Short Demo for eCQM Quality Improvement on the DDSP & Logic Explorer (duration: 913:14 20 minutes)click
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Purpose:
When selecting 'eCQM Submission' from the menu, the 'Quality Improvement' page becomes available.
Click on the 'Quality Improvement' tab to:
evaluate Evaluate the Initial Population and Observed Rate/Observation Value for eCQMs associated to active patient (accepted QRDA I documents).
review Review patient data (QRDA I document) to understand how they processed against the eCQM logic.
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Confirm that the uploaded file did not generate any high-level platform errors by reviewing the ‘Data Details’ on the Upload Data page.
If no high-level errors were generated by the file, then your file is in the queue for processing against the schematronSchematron, edits, and eCQM logic.
The processing turnaround time is dependent upon how many other files (including from other organizations) are waiting in the queue for processing.
If you continue to receive this message after 24 hours, please create a DDSP Support Ticket by clicking on the 'Need Help?' button in the upper right-hand corner of the page.
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Right-Click to Export
Right-clicking on file in ‘Active Documents’ provides the ability to Export export the data behind most of the controls on this page. Move the cursor over the data of all files or selected files as Excel or as CSV. To export specific files, select the files you would like to export and click on "Click here to download your data file". The downloaded file is an Excel file (xlsx)by left-clicking on them and then right-click to popup the menu and click on ‘Export as Excel’ or ‘Export as CSV’. To export all files, move the cursor over any file in ‘Active Documents’ and right-click then choose ‘Export as Excel’ or ‘Export as CSV’ on the popup.
Quality Improvement Counts
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Definitions for Quality Improvement Counts:
MeasuresMeasure: The measure selected in the ‘Select Measures’ Measure’ control.
Active Patients: For the selected Measure and Quarter, count of all unique patients (i.e., among the active QRDA I document) documents that are in the Initial Population of the eCQMuploaded.
Episodes of Care: For the selected Measure and Quarter, count of all unique encounters that the Active Patients had during the calendar quarter.
A patient that is discharged one time during the calendar quarter will have a one-to-one relationship between “active patient” and “episode of care”.
A patient that is discharged three times during the calendar quarter, will have a one-to-three relationship such that there is one “active patient” related to the three “episode of care”.
For example:
If there are five (5) “active patients” “Active Patients” in the eCQM for the calendar quarter with one (1) encounter each, the number of “episodes “Episodes of care” Care” equals five (5).
If there is one (1) “active patient” “Active Patients” discharged five times during the calendar quarter, the number of “episodes “Episodes of care” Care” equals five (5).
If there are five (5) “active patients” “Active Patients” during the calendar quarter where:
two Two (2) were discharged two (2) times and
three Three (3) were discharged one (1) time,
the The number of “episodes “Episodes of care” Care” equals seven (7).
Active DocumentDocuments
The last accepted QRDA I document processed by the DDS Platform DDSP with the same Key information (Patient ID in the PatientRole element and Quarter in the effective date in the Reporting Parameters section) will become the Active Document within the Platform and be counted as the Active Patient on this page. Do not split a patient's data into multiple QRDA I documents (e.g., ED and Stroke data) as the last QRDA I document processed for the patient will be the Active Document/Patient, which will affect your hospital's measure rates.
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The ‘Population Breakdown for the Selected Measures Measure (Episodes of Care)’ Waterfall Chart shows how each patient’s episode of care were processed against the selected eCQM, for the selected calendar quarter.
A QRDA I document contains data for all episodes of care for a single patient that are related to a calendar quarter.
Patients admitted in one quarter and discharged in another quarter, will be counted in the calendar quarter in which they were discharged.
See definition of the components of the Waterfall Chart below.
Select
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Measure (left-hand side of page):
The ‘Select Measures’ Measure’ element contains a drop-down list of the eCQMs that were processed against the uploaded patient data that were Accepted.
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Patients (QRDA I documents) which have been replaced by being re-uploaded are not accessible. Only the last version of a given document is ‘active’ and may be reviewed. For example:
The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is uploaded on 4/1 in a zip file named ‘MJ’.
The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is re-uploaded on 4/2 in a zip file named ‘MJ-2’.
Only the 4/2 version of the Mary Jane QRDA I document is ‘active’ and available to be reviewed on this page.
Clicking on the ‘Magnifying Glass’ icon next to an active QRDA I document launches the Source Viewer and and eCQM Logic Explorer Explorer which provides:
a A review of the patient data and how the active QRDA I document was processed against the eCQM logic, and if necessary
the The list of Schematron and Edit warnings that the file generated along with the ability to view the specific XML file structure of where the warnings occurred.
Review
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Patient Results (right-hand side of page, below 'Active Documents'):
Clicking this button will take you to a new page that will display how each patient's episode of care processed against the measure.
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Definitions for the Waterfall Chart Population Breakdown for the Selected Measure:
Page Element | eCQM processed against | ||
Episodes of Care | Count of all Active episodes of care evaluated by the eCQM.
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Not in Initial Population | Count of episodes of care which did not pass the Initial Population logic.
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Initial Population | Count of episodes of care evaluated which meet the Initial Population as documented in the specification | ||
Does Not Meet | Count of episodes of care in the Initial Population that does not meet the measure population criteria for the measure | ||
Measure Population | Count of episodes of care that meet the population criteria for the measure
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ExclusionExclusions | Count of episodes of care that are removed from the Measure Population because they meet specific criteria that made it clinically unnecessary for the patient to receive the numerator clinical action.
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ExceptionExceptions |
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Denominator / Population |
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Cases Failing the Measure |
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Numerator |
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Page Elements | User Action | Population Breakdown | Select MeasuresMeasure | Select QuartersQuarter | Documents |
Population Breakdown for the Selected Measure | Clicking a measure result (population bar) within the Waterfall Chart | Highlights population bar for that measure result | No change | Displays quarter(s) for which patient data exists with that measure result | Displays the patient’s active QRDA I document(s) which received the measure result |
Select MeasuresMeasure | Clicking a specific measure | Displays measure result breakdown for selected measure | Displays selected Measure in drop-down box | Displays quarter(s) for which patient data exists for the selected measure | Displays each patient’s active QRDA I document in the Initial Population of selected measure |
Select Quarter | Clicking a specific quarter to further filter the measure data | Displays measure result breakdown for selected measure and quarter | No Change | Highlights selected Quarter | Displays each patient’s active QRDA I document in the Initial Population of selected measure and quarter |
Active Documents | Clicking a specific patient’s QRDA I document | Displays measure result for the selected patient | No Change | Displays quarter associated for the selected QRDA I | Highlights selected patient’s QRDA I document |
Clear Selection | Clicking ‘Clear Selection’ button | Returns the entire page back to its original state | |||
Important Information for Using the Quality Improvement page