Data Collection Support Webinar

2. Data Collection Support Webinar MetaStar, Inc. August 16, 2006 Candi Davis Carol Ferguson Pam Clemens

3. Validation UpdateQuarter 4 2005 • Week seven of hospital validation processing has been completed by the CDAC • Results have been posted for a total of 60 hospitals • 59 hospitals have passed

4. MedQIC Resources • Today’s examples, fact sheets about major abstraction changes • Location: www.medqic.org • Click on Hospitals • Click on Other Resources • Scroll down

5. MedQIC Resources • See Fact Sheet: Select Heart Care Clinical Changes • Shows changes for July 1, 2006 • Content Summary: • CMO exclusion added • AMI-7 Terminology change and added exclusion • AMI-8 exclusion added • AMI-8a timeframe reduced • AMI-T1b deleted • HF All Measures added exclusion of CMO

6. MedQIC Resources • See Discharge Instructions Fact Sheet • Content Summary: • Specification Manual Version 1.04 FAQs • FAQ Significant Changes • New FAQs • Summary of Forthcoming Changes in Abstraction Guidelines Versions 1.04 and 2.0

7. MedQIC Resources • See Fact Sheets: Selected Pneumonia Clinical Changes • Shows changes for July 1, 2006 • Content Summary: • All Measures new element added Chest X-Ray • PN-2, PN-4, PN-7 now include transfer patients • PN-6 PO quinolones now allowed for non-ICU patients and new element added Risk Factors for Drug Resistant Pneumococcus

8. Release Notes • Definition: Provide modifications and/or clarifications to the Specifications Manual for National Hospital Quality Measures • Releases to occur at least 120 days prior to implementation date • Location: www.qualitynet.org • Click on Hospitals • Click on Specifications Manual • Click on version (or scroll down to select date range)

9. Release Notes • For “Specification Manual Release Notes and Manual Update 2006 Deadlines” • Location: www.qualitynet.org • Click on Hospitals • Click on Specifications Manual • Scroll down to Timelines for Specifications Manuals, Release Notes • Click on 2006 Timeline – Specifications Manual and Release Notes

10. Release Notes • Version 2.0b, Version 2.0a, Version 2.0 • Effective with Discharges July 1, 2006 • Released on March 3, 2006, May 1, 2006, and June 23, 2006 • See Fact Sheets on MedQIC for both abstraction changes and measure changes

11. Release Notes • Version 2.1 • Effective with Discharges October 1, 2006 • Released on June 9, 2006 • Major Abstraction Changes • SCIP - Addition of Card-2, VTE-1, and VTE-2 • SCIP – Removal of “Admission Diagnosis of Infection” • SCIP – Removal of “Antibiotics During Stay” and Antibiotics Prior to Arrival” • SCIP - Other • PN - Removal of Antibiotic During Stay and Antibiotics Prior to Arrival elements • PN – CMO inclusions added and some removed • PN – Removed data element “Pneumonia Working Diagnosis on Admission” • PN – Added “Pneumonia Diagnosis: ED/Direct Admit”

12. Release Notes • Version 2.1a • Effective with Discharges October 1, 2006 • Released on August 4, 2006 • Major Abstraction Changes • Documentation of medication administration on a MAR must be dated. If, in the course of abstraction an undated MAR is found in the medical record, it cannot be used.

13. Future Release Notes • Effective with Discharges January 1, 2007 • Expected to be released on September 8, 2006 • BE ALERT TO UPDATED VERSIONS

14. Release NotesDiscussion Topics • Process for reviewing • Process for disseminating information to abstractors • Vendor assistance • Other

15. Discharge Instructions Address Medications • QUEST #53100 • Question (March 16, 2006): • I have reviewed 52087, 50763, 52393, and 52291. I understand, that beginning immediately, we should not reference discharge summaries dictated > 30 days post discharge for HF discharge med reconciliation. Should we also disregard discharge summaries dictated > 30 days post discharge for all other indicators – HF, PN, & AMI? If yes – what is the rationale?

16. Discharge Instructions Address Medications • QUEST #53100 • Answer Published March 30, 2006: • Please refer to the appropriate version, as related to the date of discharge, of the Specifications Manual for National Quality Measures. The General Abstraction Guidelines, within the Data Dictionary section of the manual under ‘Medical Record Documentation’ states: When abstracting a medical record, use only documentation present at the time of abstraction. Documentation which is dated/timed after discharge should not be used unless it is added during the hospital’s normal course of completing a medical record. Per Medicare regulations, a hospital has 30 days to complete a medical record. This applies to all topics.

17. Data Dictionary • Instructions To access the Data Dictionary: www.qualitynet.org • Click on Hospitals • Specifications Manual • Select Version 2.0b • Click on Section 1 Data Dictionary • In the File Download window, select either Open or Save Adobe document • See page 5 of 10 for Medical Record Documentation • Other related FAQs: #50200, #58439, #55081, #63423, #55370, #50763, #61091, #56257, and #60566.

18. Arrival Time • Information received from the HR QIOSC • 1) Definition of "at the hospital": "At the hospital" represents....what time did the patient step foot, or arrive at, the hospital that is being abstracted? If you are the receiving hospital in a transfer...the arrival time is, again, the time the patient arrived at your facility. You only want to abstract the care YOU provided for the patient. Within the algorithm, it works with these patients by excluding them from different measures that do not apply.

19. Arrival Time • (e.g. for 01/01/06 discharges, you answer Admission Source as "4 Transfer from a hospital or A Transfer from a Critical Access Hospital"...for PN 3b, you stop abstracting and this patient is not in this measures population.) • (e.g. for 01/01/06 discharges, you answer Discharge Status as "02 Discharged/transferred to a short term general hospital for inpatient care"...for PN-2, you stop abstracting and this patient is not in this measures population.)

20. Arrival Time • 2) If arrival time is incorrect, this will be validated and a mismatch will occur. When discussing transferring, it really comes down to the Admission Source/Discharge Status measures when if affects being excluded from the measure population.

21. Arrival Time • 3) Transfer among campuses: See examples. • Example #1: • Admitted to Hospital A: 01/01/2006 • Transferred to sister hospital: 01/03/2006 • Discharged from sister hospital: 01/04/2006 • Abstract and submit to CMS as--Hospital A admission from 01/01/2006 - 01/03/2006 and patient's discharge status from Hospital A would be "02 Discharged/transferred to a short term general hospital for inpatient care."

22. Arrival Time • 3) Transfer among campuses: • Example #2: • Admitted to Critical Access Hospital 01/15/2006 at 11:23 • Transferred to Hospital A: 01/16/2006 at 15:00 (arrived directly to floor) • Discharged from Hospital A: 01/20/2006 • Abstract and submit to CMS as--Hospital A admission from 01/16/2006 - 01/20/2006 and patient's arrival time would be 15:00 • The admission source would be "A Transfer from a Critical Access Hospital." • The Critical Access Hospital will do their own abstraction from the record 01/15/2006-01/16/2006.

23. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320 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-06-25