Assist Missouri's health care providers in using
electronic health records to improve the access and
quality of health services; to reduce inefficiencies
and avoidable costs; and to optimize the health
outcomes of Missourians


4
For providers who do not have a certified EHR system We help you choose and implement one in your office
For providers who already have a system - We help
eligible providers meet the Medicare or Medicaid criteria
for incentive payments
This regional extension center is funded
through an award from the Office of the
National Coordinator for Health Information
Technology, Department of Health and Human
Services Award Number 90RC0039/01
Cerner and the University of Missouri Health System have an independent
strategic alliance to provide unique support for the Tiger Institute for Health
Innovation, a collaborative venture to promote innovative health care solutions
to drive down cost and dramatically increase quality of care for the state of
Missouri. The Missouri Health Information Technology Assistance Center at the
University of Missouri, however, is vendor neutral in its support of the adoption
and implementation of EMRs by health care providers in Missouri as they move
toward meaningful use.
Tracking Quality Measures
Objectives
To introduce you to the value of tracking
quality measures
 To explain the origins of NQF quality
measures
 To explain how this helps attain meaningful
use criteria
 Provide Roadmap and Words of Wisdom

Clinical Data Maturity Model
Quality
Improvement
Adoption
Encounter Based
Ref: Arcadia Solutions
Accountable
Care
Management
Quality of
Data Equals
the Quality of
Care
Delivered
Patient Based
Population Based
VALUE OF TRACKING
QUALITY MEASURES
What is a Clinical Quality Measure
Clinical outcome
 Measurable
 Trackable
 A clinical quality measure is a mechanism used for
assessing the degree to which a provider
competently and safely delivers clinical services
that are appropriate for the patient in an optimal
timeframe.1

1Retrived from: http://www.qualitymeasures.ahrq.gov/about/inclusion-criteria.aspx
quality attributes
Safety - patients should not be harmed by the
care that is intended to help them
 Patient-Centered – Patient care should be based
on individual needs and driven by the patient
 Timely - waits and delays in care should be
reduced
 Effective - care should be evidence-based
 Efficient - reduce waste
 Equitable - care should be equal for all people

Value….

Improve healthcare for patients and population based on valid data
measured and reported over time

Data helps demonstrate how quality healthcare is delivered,
obtained and sustained

Improve overall healthcare of an individual and/or a population by
using evidence based medicine

They help improve the quality of healthcare by setting priorities and
goals for performance improvement

Drive Healthcare Change across the nation/international

Help to identify gaps in patient care populations (cervical cancer
screening)
Types of measures used in MU
Process: a measure that focus on a process
which leads to certain outcome, meaning that
a scientific basis exists for believing that the
process, when executed well, will increase the
probability of achieving a certain outcome.
Outcome: A measure that indicates a result of
the performance (or nonperformance) of a
function or a process. 1
1Retrived from: http://www.qualitymeasures.ahrq.gov/about/inclusion-criteria.aspx
ORIGINS OF NQF
MEASURES…
Measures accredited by:
 National
Quality Forum (NQF)
measures are at the center of MU

These measures help to improve
quality by
1.
2.
3.
Bringing together experts in the field to
define quality with uniform standards
Report and analyze where there are
gaps in quality
Caregivers use theses measures to
improve, measures, and report
NQF measures
Value

Important to measure

Scientifically Acceptable

When measures are implemented they will produce reliable and valid
results. i.e Preventive Care & Screening Measure.
Useable and relevant



Measuring something that will make a difference in healthcare of a
population, where the evidence is the highest measurement that can
have a positive impact on healthcare quality. i.e. Preventive Care &
Screening Measure Pair for Tobacco Use and Cessation Intervention
Asking the right questions to the right audience. Not ask a 2 year old
if they smoke, might ask parents if there is 2nd hand smoke exposure.
Asking questions that will drive change
Multiple stakeholders finds value in tracking the measures and
outcomes
Feasible
Data is readily available and retrievable without undue burden
The benefits of using NQF measures:
Standardization across measures
 Provides central benchmarking
 Best Practices



Allows you to compare your measures with local,
state, and national standards
Prioritizes Health Care initiatives

Focus on the most important conditions
Compare apples to apples within any EHR
system.
 Common goal to improve quality of health care

HOW DO QUALITY MEASURES
RELATE TO MEANINGFUL USE
Meaningful Use goals

Use of certified EHR technology for electronic
exchange of health information to improve
quality of health care

Use of EHR to submit clinical quality and
public health measures

Use of EHR in a meaningful manner to
improve patient care and safety
Adoption Stages of Meaningful Use

Stage 1- Data Capture – “get your feet wet”





Improve quality, safety, efficiency, and reduce health
disparities
Engage patients and families
Improve care coordination
Protect privacy and security of personal health info
Improve population and public health
Stage 2- Data Aggregation – Validate and generate
data
 Stage 3- Data used to impact Outcomes – make
informed decisions based on authenticated data

3 Core CQM Measures



(NQF 0013)Hypertension: Blood Pressure
Management
(NQF 0028 a & b)Tobacco use assessment &
tobacco cessation intervention
(NQF 0421)Adult weight screening and follow-up
ROAD MAP TO TRACKING AND
REPORTING QUALITY
MEASURES
Strategy for tracking measures
Planning
• Develop team, project plan and schedule meetings
Current State Assessment
• Identify metrics that currently don’t meet standards
Root Cause Analysis
• Meet with key staff to identify the root cause for the gap
Identify remediation strategies
• Determine the most effective actions to address the gap
Plan and Execute
• Create a plan and timeline to reduce gaps, and execute
Review and remediate
• Continuous quality improvement checkpoints
Words of Wisdom








Create the right team

Start small
Engage everyone

Validate data

 Data capture reflects
quality of care provided

Communication at all

levels
Leadership buy-in and
support

Patient focused
Create a plan and follow it 
Be patient, the road is long
and slow… This is a
journey
Persistence pays off
Change agent needed to
drive change
Embrace change
Think outside the box and
don’t take “no” for an
answer from your vendor
Hold everyone
accountable
Standardize and Document
Contact Information

Noelle Parker- nparker@mo-pca.org
Missouri Primary Care Association
3325 Emerald Lane
Jefferson City, MO 65109-6879
(573) 636-4222
www.mo-pca.org
Press *6 to unmute your phone
to ask a question
Privacy & Security
Wednesday, October 12th
Presenter:
Becky Thurmond Fowler
University of Missouri
Division of Information Technology,
Information Security & Access Management

Contact MO HIT Assistance
Center for details and pricing

Website: http://ehrhelp.missouri.edu

E-Mail:
◦ EHRhelp@missouri.edu

Phone:
◦ 1-877-882-9933