We’re exploring the topic of digital strategy for high-value care in this week’s edition of Ask Dr. Mingle. Click play on the episode below to hear Dr. Dan Mingle explain:

• That high-value care is a combination of quality, safety, and cost
• Why having a digital strategy is essential for high-value care
• How your EHR can support your digital strategy and improve your measurement capabilities
• And the role of numerators and denominators in measurement

Question One: Digital Strategy for High-Value Care Explained

Kyle says: “Many of our viewers ask about digital strategy, so we are dedicating this session to the discussion of digital strategy.”

My apologies to our viewers that my previous comments on digital strategy for quality measurement focused primarily on what’s wrong with eCQMs. There is substantial value for you in your local digital strategy. Every high-value practice needs one. If your only goal in measurement is Medicare compliance, then eCQMs are all you ever need.

But if your goal is high-value care, that is:

• Quality – Delivering everything to our patients that they need or should have
• Safety – Avoiding all things they should not have
• Cost – Doing it efficiently

You should have a digital strategy.

Measurement should be routine, comprehensive, and built into your patient care.

When I was in active practice, I was frustrated that I was unable to quickly access a list of my hypertensive patients, my diabetic patients, and any other category that exists. I was excited and drawn into electronic medical records to, at last, enable a system that could give me relatively easy access to those lists.

This is where EHRs differentiate themselves: in the degree to which they support your digital strategy for quality measurement and high-value care.

It’s time to rethink and refocus your EHR efforts toward your digital strategy.

What does it take to optimize your digital high-value health care?

• Your EHR has to be capable
• Your documentation templates must be rigorously built
• Your data collection and documentation workflows must be meticulously defined, taught, and maintained

Question Two: Quality Measurement & High-Value Care

Kyle asks: “Can you help me understand measurement using my EHR?”

Quality measurement is the relationship between denominators and numerators.

Every measurement defines a denominator first: a set of criteria that makes patients eligible for the measurement.

Numerators – the evidence of the success of an intervention – also define measurement: this could be a number, like a goal blood pressure or A1C. It could also be an order, like a prescription, a specific test, or a referral.

Patients who are eligible for a given intervention are denominators.

The intervention given, or the results of that intervention, is the numerator.

It might seem, at first, that the terms denominator and numerator are impersonal. But they are not. They are highly personal. The list of characteristics that define what a patient is eligible for and what results or actions you take on those eligibilities uniquely defines each person, like a fingerprint.

You need to be able to identify, from your EHR, all patients eligible for any given intervention and its results.

It sounds simple, but it is a challenging task.

Three things need to exist to get that data out:

• The data should be in your EHR as structured data.
  • Structured data is distinctly different than textual data. For text, you dictate or type it in. It can be misspelled, misplaced, or neglected. In contrast, you choose structured data from a list. Its location and syntax are standardized – unchanging.
• You should structure your EHR as a database from which you can search for and find specific data elements.
  • There must be a predictable and findable location for each data element that is recoverable with standard and available query tools.
    • A query tool is the application and language you use to recover the data.
• You or your designee must have access to that database and the query tool.
  • Many EHRs make the database and the query tools inaccessible, often hiding it behind a paywall or building contractual language that prohibits advanced utilization of the data they hold.

Question Three: Quality Measurement – Denominator Details

Kyle asks: “Dr. Mingle, can you explain more explicitly about denominators?”

To understand denominators, consider each characteristic you need to know about a patient to treat them safely and effectively:

• Demographics, like age, sex, ethnicity, occupation, and other social determinants of health
• Vital signs, like height, weight, blood pressure, temperature, etc.
• Family History of possible inheritable conditions
• Pertinent symptoms, like pain, depression, etc.
• Pertinent physical findings
• Active and past diagnoses and procedures
• Medications
• Allergies
• Immunizations

Each of these elements and others are needed to define all desired denominators. You want each data point held accurately and accessibly in your EHR.

Question Four: Quality Measurement – Numerator Details

Kyle asks: “What about the numerators?”

Any measurement, observation, or order is a potential numerator – they must be held accurately and accessibly in the EHR for you to use them, though.

Remember, your EHR should hold anything you do or order as structured data. Examples of this could include:

• A prescription or medication list
• Lab and X-ray orders
• Referrals
• Or instructions you or your staff are providing to patients
  • In this case, these instructions should be represented as an order so that you can recover it and identify that it has been done

Note that many things can be either elements of the denominator or the numerator.

For instance, a prescription for hydrochlorothiazide, a common blood pressure medication, could be the numerator of a measure indicating you took appropriate action on a patient with high blood pressure.

It can also be a denominator element in a measure looking for patients who should have their serum sodium and potassium levels and kidney function checked.

Summary: Digital Strategy for High-Value Care

This is a good start on this subject, but there’s much more to explore in later episodes of Ask Dr. Mingle. 

In summary:

• Reimagine your EHR as a source of denominators and numerators.
• Consider the denominator factors that identify your patients as eligible for any interventions you do or might want to do.
• Think about the numerator factors that identify success in controlling the conditions you treat or monitoring the patients you treat.
• Identify the documentation workflows that accurately post that data into your EHR.
• Identify the data tools to access and recover the denominators and numerators you are interested in.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

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