New York State Clinical Core Plus Tool

The Clinical Core Plus (CCP) tool will allow the New York State Practice Transformation Network (NYSPTN) to efficiently import and track Key Performance Indicators (KPIs) across our network in a streamlined manner. Data will be collected from providers for clinical KPIs and operational measures through this capture tool and will be the master source of data collection to track over 5,000 clinicians for the NYSPTN. CCP will receive data streams to track the 13 clinical metrics managed by the NYSPTN. Critical to this CCP is the ability to parse and display the KPI measures by the NYSPTN program. CCP will automatically populate the KPI data through CCDA integration services. This eliminates the need for providers to manually enter their KPI data. Once the KPIs are captured in the NYSPTN CCP and aggregated for numerator and denominator data, the CCP will present the KPI performance by provider and by practice for access by users. The KPI dashboard will display these performance metrics in the CCP Portal application for review by users. This tool will integrate with practice Electronic Health Records to enable real-time feeds of KPI information across the NYSPTN. The launch of CCP will alleviate the issue of missing practice information, and will fully capture the automated transformation progression of the NYSPTN. 

Features of CPP include:

  • Long established infrastructure
  • System dynamically adjusts
  • Provider list and management
  • TA assignment to providers
  • Milestone tracking plus color coordination
  • KPIs – clinical and non-clinical
  • Demographic tracking
  • TA progress tracking
  • Data aggregation
  • Analytics

KPI Measures

The TCPI Grant Contract includes a specific list of KPIs for the NYSPTN, as well as a list of national KPIs. The national KPIs will be announced by CMS and communicated to the Contractor accordingly.

The NYSPTN is currently using the following measures. Please note that KPIs are subject to change as CMS and/or the NYSPTN Leadership Team define KPIs for the TCPI program.

KPI Description
KPI 1: Increase in billing for wellness visits
KPI 2: Controlling high BP
KPI 3: Diabetes: A1C poor control
KPI 4: Clinician PQRS enrollment and reporting
KPI 5: Maintain or improve MU
KPI 6: Tobacco use screening and cessation intervention
KPI 7: 24/7 access policy documented
KPI 8: Potentially preventable ED Visit Reduction
KPI 9: Cost savings from Potentially Preventable ED visit reduction
KPI 10: Increase in billings for chronic care management (CCM) services
KPI 11: Increase in billing for transition care management (TCM) services
KPI 12: Cost savings from unplanned hospital readmission within 30 days
KPI 13: Reduction in unplanned hospital readmissions within 30 days