Chasm Between Cancer Quality Measures and Electronic Health Record Data Quality

PURPOSE The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires eligible clinicians to report clinical quality measures (CQMs) in the Merit-Based Incentive Payment System (MIPS) to maximize reimbursement. To determine whether structured data in electronic health records (EHRs) were adequate to report MIPS CQMs, EHR data aggregated by ASCO's CancerLinQ platform were analyzed. MATERIALS AND METHODS Using the CancerLinQ health technology platform, 19 Oncology MIPS (oMIPS) CQMs were evaluated to determine the presence of data elements (DEs) necessary to satisfy each CQM and the DE percent population with patient data (fill rates). At the time of this analysis, the CancerLinQ network comprised 63 active practices, representing eight different EHR vendors and containing records for more than 1.63 million unique patients with one or more malignant neoplasms (1.73 million cancer cases). RESULTS Fill rates for the 63 oMIPS-associated DEs varied widely among the practices. The average site had at least one filled DE for 52% of the DEs. Only 35% of the DEs were populated for at least one patient record in 95% of the practices. However, the average DE fill rate of all practices was 23%. No data were found at any practice for 22% of the DEs. Since any oMIPS CQM with an unpopulated DE component resulted in an inability to compute the measure, only two (10.5%) of the 19 oMIPS CQMs were computable for more than 1% of the patients. CONCLUSION Although EHR systems had relatively high DE fill rates for some DEs, underfilling and inconsistency of DEs in EHRs render automated oncology MIPS CQM calculations impractical.

Analyzing the impact of financial policies on construction projects performance using system dynamics

PurposeThe research aims to analyze the effects of financial policies on a cash flow system to meet project performance goals and improve profitability. The policies are divided into four groups; owner related, bank-related, labor-related and supplier-related policies. This research presents a developed model for planning, forecasting and managing the cash flow in construction projects using system dynamics (SD).Design/methodology/approachA System Dynamics (SD model is developed to evaluate the effect of different financial policies on construction project performance. By identifying the feedback loops in the cash flow system, a dynamic model is developed to forecast, plan and manage different policies, including prepayment, overbilling, loans, incentive payment, delay in payment and equipment lease.FindingsA case study (a construction activity as part of a pharmaceutical factory development project) is used to analyze the cash flow and financing policies. The findings demonstrate the effects of different policies such as incentive payments on project cash flow estimation, which proved to reduce the project duration, improve the profit and increase the financing during the project execution.Originality/valueThe presented model would be a major attempt to estimate precisely the cash flow and the effect of employing different financial policies on project performance. Applying this model, project managers and decision-makers have the opportunity to model different financial policies concerning a variety of limiting variables applicable to each situation. Ultimately, with this, one can make more reasoned decisions and, in effect, optimize the utility of the project.

The Merit-based Incentive Payment System: Pearson’s Chi-Square and Categorical Dependent Variable Models Analyzed for Domains—Effective Clinical Care and Efficiency/Cost Reduction

Background: Following the 2015 repeal of the Sustainable Growth Rate formula, the US Centers for Medicare & Medicaid Services’ formula under which physicians were reimbursed, two payment systems were put in place to incentivize physicians, one of which was the Merit-based Incentive Payment System (MIPS). MIPS emphasizes high-quality care that is accessible, affordable, and supports a healthier population. Objectives: This research aims to measure characteristics of MIPS relevant to National Quality Strategy (NQS) domains, quality measure types, and clinical specialties; categorize MIPS with NQS domains and quality measure types by MIPS specialty types; and quantify the relationship between MIPS specialties, measure types, and two NQS domains, Effective Clinical Care (ECC) and Efficiency/Cost Reduction (E/CR), for years 2017 through 2020. Methodology: The Pearson’s chi-square test examined distributions of the analyzed categorical variables. The Categorical Dependent Variable Method examined the association between the dependent and independent variables. Results: The Pearson’s chi-square test showed statistically significant distributions between ECC and E/CR when analyzed with the types of quality measures. There were more process measures (93.81% vs 89.64% [P=.000]) in 2018 versus 2017. This changed minutely with significantly less process measures (93.75% vs 93.81% [P=.000]) in 2019 versus 2018. Finally, measure types changed minutely but significantly with less process measures (93.81% vs 93.75% [P=.000]) in 2020 versus 2019. The regression model showed that ECC was significantly associated with outcome measures through all analyzed years of this research. Conclusion: The above findings show scope for including additional outcome measures, given its importance in MIPS. There is potential to increase the percentage allocation for reporting more outcome measures in quality. This re-allotment infers reporting more outcome measures aligning with priority outcome measures (PROMs). Re-allocating the incentive formula to report more outcome measures aligned with PROMs shows potential to increase reporting of more outcome measures under MIPS.

Recruitment, Enrollment, and Retention: Creative Techniques to Overcome Obstacles

The process of recruiting, enrolling, and retaining older adults in research studies has been challenging, even prior to the COVID-19 pandemic. This symposium presents research conducted and lessons learned on recruiting, enrolling, and retaining older adults, including those with cognitive impairment. Insights are provided on what techniques are most beneficial for improving rates of research participation, spanning time prior to and during the pandemic. The first presentation reports on qualitative perspectives of persons living with dementia and their caregivers as to what helped them decide to enroll into a clinical trial together. The second presentation speaks to how variations in incentive payment allocations played a role in consent decisions of patients with amnestic mild cognitive impairment and their study partners. The third presentation discusses the effectiveness of an adapted framework and strategies to increase the recruitment and retention of older Latinos with Alzheimer’s Disease and Related Dementias (ADRD) into a clinical trial. The fourth presentation shares techniques for recruiting older adults for a survey study during the pandemic. The fifth presentation defines challenges during a longitudinal study when the pandemic and other natural disasters occurred and strategies for success. Taken together, these presentations will inform researchers on techniques that could be used to improve recruitment, enrollment, and retention of older adults in clinical research.

The 4Ms of Age-Friendly Care: Successful Infusion into Electronic Medical Records Leads to Improved Care

Electronic Medical Records (EMR) and Health Information Technology (HIT) have changed the daily operations of the healthcare industry. For primary care systems/clinics, it has meant the purchase and tailoring of systems to fit specific needs of users and patients. As one of the HRSA funded Geriatric Workforce Enhancement recipients, the AR Geriatric Education Collaborative (AGEC) worked with a rural federally qualified healthcare clinic system for over a year to help them become IHI certified in Age-Friendly Care and the EMR has been a critical link. The system was crucial in identifying compliancy to the clinical Merit-based Incentive Payment System (MIPS) measures which helped identify the areas where most improvement was needed. Included in the process was a new geriatric screening tab in the EMR system. This tab contains 8 screenings including: depression, anxiety, alcohol use, prescription opioid use and recreational drug use, mentation, medication and mobility. This is in addition to asking “what matters” so that all four of the 4M’s age friendly framework components were included. Clinicians are successfully using the systems and improvements in outcomes are beginning to be noted. The outcome MIPS measures are obtained quarterly from an EMR report and data is shared with the staff and new quality improvement projects are developed using PDSA (plan, do, study, act) cycles based on the outcomes of the data. Next steps with the EMR will be the development of flags that will notify the clinicians when a screening is needed.

A Tale of Three Himalayan Towns: Would Payment for Ecosystem Services Make Drinking Water Supply Sustainable?

The Himalayas are the source of freshwater to about one-fourth of the world’s population. Paradoxically, water scarcity is one of the most prominent climate crises in the Himalayan region in general and its cities in particular. Rapid urbanization coupled with climate change is causing the rapid disappearance of natural springs resulting in water shortage in the urban areas. Governments are investing in new water supply projects to fulfil the demand of city residents as existing water sources are drying up. Solely focussed on establishing the physical infrastructure to supply water from source to users, and these drinking water projects have by and large failed to protect the water sources. These projects rely on the assumption of a fixed quantum and quality of the water source not taking into account the impacts of changes in climate and the activities of upstream communities on the ecosystem. For sustainability of the drinking water supply, it is necessary to have subsidiary plans that bring together the upstream water source communities (service providers), downstream communities (service users) and the local authority. Incentive paymentfor ecosystem services is a strategy to incentivize upstream non-user or low-user communities, whose role is critical in maintaining and improving the water supply and preserving the watershed area. This chapter highlights practical aspects of the design and implementation of incentive payment schemes drawing on research from three case studies from three small Himalayan towns in Nepal.