Real World Test Plan

TCM Management

Justification

One of our clients is involved in several Transitional Care Management Programs. We will support them with our Real World Testing plan. As part of this program, patients are tracked for a 30-day period post-discharge. This test plan will ensure we can import data from partner hospital Epic systems and streamline the administrative tasks necessary for this program.

User Stories

  • For each of their patients, we will send a Discharge Summary and C-CDA from their partner hospital’s Epic
  • We will import this data into our system. Both demographic details and medication lists will be reconciled
  • All medications a patient needs will be ePrescribed through our system
  • When a patient completes their 30 days, we will export an updated C-CDA

Associated Certification Criteria  

  • 170.315(b)(1) – Transitions of Care
  • 170.315(b)(2)–Clinical information reconciliation and incorporation 
  • 170.315(b)(3) – Electronic Prescribing
  • 170.315(b)(6) – Data Export*

Measures  

  1. Count of patients in TCM program we import data for in a 30-day period. This metric will give a total count of the discharge summaries and C-CDA’s we import data for   
  2. % of patients in the TCM program we import data for in a 30-day period. This ratio will track how often this import is used. The denominator will be the count of patients enrolled in the TCM program, the numerator how many we import discharge summaries and C-CDA’s for. 
  3. Count of patients enrolled in the TCM programs that we send prescriptions for in a 30-day period.  
  4. % of patients in the TCM program we send ePrescriptions for in the measured 30-day period. This ratio will track the % of patients in the TCM program who had medications ePrescribed. The denominator will be a distinct count of patients enrolled in the program, the numerator a distinct count of patients who had an ePrescription sent  
  5. Count of patients enrolled in the TCM programs that we complete the data export for in a 30-day period. 
  6. % of patients in the TCM program we export data for in a 30-day period. 

Expected Outcomes 

For each measure, we expect that we will have more than 10 qualifying patients in a 30 day period and that each of our ratios will be above 70%.  

Schedule of Key Milestones  

  • February 28, 2022. Finalize coordination with Epic to receive Discharge Summaries and C-CDA files  
  • March 1st – March 31 2022. Gather data  
  • April 30th, 2022: Complete report summarizing data    

 

New Client - CQM Data Import [CP-CQM] 

Justification  

We are blessed to have gained a few EMR clients during the pandemic. We will use this Real World Test Plan to assist them with their quality reporting. We will accomplish this by:  

  1. Auditing the CQMs we already have setup for them and ensure we are generating compliant QRDAs for them by importing this data to the QPP portal  
  2. Conducting trainings for our new clients to ensure they are comfortable using our reporting website to track their CQM scores.  
  3. As some of our clients switched to our EMR in the middle of 2021, we will import the CQM data from their old EMR systems  

Associated Certification Criteria  

  • 170.315(c)(1) - Clinical quality measures (CQMs) — record and export
  • 170.315(c)(2) - Clinical quality measures (CQMs) — import and calculate
  • 170.315(c)(3) - Clinical quality measures (CQMs) — report

Metrics  

  1. Count of how many QRDA files uploaded to the QPP portal  
  2. Count of how many clients we import CQM data for  

Expected Outcomes  

Our target is to import at least one set of QRDA files to the QPP portal. Due to COVID-19, many of our clients have already requested we file MIPS reporting exclusions for them.  

We received a lot of pushback from our clients’ previous EMR systems as we brought them into ours. So much so, we file an Information Blocking ONC complaint against CureMD, who requested an unreasonable amount of money ($14,000) to give us a data export. Unfortunately, after many follow ups, we still have not received a response from the ONC on our complaint. This behavior was consistent with our other EMR transitions. Given the challenges in working with other EMRs, our target is to complete the QRDA import for one client.  

Schedule of Key Milestones 

  • December 31st, 2021- Receive QRDA data files from our new clients’ old EMRs. Complete trainings to ensure clients are comfortable pulling reports 
  • January 31st, 2022- Complete QRDA import  
  • February 28th, 2022- Upload files to QPP portal  

 

Patient Portal [CP-PP] 

Justification  

Many patients seen by our providers use our patient portal to gain access to their health information. We will track their usage with this Real World Test plan. We will implement site tracking on our patient portal to see how many patients use the portal.  

User Stories  

  • We will track a count of how many patients log into the portal to see how many view their information  
  • We will track a count of how many patients download their data  
  • Finally, we will track a count of how many patients transmit their information to another party  

Metrics  

  1. % of Patients who view their info = Count of unique patients logged in/ #of Patients who have patient portal enabled in a 30 day period  
  2. Count of how many patients download their data in a 30-day period  
  3. Count of patients who transmit their information to another party in a 30-day period  

Expected Outcomes  

Given the large patient population that already has access to the portal, we anticipate that 5% of them will login within a 30-day period. We expect that 10% of these patients will download and transmit their data.  

Associated Certification Criteria  

View, download, and transmit to 3rd party” criterion in § 170.315(e)(1) 

Schedule of Key Milestones  

  • August 30th, 2022- Complete the implementation of site tracking across the patient portal  
  • September 1st, 2022- Begin collection of patient portal data  
  • September 30th, 2022- Complete data collection  

 

Immunization Registry [CP-IR] 

Justification  

We’ve enrolled several of our providers with the New Jersey Immunization Registry. We will track their usage with this Real World Test plan. New Jersey automatically enrolls all patients born after January 1, 1998 into the Immunization Registry. Over a 30 day period, we will track how many of these patients we send immunizations to the registry for. We will also track how many of these patients we are able to pull back the immunization history and forecast for. We will make our sample period during flu shot season so we can track maximum immunization data.  

  User Stories  

  • As a user enters a vaccine into our system, we will automatically send this data to the registry  
  • A user will have the option to pull immunization registry data back and have it display on their screen  

Metrics  

  1. Count of patients born after 1/1/1998 who have their vaccine information sent to registry/ count of patients born after 1/1/1998 vaccinated over a 30-day period  
  2. Count of patients born after 1/1/1998 who we successfully pull vaccine information for/ count of patients born after 1/1/1998 who information is requested for over a 30-day period  

Expected Outcomes  

We expect at least 80% of patients vaccinated will have their information successfully transmitted to the registry and that at least 80% of the requests from the registry of vaccination information will be successful.  

Schedule of Key Milestones  

  • August 30th, 2022- Complete registration of any remaining clients to the vaccination registry 
  • September 1st, 2022- Begin collection of vaccination data
  • September 30th, 2022- Complete data collection  

Associated Certification Criteria  

The public health criteria in § 170.315(f) 

  • § 170.315(f)(1) - Transmission to immunization registries 
  • § 170.315(f)(2) - Transmission to public health agencies — syndromic surveillance 

 

Deepscribe [CP-DPS] 

Justification  

At our client’s request, we completed an integration with an AI power charting vendor. This vendor connects to our API to pull relevant patient information and then pushes back documentation from the visit. Much of the information exchanged follows the data standards of 2015 Edition CCDS. The ability to exchange a subset of this data validates that we can meet this requirement. For our Real World Test plan, we will gather data on this for a 30 day period.  

User Stories 

  • A user should be able to view all patients checked in under the Claimpower platform in the Deepscribe platform for a given date range  
  • Documentation from the patient’s visit should automatically come back into Claimpower  
  • The data exchange is logged  

 

Metrics  

Number of patients data is transmitted for/ total number of patients checked in over a 30 day period  

Expected Outcomes 

We expect that 100% of the patients checked in will successfully transmit to the Deepscribe platform and that 100% of the patients in the Deepscribe platform will have their chart data sent back to Claimpower.  

Schedule of Key Milestones  

  • January 1st, 2022- Begin data collection
  • January 31st, 2022- Complete data collection
  • The application programming interface criteria in § 170.315(g)(7) through (g)(9)
  • § 170.315(g)(7) - Application access — patient selection 
  • § 170.315(g)(8) - Application access — data category request 
  • § 170.315(g)(9) – Application access – all data request 

 

Direct Project [CP-DPO] 

Justification  

A few of our clients are enrolled with EMR Direct to exchange information with other providers. For our Real World Test plan, we will track their utilization of this for a 30 day period. Many of our clients have told us that they are unable to find direct email addresses for other providers they work with. We will assist them in creating a list of all the specialists they work with and reaching out to them for their secure email addresses.  

User Stories  

A user should be able to use EMR Direct to exchange a patient’s health information with another provider  

Expected Outcomes  

Given the troubles our clients have previously communicated to us with finding specialists Direct Email addresses, our target is to complete this exchange for at least 1 patient.  

Metrics  

Count of patients who have their information exchanged using EMR Direct.  

  1. The transport methods and other protocols criteria in § 170.315(h) 
  2. § 170.315(h)(1) – Direct Project