Jamie Kim's question on OPA CDC call - do we have lab values (results for GDM?) as part of this data set?

the actual results or within or outside reference range vs normal

AllianceChicago - Yes - we are using lab values to create GDM=YES if it was not coded as an ICD code. Yes, hoping to use those values. Using them pre-natal to validate and identify patients who might be at risk, so they can generate a list of higher risk patients if there is not an ICD.  Already doing this - can be modified if NACHC prefers Yes/NO rather than just values.

OCHIN - Yes, we can support the results w/in the query, but have not pulled in reference ranges.  Yes, it is useful information. Wants to think about.  OCHIN is already supplying the values, but would have to consider if reference ranges/abnormal flags would be feasible.

Do you prefer NACHC to dump in the reference ranges and the values?  Note - reference ranges may be different.

1. Do we want to create a data element for record linkage
2. Do we want to create a PP depression screening
3. Do we want to create a measure for high risk pregnancy

AllianceChicago 

QA Validation

QI Plan

Any change in:

• Partner onboarding: Working with 3 CHCs, have met with 2 of them, the other is going slower, working mostly through email because of COVID focus.  Looking at creating a registry to follow high risk patients: GDM, those in early PP and BP checks for those with HTN or pre-eclampsia, ... in the early pp periods.
  • One site wanted to look at episodes to track as a priority
  • The other wanted to look at outcomes as a priority
• QI planning
  • Starting in March likeley - to be able to use the data to look at PP metrics to allow them to do the case management.
  • Best to be able to identify what is being done across all sites - either one document or two QI plans if they are different.  Most likely it will be the same across the two, because they have to both agree on which will be done because of the IT requirement of chosing one at a time because of limited time/resource.
• EHR configuration
  • Reviewing current documentation in ecentricity and looking at other systems
  • Have pulled the monthly report
  • In looking at value sets vs proprietary codes - looking at how to capture the most in terms of contraception.
• Data challenges
• Data discovery

Lessons Learned

• When we asked what our centers' priorities were and brought it to the IT team and needed to prioritize only one of the two reqeusts, or the third one they have because there is only bandwidth to change one - episodes vs outcomes, so, going back to the CHCs to get their opinions on priority.

OCHIN

QA Validation

QI Plan

women's health express lane 

Any change in:

• Partner onboarding - 2 health centers are getting started, one more may come on. Identifying which metrics they are most interested in tracking. GDM in pp period is first, depression screening also of interest, contraception, too. EHR configuration is PP Express Lane.  This would be a new build for the CHCs - to trigger the right care, more easily tracked.  Practitioners could use the tool to organize the things that need to be done during the visit
• QI planning
  • Before and after look at the workflows - you can show the new workflow or modify the old one to show how things have changed. If you want to, you can also describe at high level what is being added.  You don't have to document a whole workflow, NACHC is trying to understand the before and after, so we can help others identify their gaps and make sure that they can pull patients back into the flow.
  • Good to aligning data piece with QI part - if you are creating new measures and outcomes we can add things to the data dictionary. OCHIN could record those; Alliance would not have to also add those.
• EHR configuration
  • Both clinics have agreed to use the PP Express Lane, Dr. Whitt is modifying the build to work on customizing to each clinic.  One is particularly interested in streamlining how they get patients back for GDM screening, so want to integrate that into Express Lane - GDM management is not in-house, but done with a perinatologist.
  • Want to combine baby visits and GDM so the pediatrician can do that.  
• Data challenges
• Data discovery
  • Looking at the data overall and for each center.
  • Need to look at last year's data to see patterns and identify the patients we need to look at.

Lessons Learned

NACHC will provide the data for these queries so partners can provide feedback, and will create dashboards for a monthly snapshot.

If the information is blank, is that a "no" because it is not documented or "unknown" - put in the notes "this patient was lost to follow-up"

It would be interesting to know - how do we know this patient is no longer receiving care - no-show?  other reason?  Finding out could be a care management activity.  This is useful data, you can just say "no they did not have a visit, they did not have contraception method listed, this patient was lost to follow-up"

Pedro mentioned that previous clinic he worked in had a template that had - patient has a primary care provider - sometimes we could see that they did have a PCP.

Are there OB/GYNs on this call? Any patient on Medicaid, you are supposed to do certain things to meet requirements of the contract - you are supposed to know if the care is you or if they transfer to someone else, the disposition for continuity is a contractual requirement.  

Add to data dictionary - how to track disposition?? how to extract that?

In AllScripts, when you close the episode, you have to document it there.

Partners

Data

Update QI Plan

Lessons Learned

NACHC

Dashboards