Data Element Guideline Review

1
Data Element Guideline Review

• Frequently Mismatched Data Elements
• Jan 17, 2008

This material was prepared by Masspro, the
Medicare Quality Improvement Organization for
Massachusetts, under contract with the Centers
for Medicare Medicaid Services (CMS), an agency
of the U.S. Department of Health and Human
Services. The contents presented do not
necessarily represent CMS policy.
8sow-ma-hosp-08-01 DataElemGuideReview_PPT-jan
2
Validation Purpose and Process

• Purpose to assure accuracy and integrity of
  publicly reported data
• Random sample of 5 charts per quarter for all
  hospitals with a minimum of 6 discharges in the
  Warehouse
• Selected from all cases submitted not topic
  specific
• Reabstracted by CDAC abstractors
• Percent agreement at the element level is
  calculated
• Hospital must meet or exceed 80 agreement to be
  considered valid
• Hospitals receive educational feedback via
• Validation Detail Report
• Appeal opportunity is provided if the overall
  score for the quarter is lt 80

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Validation Abstraction Resources

• Specifications Manual - Information relating to
  specific measures and abstraction instructions
• www.qualitynet.org gt Hospitals gt Specification
  Manual
• Manual subject to biannual updates as data is
  reviewed and issues are identified
• Select the version pertaining to the correct time
  frame
• QUEST Quality Net home page

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Validation Tips

• Know the measures
• Know the data elements
• Know the allowable documentation sources and
  priorities
• Consider these when designing your forms
• Data can be updated and resubmitted until the
  data transmission deadline each quarter

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Congratulations! FY 2008 APU (Q1-3 06)
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Validation

• Zero Numerator Cases
• Record Not Received
• Invalid Record Sent
• Incorrect Date(s) of Service

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Validation

• Parent Element Mismatches
• Chest X-Ray PN
• Transfer from Another ED AMI / PN
• PN Diagnosis ED / Direct Admit PN
• Comfort Measures Only AMI / HF / PN
• Blood Cultures Prior to Arrival PN
• Infection Prior to Anesthesia SCIP
• Adult Smoking Counseling AMI / HF / PN
• Contraindication to both ACE / ARB at DC
  AMI / HF
• Surgery Start Date SCIP
• Healthcare Associated PN PN

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AMI

• Contraindication to ASA on Arrival

Irrespective of whether or not the patient
received or will receive Aspirin
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AMI

• Contraindication to ASA on Arrival

• Search entire record
• One positive finding trumps all negative findings
• Appendix C Table 1.1 list of Aspirin products
• Appendix C Table 1.4 list of Warfarin products

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AMI

• Contraindication to ASA on Arrival
• Allergy
• Pre-arrival Coumadin / Warfarin
• Include home meds
• Include on temporary hold
• Include noncompliant patients
• Do not include given in ambulance

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AMI

• Contraindication to ASA on Arrival
• Documented reason for not giving ASA
• ANY documentation anywhere in the record by any
  MD,NP or PA indicating the practitioner does not
  want aspirin therapy for this patient.
• Include crossed out pre-printed medication order
• Include No aspirin
• Include D/C aspirin
• Include Hold aspirin
• Include Intolerant of aspirin
• Include Problems with aspirin in the past
• NOTE the common element mention of aspirin.

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AMI

• Contraindication to ASA on Arrival
• Pre-arrival conditions
• Any reference in current record or transfer
  record to
• Allergy
• Aspirin is linked to a specific problem
• Aspirin Is linked to intolerance
• Hold Aspirin must be linked to the reason why
• D/C Aspirin must be linked to the reason why

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AMI

• Contraindication to ASA at Discharge

Irrespective of whether or not the patient
received or will receive Aspirin
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AMI

• Contraindication to ASA at Discharge

• Search entire record
• One positive finding trumps all negative findings
• Appendix C Table 1.1 list of Aspirin products

15
AMI

• Contraindication to ASA at Discharge
• Allergy
• Coumadin / Warfarin prescribed at discharge
• Appendix C Table 1.4 list of Warfarin products

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AMI

• Contraindication to ASA at Discharge
• Documented reason for not giving ASA
• ANY documentation anywhere in the record by any
  MD,NP or PA indicating the practitioner does not
  want aspirin therapy for this patient.
• Include crossed out pre-printed medication order
• Include No aspirin
• Include D/C aspirin
• Include Hold aspirin
• Include Intolerant of aspirin
• Include Problems with aspirin in the past
• NOTE the common element mention of aspirin.

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AMI

• Contraindication to ASA at Discharge
• Documentation of a plan to delay aspirin therapy
  at discharge must be linked to the reason why in
  order to select Yes to contraindication.
• Begin aspirin after first clinic visit No
• Begin aspirin after first clinic visit if
  hematuria subsides Yes
• Will start aspirin at follow up visit No
• Will restart aspirin when patient can tolerate
  Yes

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AMI

• Contraindication to ASA at Discharge
• Pre-arrival conditions
• Any reference in current record or transfer
  record to
• Allergy
• Aspirin is linked to a specific problem
• Aspirin Is linked to intolerance
• Hold Aspirin must be linked to the reason why
• D/C Aspirin must be linked to the reason why

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AMI

• Contraindication to B-Blockers
• on Arrival
• Irrespective of whether or not the patient has
  received or will receive a Beta Blocker
• Appendix C Table 1.3

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AMI

• Contraindication to B-Blockers
• on Arrival
• Allergy
• HR lt 60 off Beta Blockers
• Heart Failure
• Shock
• Heart Block 2nd or 3rd Degree
• Other reason documented by practitioner

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AMI

• Contraindication to B-Blockers
• on Arrival
• Allergy
• HR lt 60
• Pt has not received a Beta Blocker prior to the
  recorded HR lt 60
• Check home med list
• Check ambulance record
• Reference to bradycardia is not enough
• Must be numeric

22
AMI

• Contraindication to B-Blockers
• on Arrival
• Heart Failure
• Dont use CXR report
• MD/NP/PA reference CXR report is okay
• Admitting or differential diagnosis
• Any MD/NP/PA reference to HF within 24 hours of
  arrival

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AMI

• Contraindication to B-Blockers
• on Arrival
• Shock
• Heart Block
• 2nd or 3rd degree
• As of 10.1.07 discharges the HB no longer needs
  to be linked to an ECG
• any reference to 2nd or 3rd degree heart block
  within 24 hours after arrival that does not also
  mention a functioning pacemaker select Yes.

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AMI

• Contraindication to Beta Blocker
• on Arrival
• Documented reason for not giving Beta Blocker
• ANY documentation anywhere in the record by any
  MD,NP or PA indicating the practitioner does not
  want Beta Blocker therapy for this patient.
• Include crossed out pre-printed medication order
• Include No beta blocker
• Include D/C beta blocker
• Include Hold beta blocker
• Include Intolerant of beta blocker
• Include Problems with beta blocker in the past
• NOTE the common element mention of Beta
  Blocker.

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AMI

• Contraindication to B-Blockers
• at Discharge
• Irrespective of whether or not the patient has
  received or will receive a Beta Blocker
• Appendix C Table 1.3

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AMI

• Contraindication to B-Blockers
• at Discharge
• Allergy
• HR lt 60 off Beta Blockers
• Heart Block 2nd or 3rd Degree
• Other reason documented by practitioner

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AMI

• Contraindication to B-Blockers
• at Discharge
• Allergy
• HR lt 60
• Reference to bradycardia is not enough
• Must be numeric
• Pt is not on a Beta Blocker

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AMI

• Contraindication to B-Blockers
• at Discharge
• Heart Block
• 2nd or 3rd degree
• As of 10.1.07 discharges the HB no longer needs
  to be linked to an ECG
• any reference to 2nd or 3rd degree heart block
  anytime from arrival through discharge that does
  not also mention a functioning pacemaker select
  Yes.

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AMI

• Contraindication to Beta Blocker
• at Discharge
• Documented reason for not giving Beta Blocker
• ANY documentation anywhere in the record by any
  MD,NP or PA indicating the practitioner does not
  want Beta Blocker therapy for this patient.
• Include crossed out pre-printed medication order
• Include No beta blocker
• Include D/C beta blocker
• Include Hold beta blocker
• Include Intolerant of beta blocker
• Include Problems with beta blocker in the past
• NOTE the common element mention of Beta
  Blocker.

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AMI HF

• Contraindication to
• Both ACE I ARB at Discharge
• Irrespective of whether or not the patient has
  received or will receive a Beta Blocker
• ACE I - Appendix C Table 1.2
• ARB - Appendix C Table 1.7

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AMI HF

• Contraindication to
• Both ACE I ARB at Discharge
• Allergies to both drug classes
• Mod or Severe Aortic Stenosis
• MD/NP/PA documentation of intent to withhold ACE
  I and ARB therapies at discharge

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AMI HF

• Contraindication to
• Both ACE I ARB at Discharge
• MD/NP/PA documentation of intent to withhold ACE
  I and ARB therapies at discharge
• ANY documentation anywhere in the record by any
  MD,NP or PA indicating the practitioner does not
  want either ACE I or ARB therapy for this
  patient.
• Include crossed out pre-printed medication order
• Include No (ACE I)(ARB)
• Include D/C (ACE I)(ARB)
• Include Hold (ACE I)(ARB)
• Include Intolerant of (ACE I)(ARB)
• Include Problems with (ACE I)(ARB) in the past
• NOTE the common element mention of ACE I and
  mention of ARB.

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AMI HF

• Contraindication to
• Both ACE I ARB at Discharge
• MD/NP/PA documentation of intent to withhold ACE
  I or ARB therapies due to one of the following
• Angioedema
• Hyperkalemia
• Hypotension
• Renal Artery Stenosis
• Renal disease, dysfunction or worsening renal
  function
• MD/NP/PA documentation of intent to withhold ACE
  I therapy at discharge and an ARB allergy
• MD/NP/PA documentation of intent to withhold ARB
  therapy at discharge and an ACE I allergy

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Table of Inclusions for Contraindications
Masspro
 
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HF

• Discharge Instructions
• 14 of all mismatches last year
• 35 of D/C Instruction mismatches R/T Meds
• 21 of D/C Instruction mismatches R/T Symptoms
• Is it time to remove med lists from discharge
  summaries?
• At least one discharge med list must be signed by
  an MD/NP/PA
• Simplify Provide the same elements of
  instruction to ALL patients at discharge.

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All

• Admission Source Through 9/30/07 discharges
• If SEEN in ED
• the admission source is ED.
• Point of Origin Beginning with 10/1/07 discharges
• Admission source is Emergency Room ONLY if the
  patient comes in from home or presents to the ED
  of their own accord.

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All

• Point of Origin Beginning with 10/1/07 discharges
• Value 1 Non-healthcare facility
• Value 2 Clinic must be referred to as a clinic
  or as urgent care.
• Value 4 Transfer from a hospital (different
  facility) inpatient or outpatient including
  another ED.
• Value 6 Another Healthcare facility not defined
  elsewhere in this code list Assisted Living.

38
All

• Discharge Status
• Home vs VNA
• Look for evidence that the doc is setting up VNA
  (progress note, D/C orders)
• SNF vs NH
• You must see reference to nursing care or skilled
  care.
• Same facility, referred to as SNF on admission,
  referred to as NH on discharge. Discharge status
  is NH.

39
PN

• Antibiotic dosing
• Abstraction
• Note the name (may be UNK), route, date and time
  for each antibiotic administered in the first 36
  hours after arrival.
• Enter data relating to the First administration
  of each Antibiotic/Route
• 1/2/08 130 pm UNK IV
• 1/2/08 130 pm - Zithromax IV
• 1/3/08 800 am - Zithromax PO
• Beginning with 10/01/2007 discharges

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PN

• Antibiotic dosing
• Reference to antibiotic dose given must be signed
  (unless found on ER documentation).
• No name mentioned select NOS
• Name is illegible select NOS
• Name is not on Table 2.1 select NOS
• Use one source for the data
• Name must be on the same line, cannot be
  referenced from the doctors order
• Date may be on same line as the antibiotic
  administration documentation or the same page
• Time and route must be on the same line

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PN

• Abstraction
• ED note
• Top of page dated 1/3/08
• Note entry reads 1220 antibiotic given
• RN signature at bottom of page
• Abstracted as
• Antibiotic Name NOS
• Antibiotic Route UTD
• Antibiotic Date 1/3/08
• Antibiotic Time 1220

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PN SCIP

• Antibiotic Received
• Look for home meds

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PN SCIP

• Antibiotic Administration Time
• Use of UTD
• Use of Antibiotic NOS
• Allowable routes
• Single Data Source

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SCIP

• Surgery End Time
• Priority order ACNOP
• Use of UTD
• Multiple procedures

45
SCIP

• Infection Prior to Anesthesia
• Infection or Possible / Suspected infection
• Timing of documentation
• Symptoms not enough
• Inclusions / Exclusions

46
SCIP

• Postoperative Infections
• Time frame
• Infection or Possible / Suspected infection
• Timing of documentation
• Symptoms not enough
• Inclusions / Exclusions

47
SCIP

• Surgical Incision Time
• Priority order Synonyms
• Use of UTD
• Multiple procedures
• Cystoscopy Exception

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Frequently Mismatched Data Elements

• Questions?