Report Standardization to
Improve PQRS Measure
Outcome
Travis Browning, MD
Kristen Bishop, MD
Richard Batz, MD
Julie Champine, MD
UT Southwestern Medical Center at Dallas
Disclosures
Travis Browning, MD
• None
Richard Batz, MD
• None
Julie Champine, MD
1
Objectives
• Different divisions
• Different hospital systems
2
The System
Included
3
Evaluation
• http://www.acr.org/~/media/ACR/Documents/P4P/Resources/2
014/Specs/Measure195_specs_2014.pdf
Reporting Template
4
Improved
system
template
Data
5
PDSA Cycles
Pre-change
PDSA Cycles
6
PDSA Cycles
Removing Duplicates
7
PDSA Cycles
PDSA Cycles
8
PQRS Measure #195 – Medicare Original Payor
400 100.00%
90.00%
350
80.00%
Number of Imaging Exams
300
70.00%
250
60.00%
200 50.00%
40.00%
150
30.00%
100
20.00%
50
10.00%
0 0.00%
Post Template Post Template
Prechange
Pre Coding System Change Post Coding System Change
PQRS Success 289 351 105
PQRS Failure 37 23 0
% PQRS Success 88.65% 93.85% 100.00%
% PQRS Failure 11.35% 6.15% 0.00%
350 100.00%
90.00%
300
80.00%
Number of Imaging Exams
250 70.00%
60.00%
200
50.00%
150
40.00%
100 30.00%
20.00%
50
10.00%
0 0.00%
Post Template Post Template
Prechange
Pre Coding System Change Post Coding System Change
PQRS Success 277 328 103
PQRS Failure 36 21 0
% PQRS Success 88.50% 93.98% 100.00%
% PQRS Failure 11.50% 6.02% 0.00%
9
PQRS Measure #195 – All Payors
450 100.00%
400 90.00%
80.00%
350
Number of Imaging Exams
70.00%
300
60.00%
250
50.00%
200
40.00%
150
30.00%
100
20.00%
50 10.00%
0 0.00%
Post Template Post Template
Prechange
Pre Coding System Change Post Coding System Change
PQRS Success 302 396 221
PQRS Failure 395 399 0
% PQRS Success 43.33% 49.81% 100.00%
% PQRS Failure 56.67% 50.19% 0.00%
Project Outcomes
10
Lessons Learned
11