Building the Foundation
The key activities below will guide you through the process:
- Establish a data governance and reporting team.
- Understand the PHMI measures and specifications.
- Program and run measures.
- Assess internal data integrity.
- Identify and acquire external data.
- Conduct data validation and reconciliation.
- Report and use data to improve care.
After working through the key activities, you will be able to:
- Form a data governance and reporting team.
- Produce core quality measures using HEDIS specifications that have been adapted for PHMI.
- Develop and implement a data validation process that identifies gaps and solutions for improving data quality, such as reconciliation with managed care plans (MCPs).
- Produce quarterly core quality measures stratified by site and by race and ethnicity to identify and reduce disparities and improve performance.
Key Activity 1: Establish a data governance and reporting team.
Producing data that accurately reflects the care and services patients are receiving requires strong processes for data oversight, quality control and ensuring the data can be used throughout the practice (also known as data governance). A data governance and reporting team with clearly defined roles, responsibilities, systems and processes is critical to ensuring sustained high-quality data and reporting. A leadership structure should be established to oversee the work of developing policies and procedures that define and guide expectations for use of the electronic health record (EHR) system and the population health management platforms, and to ensure that they result in accurate and complete data to effectively manage your patient populations.
1. Determine which roles in your practice or larger organization are responsible for data governance.
Each organization may have different councils or committees already in place that meet data governance needs or could be adapted to include robust data governance. Larger organizations may need multiple dedicated layers of governance, but smaller ones could incorporate oversight into existing leadership committees and roles. Regardless of the size of an organization, the scope of governance is roughly equivalent, but the complexity and the roles of those engaged in data governance may vary.
At a minimum, the data governance and reporting team should include:
- An executive sponsor.
- A clinical informatics or analytical staff member.
- A quality improvement coordinator.
- A clinical contact who can provide expertise on the clinical data feeds.
Individuals in these roles become stewards of improving and ensuring the integrity of data collection, analysis and reporting. Their scope will include:
- Identifying data priorities that align with organizational priorities.
- Developing or updating data-related policies and procedures.
- Taking responsibility for the application of policies and procedures.
- Identifying and defining specific data-entry improvement opportunities
- Working with leadership and the clinic staff to address workflows for intake, registration, provider and care team staff documentation, and other applicable processes to ensure needed information is being obtained.
- Overseeing external data ingestion.
- Overseeing performance measurement analysis.
- Overseeing reporting performance results.
2. Determine the data governance strategy.
The scope of the data governance and reporting team includes establishing the basic framework that consists of the policies and procedures, standards, ownership, decision rights, roles and responsibilities, and data accountability as it relates to:
- Collection.
- Retention.
- Use.
- Accessibility.
- Sharing of healthcare data.
Practices will also need to determine which reporting system will be used to report each measure (e.g., within a data platform, regionally by an RAC or through a manual report development process).
Policies and procedures for EHR and population health management platforms can be expansive, touching all areas of an organization. At a minimum, they should
include the following key components, tailored to your data collection needs and EHR platform:
- A description of the appropriate use of EHR system documentation features and
capabilities. - A description of standards of conduct for program integrity of documentation
and how it will be included in staff and management training. - Health information management of any external informational content.
- Definition of role-based access to health record-related information.
- Policies and procedures on information acceptance, retention and formats.
- Attestation that quality requirements are aligned with latest DHCS Medi-Cal managed care targeted guides and requirements for primary care providers.
- Workflows to optimize data collection (intake, registration, documentation, etc.).