Hello, everyone. I am Kristen Young, a Clinical Quality Advisor for the NCDR Registries, and I'm joined by my fellow colleague today, Denise Pond, and she is also a Clinical Quality Advisor for the NCDR Registries. So we want to welcome you to Session 4, titled, A Conversation with the Experts. But in this session, our experts are our NCDR participants. So again, welcome to A Conversation with the Experts, A Participant's Perspective, where we have tapped into some pretty awesome NCDR participants from across the United States to share their perspective and expertise as it relates to all of you who are watching or joining us today. So without further ado, I'm going to begin this conversation with a very quick introduction of our expert panel, but friends, please share your props of where you're from, the state, whatever you want to say real shortly, just to show your representation. So first on the list, we have Tammy Enriquez. Hi. I work out at BayCare Health Systems in the Tampa Bay area, and I work on AFib, specifically for the registry. Happy to be here. Wonderful. Next on the list is Selina Yedla. Hi. I'm Selina Yedla. I'm the NCDR coordinator at University of Maryland, Baltimore, Washington Medical System, and I'm from Maryland. Nice to be here. Wonderful. Thank you. Marina Moore. Hi. I'm Marina Moore. Hi. I'm from Farmington, Missouri, and I represent Mercy Health Systems across the United States, and I'm very glad to be here, too. Thanks for inviting us. Thank you. Next, we have LaShawn Betzel. Hi. My name is LaShawn Betzel, and I represent South Georgia Medical Center. I'm a quality improvement specialist, and I'm originally from Tampa, Florida. Welcome. And Victoria Harrow. Hi. I'm Vicki Harrow. I work with the University of California, San Francisco, and the Pediatric Heart Center in Mission Bay. I'm the impact registry coordinator. Thank you so much for having me. Thank you. And Sarah Jade Berta. I'm from the Pocono Mountains in Pennsylvania. I am representing Q-Centrix as a third-party vendor tool, and I'm so glad that you asked me to be here today. Wonderful. Thank you. And finally, Lisa Detling. Hi. I'm Lisa Detling, and I'm from Vancouver, Washington, and I'm representing PeaceHealth, and I'm an RN clinical data abstractor, and I work on the TBT registry for TAVR and MitraPlex. Wonderful. And just want to extend, again, another thank you for you guys taking the time out of your already busy schedules to come and join us today for the Quality Summit. We're super excited to have you here today. So we kind of want to dive into some really good questions that have come up, whether it's through what participants have sent in or things that we observe as CQAs that you can probably help us in regards to guiding our participants who are watching here today. So first thing off the top of my head is regarding physician engagement. So at times, whenever we're clinical quality advisors and we get questions from our participant sites, they can really copy and paste an entire medical record into the question, but we really can't give advice sometimes because we're just missing certain pieces of documentation in the medical record, and that is needed, of course, to have consistent and meaningful data. So who here on this panel today, just by a show of hands, has ever experienced a lack of appropriate documentation or needed documentation to code things or abstract things? All right. So a unanimous, but you know this is just something that our participants, you know, you guys are our participants, and it's just a challenge. So since all of you rose your hand, I am going to open up the floor to really share with us, especially during times of innovation, what kind of ways did you come up to get your physicians more engaged and to kind of put that documentation into the medical record? Who would like to go first? I'll go first on that question. It's one of the things that BayCare has done here is they've attached the monetary consequences to some of the physicians for measure fails. So if they don't meet the measures, it kind of hits them in the pocketbook sometimes. So that certainly gets a little more participation, and I think people pay more attention to the registries. They don't do it on all of them, but the ones that they do it on, I think it is effective. Yeah, definitely hitting them where it hurts, that would probably be in the pockets, right? How about anybody else? Does anybody else have any other ideas that you could share with our participants and how to engage your physicians more? Or if there's missing documentation, how do you get it? We actually incorporated a new form and template into one of our registries. It was an upgraded version of the registry, and we wanted to make sure and capture one of the new measures. So we actually created an updated version of a previous tool and form, and we dispersed it to the physicians that are affected. And that way we don't miss the measures and we capture them correctly. Well, thank you for sharing that. Thank you for sharing that. We talk to participants every day about their data, and they're always curious about what other participants are doing. And it sounds like that you adapted a form for the new version 2.3 of the EP device and plant registry, which is a great idea. And we just want to know, what do you do with those data results at your facilities? Anybody want to share on that? Sure, I can. At our facilities, we typically have two meetings that we share that information from. One is the STEMI committee meeting, and it is monthly. And the second meeting is at the cardiovascular department head meeting, and that is quarterly. So both of those teams are multidisciplinary teams. And then the cardiovascular department meeting also has senior leadership and all of the physicians that are employed by the facility. And then we also take that information to the board yearly. So, Marina, you bring up a very valid point, and it really is what we try to tell our participants, and that you shouldn't be just looking at your data alone. This isn't kind of like a solo process. It really is a collaborative piece. And not only sharing it with your leaders, but also there's value in sharing it with your stakeholders as you're doing in your hospital, because, again, it's what I said in the last session, for those of you who may have watched, you know, you can't measure what you're not looking at. And whenever you're looking at the data, you really need to get it under the eyes of other stakeholders to improve or invoke change at your facility. So that's wonderful to hear, Marina. Does anybody else have any other feedback in regards to what you do with your data? We do similar things. I must say, over the past year or so, we've really ramped up with what we've been doing and some education and different reports we send to our director. And then, of course, she passes that on upward in her meetings as well. So it really gets a lot of things out there and on the table for the different registries. So that's good. So let's say that we were talking to somebody who is completely new to the data abstraction process in regards to what you do with your data. What would you tell them kind of like broad steps to follow? How did you figure out who needs to see your data? Was it just your boss or your leader, rather, telling you who needs to be involved? Or did you do cold calls and say, hey, you might be interested in this? What would you tell a new person to kind of start with sharing data? Anybody have any feedback on that? This is Lisa, and I'm fairly new to the registry. I will say that what I did was not only did I talk to my manager to find out kind of that, but I also talked to the TAVR coordinator to find out who are the leads for the medical directors so that I could find out who needed the information. And we have one hospital in particular that is really good about on a monthly basis our dashboards are being seen, and so is the data. Like I said, on our quarterly meetings, and they go over it, and they try to find areas that they can improve upon. And just by a show of hands, do you guys have any physicians or stakeholders that you've assigned privileges to look at the dashboard themselves? Is that an avenue that you explore? Lisa, you do? Marina? Oh, Tammy. Oh, quite a few do. That's pretty awesome. Because sometimes our participants think that it's only for those who are entering data, you know, into the registries. But, you know, it can be shared with anybody that the RSM assigns dashboard privileges to. So that's really good to know and to share that you guys are all doing that at your facility. And quite impressive. So let's go back to – I want to – was it LaShawn? LaShawn, you talked about using the smart – I know, I'm picking on you. You used smart phrases and the forms. I think that that was you that mentioned that. Okay. So, again, let's talk about how you incorporate that. Now, you say you send it to your physicians, but do you also incorporate it into your medical record? And if you do – well, answer that first. We do. We actually had Epic participate in creating a form, our actual tool that can be downloaded by that physician into the medical records anywhere. And then they can also scan in the hard copy. So it actually encourages them to participate. Both ways. Okay, so I think I heard you say you can scan it into the medical record, but it is also available as a template in the EHR. Yes. Is that what you said? Okay. It is. So wonderful with scanning it in. How did you get it? And what were the steps you took to get a smart phrase or a template incorporated into your medical record that you could share with our folks watching? We just initially went through when the new version came out and went through the Q2 learning educational tools that are available and wrote down any new metrics that might be changing and incorporated that into the tool. And then we introduced it to our champion physician who helps us and guides us on what metrics are more important and what metrics we often miss. And then we created the form, the template, and just upgraded it from the previous form and introduced it to our physician champion for cardiovascular. Very wonderful. That sounds really, really like a great process that you have. And from listening to all of you speaking, it sounds like you use a multidisciplinary approach. Can anybody speak to that and tell us what process you use and how you developed that approach? I can take that. In spite of growing evidence and the benefits of cardiac rehab services that are associated with reduction in the mortality and reducing the cardiovascular risk factors, we had barriers in providing this consistency of referring patients to cardiac rehab services. And so we actually had a team approach and we advocated for a multidisciplinary team, as Marina has mentioned earlier, in bringing our interventional cardiologists, our cardiologists, our ED team, our nurse practitioners, blood flow team, our pharmacists, EMS, and other leadership team on a regular monthly basis. And we allowed us to review our data and to set goals for improvement and to implement best practices. You know, there's no substitute at all for being together in one room, working together on one specific problems and, you know, break down the barriers. That really seemed to have helped us with a lot of our communication problems. Initially, our providers were actually giving a handwritten prescription to our patients, but that didn't really get them anywhere. So then we changed our cardiac rehab referral process. We standardized the process by creating an electronic referral for appropriate patients. So we used Epic to automate the referrals, which included in the order set and the discharge checklist. And we also had a best practice pop-up alert for the provider. You know, it's a clinical impression triggered when a diagnosis was entered. So if they missed it, you know, then they would see the pop-up alert and then enter the referral. We thought that seemed to help with our improvement in our referral process. But then we realized that our patients that were actually getting the benefit was not too many. And so then we actually involved our performance improvement team to see what was happening. And they found out that the Epic referrals were not getting transmitted to our cardiac rehab department and they fixed it. And that really seemed to have helped. And I, on a monthly basis, make a patient list of all the patients that are coming through the hospital with a STEMI or had a cardiac event. And I send that patient list monthly to the cardiac rehab department. And the director and the team would actually compare to see if they had all the patients that they've received referrals on the list. And in our monthly meetings, we would actually, I would put up a real-time data dashboard using our NCDR criteria to meet our CAF-PCI registry metrics. And the cardiac rehab department director would put a dashboard of all the number of patients that were enrolled and attended each month. So this process really helped us to optimize our patients' health outcomes and improve our benchmarks. Thank you for sharing. I just want to kind of quiz you guys because it sounds like everybody's doing meetings. And I heard monthly and quarterly. But how often are you, everybody, if you are meeting, just tell us a little bit about how often you're meeting. Is it a monthly, quarterly? What is it? We actually have ‑‑ I'm sorry. Go ahead. That's fine. Okay. Start over. We have a weekly cardiac call with our physician champion. And it's really evolved over the last couple of years into where we're actually able to go facility by facility in each registry and bring up our questions and issues. And if we have fallouts that aren't being addressed, and there's people on that call that can reach out to the facilities for us. And that's, like I say, it's been a process that's evolved from something that wasn't really helpful in the beginning for some of the registries to a very useful call. And managers, directors come on to the call. And it's a weekly. And very helpful. So you say call. Is it just a phone call? Or are you guys using WebEx? Tell us about the time of COVID. It's on Teams. It's on Microsoft Teams now. Okay. It used to be a call. So I always refer to it as a call. That's okay. I just want to be clear. Tammy, you mentioned multidisciplinary. Who do you include? Who do you include on those calls that make your meetings meaningful? We have the director of cardiology. We have the physician champion. He wears a lot of hats. Okay. Dr. Men. And people will come on and off. Not everybody's there every single call. But for the most part, if you need to reach out directly to the EP manager, they're usually on the call. A lot of times the directors will show up on the calls. All the abstractors are there. As well as our direct managers in our department are usually there. So. Which is very helpful. Because a lot of times, you know, these are the people you're having trouble getting a hold of. Well, you know, once a week, you can usually talk to them pretty much directly. And problems get solved pretty quickly that way. Okay. Does anybody. Go ahead, Selina. Sorry. Before the pandemic, we actually decided that we would meet in a conference room. So we're like face-to-face with each other. We also include our pharmacists. Especially our EMS team to see what barriers we have. And also, you know, if there are any questions that we can help you with. So. So! Couple more written notes. Yeah, we had sit down. Like at 6 or 7. We started with the third day, you know, with my solarPlex systems if you remember that? We sat down and we sat down for a couple minutes to talk about whatever we were hearing as well. And then we would meet at our basic meetings as well. But during the pandemic, we are mostly doing via WebEx. I love that you're including EMS though. So that's a good innovative way because you really want to include folks that are all involved in the care. You know, certain registries measure certain things. So it just depends on what registry you're in. Does anybody else want to share their multidisciplinary approach? We found it helpful for our cardiovascular quality meeting that we have once a month to include our physician champion prior to the meeting so that he can help us narrow down which metrics are more important at that time. Maybe the outliers that are coming up, the patients that are falling out, different metrics that we need to emphasize rather than taking the whole thing on at once can be overwhelming for the physicians as well when you present your data. So we find it's helpful to narrow down to the most important measures and then come back to the actual meeting, present our data and then make recommendations from that point. Then we disperse our recommendations out to the individual groups such as EMS, the hospitalist group, the mid-levels if they're involved and make further recommendations from that point. So LaShawn, before we move on, because I saw Sarah Jade and both Vicki have something to add, but I wanted to, and I just lost my question. So I'm not going to clarify it right now, but it'll pop back up in my head. Let's move on to Sarah Jade. I saw you wanted to share something. As a third party vendor that works with hospitals across the country, I've seen a little bit of everything that's already been discussed on this video. We see, we meet usually with our clients once a week to bi-weekly to monthly, and it all depends on who is involved in those phone calls. Nine times out of 10, it's mostly the quality people or the people from the cath lab or the TAVR programs that are all involved. There are some facilities that will get their physicians in on our calls from the third party vendor system into their calls. So sometimes we are actually able to voice what we need from those physicians to be able to abstract their charts appropriately. It's not always the easiest for us as the third party coming in and trying to do for multiple different facilities or multiple different places across the country. It's always a little bit different, but we always do meet with our quality people and our client contacts at least once a month, if not more frequent. And Sarah Jade, you bring a good perspective being from a third party vendor, Q-Centrics. So thank you for that. And Vicki, I saw that you wanted to add one more thing. I do, thank you. I just wanted to say between the registries and our data team, we have STS, PC4 for pediatric critical care and then PAC3. So we meet twice a week and we review the patients that are coming through the cath lab and then being admitted and then may go on to have surgeries. So we're really ensuring that we have consistency and quality across our data team for the data entry. And then beyond that, when we're working with the physicians in our quality meetings and such, and we're utilizing that data, we know it's good consistent data between our team. That is very interesting information to have from all of you and I'm sure the participants really appreciate hearing about how you use multidisciplinary teams and who's included in those teams. But I do wanna go back to Sarah Jade. We do hear that there are many facilities that are moving to third-party vendors and I'm sure it's very challenging. And so would you like to share some of those challenges with us from a third-party vendor doing data abstraction? Some of our major difficulties that we have as a third party is the physician engagement is probably one of the biggest ones in getting the physicians to document what we need them to document in order to be able to abstract the records according to the definitions. That makes it a little difficult at times. And then even sometimes getting your buy-in from your contacts at the facility. We can give you all your data, we can run your fallouts, we can run your dashboards, we can run everything. But if you don't get us what we need to be able to abstract appropriately, your data is only as good as what you give us. And making sure that that stuff is there for us to be able to assist you and make you look as good as the quality care that you are truly giving your patients, it needs to be documented. So I think documentation and getting people to get you what you need, or how LaShawn had said earlier about getting forms into the medical record. I can't tell you how many times I've gone to client contacts and said, it would be easier for us for abstraction and better for your data if you could make these forms or you could get this put into your, if you could template your HNPs or template some of these things, then we can abstract a lot easier and not have to try to decipher what did that physician mean? Or what did that person mean by that statement? So I think those are some of the biggest difficulties that we have as a third party. Have any of your facilities taken your advice and developed any tools that would help you obtain that information? Because it sounds like from what you've said, the physicians are. We have, we've had one of our facilities for AFib was very big with, they were a brand new program. And as we were working through it, we got the physicians to template their HNPs to include your CHAD masks, to include your HasBloods, to include previous attempts and cardioversions and different medications. And we've gotten one facility with maybe two physicians that do it consistently. The other facilities, it's still a work in progress. That's a good idea. It's challenging, isn't it? When you don't have direct contact with those physicians? Very, very difficult. So we actually identified that. And what we did was we have a physician champion, especially I do the CAP-PCR registry for the STEMI and NSTEMI. So I have a physician champion for STEMI and I have a physician champion for NSTEMI. So if I needed any documentation, and I'm not hearing from the other physician, even after communicating, then I would reach out to the physician champion. And it is his responsibility to take care of it, usually by the end of the month, before I try to give them as much as real time patients. So that way they are like, contacting the physicians to add in that addendum note in the patient's chart. And so that really seemed to be helping out with our facility. We do the same thing at UCSF. We also have physician champions and they're so helpful, so engaged. And it really helps to streamline the process and keep the data current. I really appreciate all of them so much. They're a huge help. One of the things we've done recently at our facility, they also have checklists. For ICD, they've just created one that everyone says is working very nicely. But one of the things they did is, and the expert in the actual cath lab, they will document the NYHA classification, because that's a biggie for all the registries that they do not want to document that for some reason. And so now they just, right there in the cath lab, they go, what's the class? They document it. An expert, it's signed, we use it. And it's, the first time I ever saw it, I was so happy. They also do the cardiomyopathy type, because that's another one that they don't always include. So doing it that way, and right there in the cath lab, in the log, and we put an abstract, and it's right there. We have to get the other facilities on board, but there's one that's really doing well with it. So we're hoping to expand that. And then the other thing too, is we have champion nurses in our cath lab. So I work closely with a nurse champion in our cath lab at Mission Bay. And there's a nurse champion at our cath lab at Children's in Oakland. And communicate with them regularly about any questions or details, and then the physician champions of each campus. We also try and incorporate- Lorena, I saw that you. I'm sorry. Go ahead, LaShawna. We also try and incorporate the mid-level providers, if your facility has that. Because a lot of times, if your physicians are busy, mid-level providers are more accessible, and they're able to answer our questions just as well. That's a great point, to utilize your nurse practitioners, your physician's assistants, those other licensed practitioners who can provide the information. Marina, I noticed that you had wanted to say something. Oh, I was just writing that down, what Tammy had said about the NYHA documentation in the cath lab. That is a piece that our facilities sometimes miss. So that might be a good opportunity. I've learned something already. Yay, good job. Wonderful. So I think that there's a good takeaway here, is that one, you already know the data elements that you have trouble with. But the reason why you know that is because it probably has some type of performance in your metric, right? It probably plays a key role that if you don't have that abstracted, then you don't see what you want to see in your metrics. So LaShawn, I'm coming back to you because I forgot my question, and now I remember it. But you had mentioned, oh my gosh, did I just forget it again? No, I did it. Oh, yes. You mentioned about improving only certain metrics. So how do you determine which metrics are important at your facility? Because you're not looking at all of them. You may be, but which ones are you really focused on and how do you make that determination? The Physician Champion sits down with us personally one-on-one prior to the meeting and looks at the most important things where we're missing the mark and how we can improve patient care and the outcomes in our overall facility. And so we may start with just a few of them. And then as those go on to improve and recommendations are made, then we reassess at the next meeting and maybe look at other measures. A good example is on our new ICD form for B2.3, for the EP device implants. One of the new measures that they're looking at is the shared decision-making tool. And we were finding that we were not capturing that. So we incorporated that into our new tool and then we reviewed it at our quality meeting. Very nice. Anybody else have a process that they use to determine which metrics are important or who makes that decision? So- I will say, sorry, go ahead. I was just gonna add on that. We also noticed that we knew shared decision-making was occurring, but we didn't really have the documentation. And we actually just met with some of our electronic health record analysts so that we could find out how we might be able to get a smart text or phrase into the record. And so they are now going to take that information and go to our physicians and talk to them about what they want in there and how it can be written so that it could be used system-wide. So we've just started that process. Very cool. Marina, were you gonna say something? I was. Sometimes there are other programs that your hospital participates in. I don't know if I can say names, but that you have contracts with that provide some monetary support. And they have certain measures that they will pull in. If you meet these guidelines, then you get extra points for those. Got it. Okay, so yours is a big decision. So you're using metrics for pay for performance, basically. That's the word, yes. Yeah, okay. Thank you. All right, okay. In the past several years, we've had multiple registries either have a minor or major update. What have you guys done to prepare for those version updates? We use the reference tools that are available for the registry itself, the Q2 learning videos and educational materials that emphasize the changes from one version to the next. We also use the outcome report companion guide. That seems to be very helpful to us if applicable to your facility. And then we're able to apply that to the new registry. And we also use a review that updated FAQs as they come out. We also use the upgrades to the system are usually talked about on the RSM calls that you all provide for us. So I'll take those specific slides that NCDR has created and share with our local facilities, local contacts, and they will help educate physicians. And I try to present at least one case studies that we have in the NCDR call and present that in our monthly cardiac collaborative meetings. And that seems to be helping the physicians to understand how we're looking at each data element. As the third party vendor that's outside of the hospitals and we are responsible for hundreds of facilities across the country, we have hundreds of abstractors that work for us. What we do when the version changes are coming is our quality department is extremely involved in creating mind flashes and educational materials that have to go out to each one of the abstractors and they all get tested on it. And you have to pass the quality test for the new versions. So we can be assured that across our company and across all of the companies and hospitals that we abstract for, that we are all abstracting the same way and that it's not this person's interpretation on this one and this person's interpretation at that facility that we have everybody's on the same page. So that's what we do as that third party vendor that with the big upgrades. So clarify for me, Sarah Jade, what is it you said flash, mind flash? Mind flash. It's a platform that allows you to create educational slides and then a test that goes along with it. And you have to hit that 80% on the post test. Oh, kind of like a pre-test and then education and then you take the post-test like a- No, it's the education. It's an education and then a post-test. So any of the changes that are coming, we're giving them all of their education. This is what's changing. This is what's changing. These are big changes. These are just little changes. And then they all get tested on it. And even as a team lead who leads them all, we are also responsible for taking those same exams with any of the new version upgrades. So we can all be on the same page as a company. Very cool. That's quite impressive. Yeah. Does anybody else, we're running probably almost short on time, but these were great questions and answers. But does anybody else have anything to share regarding what they do to prepare for version upgrades? I think we've kind of covered the basis and I'm so excited that we're using our videos and our resources. All right. Well, I think that we're out of time in regards to answering any more questions. So I just wanted to close out this session with saying what a great ending to not only session four, but our pre-conference. So thank you each and every one of you for taking the time out of your busy schedules. We know you're busy out there to join us, but to really provide insight to those who are watching who are either have already been in your shoes or are just new and are just beginning to follow in your footsteps. I'm gonna turn the mic over to Denise. Denise, do you have anything to add? Yes. I just want to thank our panelists. They were awesome. I really learned some things today from your perspective and I really appreciate how you use our tools. You use the quality improvement institution videos and you develop your own educational materials so that you're abstracting data accurately. And that means a world to us. And we know all the other participants that are listening work just as hard as you all do. And so we just want to thank you for the awesome job that you do. Thank you.

physician engagement

documentation challenges

data sharing

NCDR registries

multidisciplinary collaboration

improving patient care

electronic health record system

abstraction processes