Merry Medisolving featuring Randolph Health: How to Improve the Accuracy of Your eCQM Results

A quick glance at Randolph Health’s latest eCQM results might just stop you in your tracks. Since October 2024, the acute care hospital has taken its performance on the Venous Thromboembolism Prophylaxis eCQM (VTE-1) from 78.83% to 95.61%, while also boosting its rate on the Intensive Care Unit Venous Thromboembolism Prophylaxis eCQM (VTE-2), from 83.08% to 98.14%. You read that right: double-digit rate increases in under three months.

How exactly did they do it? The answer, it turns out, is that the quality of their stroke care—and by extension their VTE interventional care—was already there. They just weren’t capturing it correctly.

So, we asked Randolph Health’s quality and clinical informatics teams to walk us through how they’ve transformed their data collection and validation processes in order to deliver a more accurate reflection of their care.

The Interview

In the span of just a few months, you made significant leaps in your VTE eCQMs. How did that come about?

Tammy: We began our partnership with Medisolv in October 2024, and it was our Medisolv Clinical Quality Advisor, Karen McLaughlin, who looked at some of our VTE numbers and said, ‘You know, you’re doing so well on all these other measures. So, I don’t understand why you’re not meeting these two.’ She suspected that we were doing better than what our performance rates were showing. So, she worked one-on-one with us to really diagnose and correct the issue.

What were some of the issues that you uncovered? 

Chanda: A lot of it came down to mapping. We had some responses that users were selecting that were either not mapped or not mapped correctly. I think the biggest one we uncovered was that we had an option to say that the patient refused treatment, but we did not have it mapped as a refusal. So, it was translating into our performance rate as if we did not meet the requirements for those patients.

There were other parts of our mapping that were just outdated. Codes, for example, that needed to be updated and remapped. Having a dedicated person like Karen helping us stay up to date on all the little things is so important because we have 100 other things that we're trying to stay up to date with on any given day.

We also found that, for some of the questions, we didn’t have a good way for staff to answer them. There were some responses that were available to us through the measures’ specs that would allow our clinical staff to more clearly reflect what was happening, but that we didn't have built into our data capture.

In addition to mapping improvements, did you make any changes to your clinical workflows?

Chanda: Yes, I would say that, in general, being willing to look at all sides of the data capture process is key. Going back to our ‘patient refused treatment’ example, we also looked at the workflow and realized it was too buried within one assessment. So, we pulled it up to the surface, but then we also added it to another assessment as well, because staff weren't always opening the documentation for the VTE specific intervention. Sometimes, for example, our staff were wanting to document it while they were also documenting that they got the patient up to the bedside or the bathroom in our activities of daily living documentation.

Putting that query in more than one spot and in a spot that’s more convenient instead of us demanding, ‘You have to document this in this exact spot’ has made us capture what's happening more accurately.

So, it’s not just about getting the technical stuff right. It’s also about making data capture user-friendly for your clinicians, too.

Lisa: Absolutely. All of us on the quality and clinical informatics side have clinical backgrounds. We've all worked at the bedside before we transitioned to the jobs we have now. So, all of us have experience using our documentation system on the frontlines. And I think that’s made a difference as we moved into electronic documentation. We understood how important it was to have our clinical users—the ones who are actually using the system—involved in the process.

Chanda: There's lots of data that our team needs and we can't always figure out the best way to capture it on our own. So, we regularly meet with nursing when we have something new we need to capture. Because, yes, we could just stick it somewhere in the workflow, but what we really want is to make sure we put it in a place where they will be able to capture it meaningfully during the patient encounter. We want the data capture process to be more than ‘click a box to answer the question,’ because that leads to better data.

Tammy: Those conversations with our clinicians are also about us sharing the meaning behind the measure—the ‘why’ behind this new data capture request. A little education makes the end result much more successful.

Lisa: You can't be successful in any of this if you don't have engaged end users, whether it be physicians, nurses, respiratory therapists, whoever's touching the patient. It’s our job to give them the tools that they need to be successful. So, for us it’s really a triangle between clinicians, clinical informatics, and quality. Nothing moves forward if that triangle is not connected on all ends.

I really like the idea of a quality triangle! Tell us a bit more about how your two sides of that triangle, clinical informatics and quality, work together.

Chanda: We’ve developed a very healthy mutual understanding and appreciation of how one move in electronic documentation affects the other. So, we’ve made it a priority to make sure nothing is siloed between us. We make sure everybody who touches quality has a baseline understanding of how the components of their job may affect not only someone else’s job, but also the data feeds and reports our entire hospital relies on. There is constant communication between us.

What does that constant communication look like?

Chanda: Basically, if one of us knows there’s a change coming, even if we don't think that change is going to affect anyone else, we will, at a minimum, shoot an e-mail out to the group to say, ‘Hey, just a heads up. This policy is changing or that documentation is changing. Where else is it linked? What else might it affect?’ That has been a huge help in us working together to create better solutions.

We’ve talked a lot about improving data capture. What does your data validation process look like?

Jeff: It’s constant and it’s rigorous because it has to be. Any time we make changes to the data feed, we validate. We do positive test conditions and negative test conditions. If your details are not right, your summary won’t be right. And then your submissions and your decision-making processes will never be right.

Tammy: Jeff's favorite saying is trash in, trash out! He has been absolutely critical in ensuring that what we enter is actually what is pulled to our reports and our file feeds. He is the one who sits down with our team and truly validates every detail: looking at the measure specifications, comparing them to what we actually documented in the system, and making sure that it landed all the way through to the file feed as expected.

You’ve done such a good job of “cleaning up” your data, so to speak. What is the next goal for your data journey?

Chanda: We’ve realized that we can start to create a lot of efficiencies around what we’ve already mapped in order to measure even more things. Our Medisolv Clinical Quality Advisor, Karen, is really good at helping us identify new or untracked measures that have data elements we’re already capturing and that we’ve already mapped. She’ll say, ‘You know, you’re already capturing this and doing it well; it may be worth reporting on this other measure.’

It’s a huge help because we’re making the most of our data and saving a lot of time, too. I don’t have to worry about reading every single line of a specification and figuring out ‘Do we need to set this documentation up? Have we already mapped that?’ We can jump into the ‘performance and patient care improvement’ part of our new measures much faster.

Lisa: I think a good way to put it is that Karen and the Medisolv team help us capture the work that we do. They help us get credit for what we're already doing so that we can focus more strategically on what’s next.

About Randolph Health

Located in Asheboro, North Carolina, Randolph Health is a community healthcare system owned by American Healthcare Systems, LLC. The system includes a 145-bed acute care hospital, primary and specialty physician practices, home health services, a PACE facility and a freestanding MRI testing facility.