Data Collection Support Webinar

1
(No Transcript)
2
Data Collection Support Webinar

• MetaStar, Inc.
• October 17, 2007
• Pam Clemens
• Candi Davis

3
Announcements

• All phone lines will be muted during the
  presentation
• Time will be allowed at the end for QAs

4
Announcements

• Nov. 1 Program Management Measure Designation
  due
• Nov. 9 Hospital Compare preview period ends
• Nov. 15 Data submission deadline for 2Q07
• Validation rate graphs through 4Q06 will be
  mailed out next week

5
Announcements

• For hospitals using CART
• CART update has been delayed because of discharge
  status and admission source changes
• Paper abstraction tools are available on
  QualityNet.org
• Select Specification Manual under the
  Hospitals tab
• Then select Abstraction Paper Tools
• The data elements have been arranged in
  alphabetical order

6
Announcements

• Outpatient Prospective Payment System (OPPS)
  Final Rule for CY 2008 will be published in
  November
• Data collection of required measures for purposes
  of APU will begin January 1, 2008
• Includes both new outpatient measures and
  expanded inpatient measures

7
Clarifications/Updates

• QNet Program Management Tips
• See attached handout
• WebEx training is available on www.qualitynet.org
  under Training

8
Program Management

• Located in the secured area of QualityNet
  Exchange
• Allows hospitals to indicate the measures they
  will be submitting to the QIO Clinical Warehouse
  and submit the ICD Population and Sample Counts

9
Program Management

• Either the hospital or the vendor can submit the
  information there is no preferred method
• It is up to the vendor to work with their
  providers to determine who will be
  updating/submitting the information

10
Measure Designation

• Measure Designation an online tool that must be
  done in Program Management
• Required beginning with 2nd Quarter 2007 (April
  1, 2007) discharges

11
Measure Designation

• Is defaulted to all measures except for test
  measures
• If a hospital is sending all measures, no action
  is needed
• If a hospital is not submitting all measures, the
  measures not being sent need to be deselected

12
Measure Designation

• The warehouse will calculate those measures
  selected when a case is submitted
• If all the data elements within the designated
  measures are not included in the file, the case
  will be rejected due to missing data
• Any rejected cases will need to be fixed and
  resubmitted before the submission deadline

13
Measure Designation

• Example AMI-8
• If you are a PPS hospital you must submit data
  elements for AMI-8a (Primary PCI)
• A PPS hospital cannot deselect a required measure

14
Updates Validation

• Validation is complete for Quarter 4 2006
• 14 WI hospitals failed
• 1 PPS hospital
• 13 Critical Access Hospitals
• Number One mismatch was PN Chest
• X-ray Element (11 total mismatches)

15
Validation

• Other validation mismatches
• Invalid record sent Only a partial medical
  record copy was sent patient was never admitted
• Antibiotic administration Multiple mismatches
  related to abstraction errors related to missed
  doses, routes and start times
• HF discharge instructions Multiple mismatches
  related to medications
• Discharge status Multiple abstraction errors

16
Validation

• Quarter 1 2007 validation process has begun
• Results have been posted for 9 CAH hospitals
• All 9 CAH passed validation

17
Hot Topics Avoiding Common Validation Mismatches

• To avoid PN chest x-ray element mismatches
• Abstractors should read abstraction guidelines
  carefully
• Review complete medical record for any and all
  CXR interpretations
• Review Pneumonia Frequently Asked Questions
• Review Chest X-ray 4/1/2007 Discharges handout
• Query Quest if unsure how to answer the question
• Use Mock Records available on www.qualitynet.org
  to train and test PN abstraction competency
• To avoid parent-child mismatches and decrease
  risk for validation failures, discuss skip logic
  with vendor

18
Hot Topics Avoiding Common Validation Mismatches

• Summary of validation mismatches for Quarter 4,
  2006 where the CDAC found inclusions for CXR
  element
• Infiltrate on a CXR report anytime during stay
• A CXR interpretation found in the progress notes
  that includes consolidation and pleural
  effusion
• A CXR interpretation found in the HP that states
  infiltrate or pneumonitis
• A CXR interpretation found in the discharge
  summary that states CT of chest showed
  consolidation consistent with pneumonia
• A physician restatement of CXR interpretation
  found in the ED physicians report stating CXR
  Infiltrate in the right middle lobe
• A CXR interpretation that states pneumonia
  cannot be excluded (Reference Quest 94471)

19
Hot Topics Avoiding Common Validation Mismatches

• A word from CMS about skip logic
• The use of skip logic by hospitals and ORYX
  vendors is optional and not required by CMS and
  the Joint Commission. Hospitals should be aware
  of the potential impact of skip logic on data
  quality, abstraction burden, and CMS chart audit
  validation scores. Vendors and hospitals using
  skip logic should closely monitor the accuracy
  rate of abstracted data elements, particularly
  data elements placed higher in the algorithm flow
  (e.g., Comfort Measures data element).

20
Hot Topics Avoiding Common Validation Mismatches

• To avoid Invalid Record Sent or Incorrect
  Date(s) of Service
• Patient name, birthdate, admit date and discharge
  date on the medical record sent to the CDAC for
  validation must match what was submitted to the
  warehouse in order to be considered a valid
  record

21
Hot Topics Avoiding Common Validation Mismatches

• To avoid Record Not Received develop an
  internal policy and procedure to facilitate
  receipt and completion of this task
• Be aware of important validation timelines
• Work with medical record department/copy service
• Check copies for accuracy, completeness, and
  legibility
• Promptly Fed-Ex all five records in one mailing
• Check case selection report to confirm the CDAC
  received your records

22
Hot Topics Case Selection Timeline At a Glance

• Medical records are generally selected 10
  business days after the closing of the warehouse
• There are times when it is later, but never
  earlier than 10 days
• Plan on the request being available in QNet and
  delivered via FedEx to your facility after the
  first of the month following the submission
  deadline
• See Data Transmission Deadlines on
  www.quailtynet.org for warehouse lock down
  dates/data submission deadlines

23
Hot Topics Case Selection Timeline At a Glance

• The next data submission deadline for Quarter 2,
  2007 discharges is Nov. 15
• Look for the request being available in QNet and
  delivered via FedEx to your facility on or around
  Dec. 1
• 10 days prior to the due date, as a courtesy to
  all hospitals, MetaStar will continue to notify
  HGD and APU contacts if their records have not
  been received at the CDAC
• Additional notification is provided if any or all
  records are not received

24
Topic of the Day October Abstraction Changes

• Addendum to Version 2.3 was released on September
  28, 2007
• See changes made by the National Uniform Billing
  Committee (NUBC)
• Changed Admission Source name to Point of Origin
• Changed the intent of this data element
• Changed discharge status allowable value 05
• Deleted discharge status allowable value 70

25
Topic of the DayOctober Abstraction Changes

• Point of Origin for Admission or Visit
• The intent of this data element is to focus on
  patients place or point of origin rather than
  the source of a physician order or referral
• The point of origin is the direct source for the
  particular facility
• This is a change from previous discharge status
  assignments

26
Topic of the DayOctober Abstraction Changes

• Example 1 A SNF patient has chest pain and is
  taken to the ED of Hospital A where it is
  determined that she is suffering an AMI and
  admitted to inpatient
• The patient is then transferred to Hospital B
  for admission as an inpatient
• The Point of Origin for Hospital A would be 5
  Transfer from a SNF
• The Point of Origin for Hospital B would be 4
  Transfer from a hospital

27
Topic of the DayOctober Abstraction Changes

• Example 2 An auto accident victim was taken to
  the ED of Hospital A by EMTs, admitted to
  inpatient, stabilized, then transferred to
  Hospital B
• At Hospital B he receives additional treatment
  in the ED, and then is admitted as an inpatient
• The Point of Origin for Hospital A is 7
  Emergency Room
• The Point of Origin for Hospital B would be 4
  Transfer from a hospital

28
Topic of the DayOctober Abstraction Changes

• The ER code is limited to patients who receive
  unscheduled emergency services in the ER not
  originating from another health care facility
• As in the auto accident example, a victim brought
  to the ER would be coded as 7 since the patient
  was not previously at any other kind of health
  care facility
• Point of Origin code 7 also includes
  self-referrals in emergency situations that
  require immediate medical attention

29
Responses to Submitted Questions

• Quest Question 120770 For October 2007
  discharges and beyond I would like to confirm Is
  the core measure for PN-5b, antibiotics within 4
  hours of arrival to the hospital?
• Answer Currently PN-5b is in the Rule. However,
  PN-5b has been de-endorsed by the NQF and PN-5c
  has been endorsed. CMS has not yet made a
  decision regarding which measure will be
  reported.
• CMS will send out an official memo (Ref Quest
  10090)
• PN-5c is no longer labeled a test measure

30
Questions/Feedback
31
Contact Information

• MetaStar, Inc.
• 2909 Landmark Place
• Madison, WI 53713
• [phone] or [phone]
• www.metastar.com
• This material was prepared by MetaStar 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 reflect CMS
  policy. 8SOW-WI-INP-07-140.