As MN Community Measurement evolved from a project to an independent, non-profit organization in 2005 and expanded our measurement work, our pioneering approach to collecting the data from medical groups and clinics began to take shape.
By 2006, many medical groups were using MNCM specifications to collect data from their electronic medical records on diabetes and vascular care for their own internal improvement efforts. At the time, MNCM was utilizing claims data from health plans for its provider performance reporting. However, data from medical records is more timely, reflects the care for all patients (including those who are uninsured), and is able to be reported by clinic site. On the urging of medical groups, MNCM agreed to test the use of medical record data for measurement.
The following year, we piloted a process to collect data directly from clinics which is known as Direct Data Submission (DDS). Multiple clinics voluntarily participated in this pilot by submitting data directly to MNCM for the Optimal Diabetes Care measure. This process made reporting results for individual clinic sites possible, which showed variation even among practices within the same medical group – deepening the medical groups’ ability to target quality improvement efforts.
From this successful pilot, the MNCM Data Portal and Direct Data Submission process were born – a secure online process and infrastructure for medical groups to submit data from their medical records to MNCM and then view results and utilize reports on their performance.
Data Submission Process and Measures
The goal of the DDS process is to collect unidentifiable patient-level data from medical groups on specific health care conditions and publicly report comparable rates of health care quality at the clinic site level. All medical groups follow the same instructions for eligible population identification and data collection. Each medical group submits data to MNCM via the secure, online MNCM Data Portal. As an independent auditor and as a service to each medical group, MNCM validates the data for accuracy, calculates rates from the validated data, and publicly reports the data on MNHealthScores.org.
DDS also fulfills participation requirements for the Minnesota Department of Health’s Minnesota Statewide Quality Reporting and Measurement System (SQRMS), as well as other Minnesota health plan pay-for-performance programs and Bridges to Excellence (BTE). It can also fulfill some requirements of the Centers for Medicare and Medicaid Services’ Meaningful Use program.
The following measures use data submitted directly to MNCM by medical groups and clinics:
- Adolescent Mental Health and/or Depression Screening
- Childhood Overweight Counseling
- Colorectal Cancer Screening
- Depression Care:
- Depression Remission at Six Months
- Depression Response at Six Months
- PHQ-9 Follow-up at Six Months
- Depression Remission at 12 Months
- Depression Response at 12 Months
- PHQ-9 Follow-up at 12 Months
- PHQ-9 Utilization
- Maternity Care: Primary C-Section Rate
- Optimal Asthma Control (Adults and Children)
- Optimal Diabetes Care
- Optimal Vascular Care
- Total Knee Replacement (Functional Status and Quality of Life)
- Spinal Surgery Lumbar Fusion (Functional Status, Quality of Life and Pain)
- Spinal Surgery Lumbar Laminectomy / Discectomy (Functional Status, Quality of Life and Pain
Validating and Evaluating Data and Measures
After data is submitted through the MNCM Data Portal, MNCM completes the following validation steps to ensure results are accurate and comparable:
- Quality Checks – Demographic data, eligible population and preliminary performance results are quality checked. If errors are identified, the medical group must make corrections to the data file and resubmit.
- Validation Audit – All medical groups are subject to an audit. Medical groups selected for an audit are contacted by MNCM. A list of records for audit will be provided.
- Audit Process – MNCM utilizes the National Committee for Quality Assurance’s “8 and 30” process for audits:
MNCM randomly selects 33 records from each applicable clinic site for validation. At most, 30 records for each clinic site will be reviewed. The additional three records are oversamples to ensure 30 records will be available on the day of the review. The MNCM auditor reviews records one through eight in the sample to verify whether the submitted data matches the source data in the medical record. If no errors are found in these eight records, the compliance rate is 100 percent, and the clinic site is determined to be in high compliance. If the auditor identifies one or more errors in these eight records, the auditor will continue auditing records nine through 30 and a compliance rate is calculated. If the compliance rate is less than 90 percent, MNCM and the medical group will discuss a data resubmission plan.
- Two-Week Medical Group Review – The two-week medical group review is the medical group’s official opportunity to review and comment on the results prior to finalization. Each medical group is responsible for reviewing their own results, investigating any concerns, and submitting evidence to MNCM if a change in results is requested.
To ensure collection and reporting continues to be of value to the community, MNCM strengthened its measure review and maintenance process in 2014 by annually reviewing the DDS measures. The process includes:
- Adoption of a new measure review process that includes four levels of increasingly intensive review, research, assessment and redesign.
- Formation of the Measure Review Committee, a sub-committee of the Measurement and Reporting Committee, which is responsible for annual measure review and maintenance activities.
- Creation of a strategic measurement framework, a tool to guide the identification of gaps in the measurement landscape and guide priorities for new measure concepts.
“MNCM is committed to working with our multi-stakeholder committees to champion the highest value measures that will make the most impact in our community, while balancing burden on organizations that supply the data,” said MNCM President Jim Chase. “As performance improves, we have processes in place to ensure the appropriate retirement of measures to minimize burden.”
Resources for Quality Improvement
MNCM values the medical groups and clinics that contribute data to MNCM and wants to support their success as well. We provide resources, tools and reports that they can use for quality improvement. To that end, we make the following resources available to our data-contributing medical groups:
- Detailed data reports for clinical measures (e.g., diabetes, colorectal cancer screening, etc.) and patient experience of care
- Medical Group charts of specific clinical measures segmented by race, Hispanic ethnicity, Preferred Language and Country of Origin for groups following best practices
- Patient-reported outcome measure tools for asthma, depression, spine surgery and total knee replacement
- Patient education and engagement resources
- Provider tools and resources
- Monthly Q & A session details
- Educational webinars throughout the year
More than 1,450 medical groups and clinics supply information on quality, patient outcomes, health information technology, and patient experience. Additionally, our health plan partners provide information on cost and quality. All of these partners contribute toward health care transparency in Minnesota and improving public health by publicly reporting data.