Utilizing CDS Reports for HEN Project Progress

1. Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013 Carmela Estrada Bondad, MPH Hospital Engagement Network Health Research & Educational Trust American Hospital Association

2. Objectives • Gain understanding of what information is provided in the CDS Reports • Learn how to interpret and use your data to determine progress on the HEN project

3. Agenda • Review HEN Data Needs • Overview of Reports Available in CDS (Live Demo) • Individual Measures Reports • All Measures Report • Comparative Measures Report • Hospital Dashboard • Interpreting and Using your Data • Cynosure/HRET Improvement Calculator • Questions?

4. HEN Overview • ACA considerable focus on quality • Created the CMS Innovation Center • Public-private partnership • Set 40/20 goal • Tool: Hospital Engagement Networks • 26 contracts awarded • Contracted with 34 state and regional hospital associations • 1,600 + hospitals Hospital HAC Teams Clinicians & Front Line Staff THE PATIENT

5. What is Data Management in HEN? • Surgical Site Infection (SSI) • Obstetrical Adverse Events/EED • Injuries from Falls & Immobility • Pressure Ulcers • VTE Preventable Readmissions Adverse Drug Events (ADEs) CAUTI CLABSI Ventilator-Associated Pneumonia (VAP)

6. Why collect & report data? • To demonstrate hospitals have reduced their Hospital Acquired Conditions and Readmissions over the 2 year period • To monitor that interventions are working • Part of the PDSA cycle • Measures are used to assess the impact of changes • To identify areas of strengths, weaknesses, and challenges – guide your improvement efforts

7. Data Requirements For each of the ten clinical topics, submit: • 1 process measure (how we know our interventions are actually implemented) • 1 outcome measure (how we know our interventions are actually working)

8. Data Timeframes • Baseline Data • Prior to January 2012 • Start/End date determined by user • One aggregate numerator/denominator • Monitoring Data • January 2012 – December 2013 • One numerator/denominator for each month

9. More data submission?! • Things to consider… • What are you already measuring? • What are you planning to measure? • What other data sources exist? • Identify Existing Measures • Are they in the Encyclopedia of Measures? • If not, there is an option to add user-defined measures.

10. Data Needed Patient Level Data PHI

11. Comprehensive Data System • HRET’s project data collection system • Web-based • Secure • Flexible • https://www.hretcds.org

12. Live CDS Demonstration • Logging in • Measure “enrollment” • Organization-defined measures • Data entry • Reports • Individual Measure • All Measures • Comparative Measures Report • Hospital Dashboards

13. What type of report do I need? • Data and Run Chart for your hospital’s performance on a single measure? • Individual Measure Report • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance? • Measure Comparison Report • Data only for all Measures and data entered for your hospital? • All Measures Report

14. What type of report do I need? • List of who has CDS access/type of access? • Organizational User* • Dashboard Report on data submission status, outcome measure results, and run charts for all EOM measures? • Hospital Dashboard

15. Individual Measure Report • The Individual Measure Report allows you to see a selected measure for a selected hospital across time. • Includes: • Timeframe (Baseline or Monitoring) • Start and End Date • Numerator and Denominator values • The rate for all timeframes where the data has been submitted.

16. Individual Measure Report

17. Individual Measure Report • Click on the ‘Reports’ tab • Then select ‘Individual Measure’

18. Individual Measure Report • By selecting the ‘Chart’ tab after selecting a measure in the ‘Data’ section, you can see a run chart of the selected measure.

19. Individual Measure Report – Sample Run Chart

20. Individual Measure Report • To export:

21. All Measures Report • The All Measures Report is a report that allows you to see all measures across all topics where data has been submitted. • Includes: • Organization name • Topic • Measure Name • Timeframe (Baseline or Monitoring) • Start and End Dates • Numerator and Denominator Definitions • Numerator and Denominator Values • The rate for that timeframe • The date the data was last updated • The city and state • Medicare ID Number • HRET_MeasureID (Our designated ID for the measure) • Measure Type (Outcome or Process)

22. All Measures Report

23. All Measures Report • Click on the ‘Reports’ tab • Then select ‘All Measures’

24. All Measures Report • The circled area shows the different elements you can use to filter the data • For example, if you only wanted to view Falls Data, you could use the dropdown menu for ‘Topic’ as pictured below.

25. All Measures Report • It can be filtered by any of the listed elements that are included • The full report can be exported to Excel • Filtered data can also be exported to Excel • Note: Depending on the amount of data you have, the All Measures Report may take longer to load

26. All Measures Report • To export:

27. Comparative Measures Report • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance • Only Available for EOM and State-defined measures

28. Measure Comparison Report • Measure Comparison Report—CHART view

29. Measure Comparison Report • The data used in the CHART can be found by clicking the DATA tab. • The variables included in the DATA view are • HRET_OrganizationID—the unique HRET identifier for your organization • HRET_MeasureID—the unique measure identifier • Measure-the measure name • Timeframe– Baseline (pre-2011) or Monitoring (2012-forward) • StartDate– timeframe start date. For BASELINE, this is YOUR organization’s start date • EndDate– timeframe end date. For BASELINE, this is YOUR organization’s end date • Numerator—your organization’s numerator • Denominator—your organization’s denominator • Rate– your organization’s rate • All State Hosps Rate—the rate for all hospitals in your state reporting this measure • # State Hosps—the number of hospitals in your state reporting this measure • All Project Hosps Rate—the rate for all hospitals in the project reporting this measure • # Project Hosps—the number of hospitals in the project reporting this measure • MeasureType—Outcome or Process

30. Organization User Report • List of who has CDS access/type of access • Only Available for Data Administrators

31. Organization User Report

32. What is the Hospital Dashboard? • The Hospital Engagement Network Hospital Dashboard is a monthly report that contains data and information related to your hospital’s • Data submission status • Outcome measure results • Readmission Race data • Early Elective Delivery/Hard Stop Policy information • Run charts depicting your hospital’s progress towards the goal of reducing harm by 40% and reducing readmissions by 20% by the end of 2013. • Canned Monthly Report • Available for download under CDS Resources

33. Data Sources

34. Update Process

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42. Interpreting and Using Your Data and Reports • Using data to answer your questions • “Now that I have all of this data, what do I do with it?” • “What does my data mean?” • “Am I reaching my improvement goals?”

43. Interpreting and Using Your Data and Reports • Preparing data for analysis • What question are you trying to answer? • What is the best way to present the data? • Who is your audience for your analysis? • Do you have any outliers or strange data? • Run chart points that are clearly out of line with others • Missing data points

44. Interpreting and Using Your Data and Reports • Preparing data for analysis • What question are you trying to answer? • What is the best way to present the data? • Who is your audience for your analysis? • Do you have any outliers or strange data? • Run chart points that are clearly out of line with others • Missing data points

45. Interpreting and Using Your Data and Reports • Run the analysis • Pull the data from CDS • Run chart • Export raw data from CDS and copy/paste into excel to create your own graphs • Assess trends • Draw conclusions • Quality Checks on your Results • Present your final results • Ensure that your graphs and data are understandable to your audience • Be creative!

46. Tools for Interpreting and Using Your Data • Cynosure/HRET Improvement Calculator • Developed to help translate data into Harms prevented and Estimated Costs Savings • Available for download in CDS Resources (excel file) or in Data tab of www.hret-hen.org • Live Demo

47. Click on L4; Enter # of 30-day all cause readmissions for baseline period

48. Click on M4; Enter # of discharges for baseline period

49. Click on L5; Enter % reduction for goal (only if you want to change from 20% default)

50. Click on L6; Enter cost (only if you want to change from default)