Understanding IA_PSPA_7: Using QCDR Data for Ongoing Practice Improvement

Understanding IA_PSPA_7: Using QCDR Data for Ongoing Practice Improvement

MIPS reporting is often viewed as something a practice completes at the end of the year: collect the data, calculate the results and submit the information to CMS.

But MIPS data can be much more useful when physicians can see their performance during the performance year, while there is still time to make improvements.

That is the concept behind IA_PSPA_7 — Use of QCDR Data for Ongoing Practice Assessment and Improvements.

For Podiatrists participating with Registry Clearinghouse, this Improvement Activity is particularly relevant because Registry Clearinghouse receives updated clinical data on a regular basis, allowing Podiatrists to monitor their MIPS performance throughout the year.

Instead of simply reporting what happened after the year is over, the data can be used to identify opportunities for improvement, make changes and then monitor whether those changes are working.

What Is IA_PSPA_7?

IA_PSPA_7 focuses on participation in a Qualified Clinical Data Registry (QCDR) and the use of QCDR information for ongoing practice assessment and improvement.

The key word is ongoing.

This is not simply about sending data to a registry. The value comes from getting useful information back and using it to evaluate what is happening in the practice.

CMS includes the generation and use of regular feedback reports summarizing practice patterns and treatment outcomes among the ways physicians can participate in this Improvement Activity.

For a practice, the process can be thought of very simply:

Collect Data → Review Performance → Identify an Opportunity → Make a Change → Review Updated Data

Then repeat the process.

How Registry Clearinghouse Makes Ongoing Assessment Possible

Registry Clearinghouse receives updated data from participating practices on a regular basis.

This allows Podiatrists to see how they are performing on their MIPS Quality measures before the performance year is over.

That can make an important difference.

If a Podiatrist only receives performance results after the year has ended, there may be little opportunity to correct a problem that affected the year's MIPS results.

With regularly updated data, the physician has an opportunity to identify a problem while there is still time to investigate it and make a change.

For example, a Registry Clearinghouse report might show that a practice's performance on a particular Quality measure is lower than expected.

The next question is:

Why?

Perhaps eligible patients are being missed.

Perhaps an examination is being performed but an important element is not consistently documented.

Perhaps information is being entered into the wrong location in the EHR.

Perhaps different members of the practice are following different workflows.

Or perhaps the data reveals a genuine opportunity to improve a clinical process.

Finding the problem is the first step.

The practice can then decide what needs to change.

From Data to Improvement

Consider a Podiatry practice monitoring a Quality measure involving patients with diabetes.

Registry Clearinghouse receives updated data and the physician reviews the current performance results.

The results show that some eligible patients are not meeting the measure.

The practice investigates and discovers that an element of the diabetic foot examination is not being consistently documented.

The practice might respond by changing its EHR template, adding a reminder, educating staff or modifying its clinical workflow.

That is an improvement intervention.

But the process should not stop there.

As Registry Clearinghouse receives additional data, the Podiatrist can review the updated performance information.

Did performance improve?

If the answer is yes, the practice has evidence that its intervention may be working.

If performance did not improve, the physician can investigate further and make another change.

This creates an ongoing cycle:

Review → Improve → Measure Again

That is the real value of having regularly updated QCDR data.

How This Helps Meet IA_PSPA_7

Registry Clearinghouse's regular receipt of updated data helps provide the infrastructure a Podiatrist can use to perform the ongoing assessment contemplated by IA_PSPA_7.

There are two important parts to the process.

1. Ongoing Assessment

The Podiatrist reviews updated Registry Clearinghouse reports to evaluate current performance.

Instead of looking at MIPS data once at the end of the year, the physician can review performance as additional information becomes available.

This makes it possible to identify trends, gaps and opportunities for improvement.

2. Practice Improvement

The physician then uses that information.

If the data identifies a problem, the practice can take action. That could involve changing a clinical workflow, improving documentation, modifying an EHR template, educating staff, improving patient communication or making another appropriate change.

Subsequent Registry Clearinghouse data can then help the practice determine whether that change resulted in improvement.

The important distinction is this:

Participating in a QCDR provides the data. IA_PSPA_7 is about using that data to assess and improve the practice.

Don't Just Look at Your MIPS Score

It can be tempting to open a registry report, look at the projected MIPS performance and stop there.

Instead, look deeper.

Ask questions such as:

Which measures are performing below expectations?

Are there eligible patients who appear to be missing?

Is the problem clinical, or is it documentation?

Are all physicians and staff following the same workflow?

Has performance changed since the last data update?

Did the change we made actually improve the results?

Those questions turn MIPS data into useful practice information.

Document What You Do

Podiatrists planning to attest to IA_PSPA_7 should also maintain documentation showing how QCDR information was used.

Don't wait for an audit to try to reconstruct what happened months or years earlier.

A simple documentation file could include:

• dated Registry Clearinghouse performance or feedback reports;

• documentation of when the reports were reviewed;

• the Quality measure or patient population evaluated;

• the problem or improvement opportunity identified;

• meeting notes or other documentation showing that the results were discussed;

• the clinical, documentation or workflow change that was implemented; and

• subsequent reports showing continued monitoring of performance.

The documentation should tell a simple story:

We reviewed our QCDR data.

We identified an opportunity for improvement.

We took action.

We reviewed updated data to determine whether our performance improved.

That provides much stronger evidence of an ongoing improvement process than simply documenting enrollment in a QCDR.

Improvement Doesn't Mean You Need a Perfect Score

Quality improvement does not mean every measure needs to reach 100%.

Suppose a practice begins with performance of 72%.

After reviewing its Registry Clearinghouse data, the practice identifies a documentation problem and changes its workflow.

A later report shows performance has increased to 84%.

The practice reviews the data again and identifies additional opportunities.

The important part is the process.

The physician is using objective information to evaluate the practice and determine whether changes are producing results.

Even when an intervention does not produce the expected improvement, the data can be useful. It tells the practice that it may need to investigate further or try a different approach.

More Than MIPS Reporting

This is where participation in Registry Clearinghouse can become more valuable than simply submitting data to CMS.

Podiatrists are already investing time and resources in MIPS.

Registry Clearinghouse can help turn that effort into information physicians can actually use.

Regularly updated data allows a Podiatrist to identify potential problems earlier, make changes while the performance year is still underway and monitor whether those changes are improving results.

At the same time, that process can help support participation in IA_PSPA_7 — Use of QCDR Data for Ongoing Practice Assessment and Improvements.

The Bottom Line

IA_PSPA_7 is not simply about belonging to a QCDR.

It is about using QCDR data as part of an ongoing process of evaluating and improving the practice.

Registry Clearinghouse receives updated data on a regular basis so participating Podiatrists can monitor their MIPS performance throughout the year.

That creates an opportunity to do something much more useful than simply calculate a score at the end of the year.

Review your performance. Identify an opportunity. Make a change. Review the updated data. Measure the improvement.

When used this way, Registry Clearinghouse can help transform MIPS from an annual reporting requirement into an ongoing tool for improving practice performance and patient care.