SIM CLINICAL QUALITY MEASURES

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1 SIM CLINICAL QUALITY MEASURES CQM Reporting Refresher & Practice Performance Registry PRESENTED BY: Kyle Knierim, MD & Lauren Shviraga 1

2 OVERVIEW o Reminders on Clinical Quality Measure Reporting & Guidebook o Refresher on SPLIT Clinical Quality Measures Reporting Tool o Accessing the Practice Performance Registry through SPLIT SSO o How to view information in the Practice Performance Registry o CQM & PPR Questions? 2

3 CLINICAL QUALITY MEASURE GUIDEBOOK o SIM Clinical Quality Measure Guidebook is now available on the Practice Innovation Program website in the SIM Resource Hub ( o Details measure specifications and decision trees for SIM CQM numerators & denominators o Includes a condensed CQM list and outline of CQM reporting requirements by quarter o Includes SIM CQM Reporting Schedule 3

4 SIM COHORT 1 CQM REPORTING SCHEDULE 4

5 ACCESSING SPLIT & CQM REPORTING ** Go to and click on SPLIT icon ** 5

6 REPORTING CQMS IN SPLIT o CQMs are reported through SPLIT o SPLIT Username is your address o The following SPLIT users can enter CQMs: Practice Champions & Practice Admin. PFs & CHITAs o While PFs and CHITAs have the ability to submit CQMs on behalf of the practice, it is the Practice s responsibility to submit CQMs 6

7 REPORTING CQMS IN SPLIT o To report CQMs click on Clinical Quality Measure Reporting in the main SPLIT menu o On the main CQM Reporting Page answer the initial questions to report CQM data 1) Select the Practice 2) Select if the Practice is reporting on the Adult or Pediatric Core Measures (can be changed, but please be consistent...) 3) Select for which quarter CQMs are being entered 4) Select whether CQMs are Practice or Provider level 7

8 REPORTING CQMS IN SPLIT o If you are matched with several clinics in SPLIT, use the drop down menu to select the right one. o Once a practice is selected the CQM submission status is viewable for each quarter. o Practices are able to correct or update CQM data from previous quarters. Though, only the most recent data will be used and displayed. 8

9 CORE SIM CQMS ADULT & PEDIATRIC Adult Core CQMs Pediatric Core CQMs ** For Q2 (April 1, June 30, 2016) practices are required to report on THREE of the SIX Core Clinical Quality Measures ** 9

10 ADULT CORE CQM MEASURES VIEW 10

11 PEDIATRIC CORE CQM MEASURES VIEW 11

12 PROVIDER LEVEL REPORTING 12

13 CQM SUBMIT & RESUME ** CQM Data can be changed at anytime but should be entered CONSISTENTLY for each quarter ** 13

14 MEASURES CURRENTLY WITHOUT SPECS o If reporting data on these CQMs indicate ALTERNATIVE for the metric version o We will let you know the remaining four specifications when we know them! 14

15 STANDARD VS. ALTERNATE SPECIFICATIONS o The SIM Office has defined the preferred (STANDARD) specifications for the CQM s. o All Standard measure specifications use a 3 month measurement period. o The SIM Office and CMMI expect and encourage practices to align with the Standard CQM specifications as much as possible over time. o Details on measure specifications are in the SIM Clinical Quality Measure Guidebook available on the Practice Innovation Program website in the SIM Resource Hub o KEY POINT: Don t wait until measures are perfectly aligned to SIM standards to report! Use the ALTERNATE label for any CQM that uses similar, but not exact Standard specs. 15

16 KEY REMINDERS IN REPORTING CQMS o Practice Champions & Admins, PFs, and CHITAs are ALL able to submit CQMs o But Practices are ultimately responsible for SUBMITTING CQMs through SPLIT o CQMs can be edited after entered, but only the most recent update is used. o Practices must choose to report on the ADULT or PEDICATRIC core measures, BUT practices still have the option to report ALL SIM Clinical Quality Measures! 16

17 PRACTICE PERFORMANCE REGISTRY o The Practice Performance Registry (PPR) by the DARTNet Institute is where practices can view their SIM CQM data overtime in meaningful ways, AND compare it to other de-identified SIM Practice data o Data is updated in the PPR nightly. After a practice submits CQM data in SPLIT it can take up to a for this CQM data to display in the PPR. o Login & practice matching information from SPLIT are synced automatically with the PPR. So users can see all their practices information without making a new account. 17

18 USING SPLIT SINGLE SIGN ON (SSO) 1) Click on the Waffle Icon in upper left corner of SPLIT 2) A DARTNET SSO page will open in a new browser tab Select SPLIT account (Single Sign-On) to access the PPR 3) Re-enter your SPLIT Username and Password again NOTE: Only the first time SPLIT users access the PPR using SSO they will need to re-enter credentials on this second login screen and (this also occurs when a browser resets). 18

19 PPR TECHNICAL NOTES o CQMs entered in SPLIT do not immediately display in the PPR PPR is UPDATED nightly o DARTNet s PPR uses Microsoft Sharepoint. This is not compatible with Google Chrome IE11 or Firefox are recommended browsers o PPR user may need to download Microsoft Silverlight to access & view data in the PPR 19

20 PPR MAIN PAGE NAVIGATION o Click on the All SIM Metrics link to access the main views of the SIM CQMs. o More in-depth instructions are also available PPR User guides are also here. 20

21 PRACTICE PERFORMANCE REGISTRY (1 ST VIEW) The first PPR view shows a users CQM data compared to other SIM practices CQM data o To view CQM data select a measure from the to navigation o The Trend Line shows the average for all SIM practice data over time o The Bar Graph displays data for all practices who reported on that CQM BLUE the RED Bar is the practice currently being viewed. o Users can Double-Click on graphs to drill down to a particular practice. o Users can also view denominators and % at goal data in the chart ONLY practices a user is associated with are identified & labeled in the PPR 21

22 PRACTICE PERFORMANCE REGISTRY FILTERS o Use the filters to quickly find and display specific measures. o CQMs that match selected filters display across the top o By default the Standard and Alternate measures are shown together. Use the Version Filter to view the measures separately. o Users can access additional PPR views using the navigation arrows in the lower right corner 22

23 PPR VIEWS CONTINUED (2 ND VIEW) o The Second PPR View shows practice site data only o If users are associated with multiple practices, they can view and compare here. o If a practice site reported provider level data users can view and compare provider level data in the view easily. o The same filter functions are available on every PPR View 23

24 MULTIPLE PRACTICES EXAMPLE (2 ND VIEW) 24

25 PPR VIEWS CONTINUED (3 RD VIEW) o The Third PPR view can combine & display multiple measures at the same time for comparison o To view and compare measures select the measures using Filters o The Trend Line graph shows the trends over time for selected CQMs o The Bar Graph by default shows totals for all measures combined o Toggle between selected CQMs to compare one measure to the composite totals in the bar graph 25

26 PPR VIEWS CONTINUED (4 TH VIEW) o The Fourth PPR view shows a practices or providers CQM data compared to the median & achievable benchmark o The RED data point in the top chart shows the practice s data 26

27 PPR VIEWS CONTINUED (4 TH VIEW STATS REVIEW) omedian: (Blue line) Equal number of practices scored above and below this value. oachievable benchmark: (Orange Line) More involved; in one sentence - The score of the top performers accounting for 10% of the patient population. 27

28 PPR VIEWS CONTINUED (5 TH VIEW) othe Fifth PPR view shows scatter plots by metric and time periods. othe Scatter Plot on top depicts circles indicating denominators - larger circles represents larger denominators, and vice versa. o The Trend Line graph on the bottom compares CQM progress over time for individual practices 28

29 KEY TAKEAWAYS o CQM reporting for SIM period 2 is due by July 31, o Practices have many resources if they need help reporting CQMS! First Resource: Practices should work with their matched CHITAs and PFs. Other Resources: Practices should reference this CQM presentation (slides and recording), and the SIM Clinical Quality Measure Guidebook on the Practice Innovation Program website within the SIM Resource Hub Practices can Contact the University of Colorado SIM Team (next slide) 29

30 SPLIT & CQM CONTACTS/RESOURCES SPLIT and PPR technical support General SIM questions Practice Innovation Colorado Website 30

31 QUESTIONS? Thank you for participating 31