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1. A GUIDE TO IQR CMS’ Hospital Inpatient Quality Reporting Program A Three Part Series Beth McConville RN, BSN, CPHQ
March 2011
Hello everyone,
I want to welcome you to part II of this three part series A Guide to IQR reviewing Medicare’s in-patient quality data reporting program.Hello everyone,
I want to welcome you to part II of this three part series A Guide to IQR reviewing Medicare’s in-patient quality data reporting program.
2. Accessing and Utilizing Quality Net & My Quality Net Reports Beth McConville RN BSN CPHQ Part II of III – March 2011 In today’s session I will be reviewing how to access Quality Net and utilize the Quality Net reports.
The first question to answer, I guess, is what is Quality Net?
Quality Net is the electronic resource, provided by CMS, for all things related to their data collection and reporting programs for all provider types.
In today’s session I will be reviewing how to access Quality Net and utilize the Quality Net reports.
The first question to answer, I guess, is what is Quality Net?
Quality Net is the electronic resource, provided by CMS, for all things related to their data collection and reporting programs for all provider types.
3. When you go to www.qualitynet.org
you will see this home page; it’s divided into three categories
The Quality Net home page, which loads by default, My Quality Net and MedQIC.
Quality Net Home provides news, resources and training materials.
My Quality Net is password protected and offers hospital specific reports on data submission and measure rates, as well as a Secure file exchange allows sharing of PHI between you, your QIO (myself) and/or CMS.
Within MedQIC you’ll find Performance Improvement tools, we’ll take a look at all of these areas more closely.
But, in short, this site offers you a plethora of information about data submission, data analysis and data use.
The blue bubbles in the left hand column provide information on how to participate.
It also provides a link to register for CMS provided Listservs. They are very informative and I encourage you to see what topics are offered and register for those you feel you would benefit from. They are offered free of charge.
The text in the center is news. This is where you find announcements when the proposed and final rules come out for the data programs with links to the Federal Register...very important. All kinds of news, vital to keep up to date.
In the column on the far right you have education and training resources. Within the CART training section there are useful tools for training new abstractors.
When you go to www.qualitynet.org
you will see this home page; it’s divided into three categories
The Quality Net home page, which loads by default, My Quality Net and MedQIC.
Quality Net Home provides news, resources and training materials.
My Quality Net is password protected and offers hospital specific reports on data submission and measure rates, as well as a Secure file exchange allows sharing of PHI between you, your QIO (myself) and/or CMS.
Within MedQIC you’ll find Performance Improvement tools, we’ll take a look at all of these areas more closely.
But, in short, this site offers you a plethora of information about data submission, data analysis and data use.
The blue bubbles in the left hand column provide information on how to participate.
It also provides a link to register for CMS provided Listservs. They are very informative and I encourage you to see what topics are offered and register for those you feel you would benefit from. They are offered free of charge.
The text in the center is news. This is where you find announcements when the proposed and final rules come out for the data programs with links to the Federal Register...very important. All kinds of news, vital to keep up to date.
In the column on the far right you have education and training resources. Within the CART training section there are useful tools for training new abstractors.
4. 4 Beneath the three tabs Home, My Quality Net and MedQIC there are several provider specific tabs which, when you click on them refresh the home page with provider specific information.
However, if you place your curser over the provider tab of interest a drop down box appears with links to components of quality data collection.
Within the hospital in-patient data set you have HQA and IQR participation requirements, sections reviewing different types of outcomes data and of paramount importance, the Specifications Manual. That is your data abstraction bible. It provides all the rules you have to follow for record review and data collection.Beneath the three tabs Home, My Quality Net and MedQIC there are several provider specific tabs which, when you click on them refresh the home page with provider specific information.
However, if you place your curser over the provider tab of interest a drop down box appears with links to components of quality data collection.
Within the hospital in-patient data set you have HQA and IQR participation requirements, sections reviewing different types of outcomes data and of paramount importance, the Specifications Manual. That is your data abstraction bible. It provides all the rules you have to follow for record review and data collection.
5. 5 When you scroll down to the bottom of any Quality Net page you find a link to the Quality Net Helpdesk.
Clicking on it opens a new window with their contact information.
The Quality Net helpdesk is available to help you with accessing quality net reports or technical issues with data submission.When you scroll down to the bottom of any Quality Net page you find a link to the Quality Net Helpdesk.
Clicking on it opens a new window with their contact information.
The Quality Net helpdesk is available to help you with accessing quality net reports or technical issues with data submission.
6. 6 In the lower right hand corner of the page is a link to QUEST.
QUEST is available to help you with INPATIENT data abstraction questions.
If you are unsure how to answer a data abstraction question you first look at the data element page in the Specifications Manual.
If the Specification Manual is unclear or does not address the particular language you found documented you can utilize this tool to see if anyone has asked a similar question and peruse the answers already provided.
If you still can’t find an answer you then contact me – preferably in email, with the discharge date, the data element you are attempting to answer and the documentation available to you relating to that data element. Email that info to me and then I will email you a response. This way you have something in writing to reference in the event you are in a position to appeal a mismatch. No PHI via email please.
I digressed a little but lets take a look now at the QUEST tool.
When you click on the QUEST link...In the lower right hand corner of the page is a link to QUEST.
QUEST is available to help you with INPATIENT data abstraction questions.
If you are unsure how to answer a data abstraction question you first look at the data element page in the Specifications Manual.
If the Specification Manual is unclear or does not address the particular language you found documented you can utilize this tool to see if anyone has asked a similar question and peruse the answers already provided.
If you still can’t find an answer you then contact me – preferably in email, with the discharge date, the data element you are attempting to answer and the documentation available to you relating to that data element. Email that info to me and then I will email you a response. This way you have something in writing to reference in the event you are in a position to appeal a mismatch. No PHI via email please.
I digressed a little but lets take a look now at the QUEST tool.
When you click on the QUEST link...
7. 7 ...a new window opens.
Enter a few key words. I find entering the name of the data element you are trying to answer along with one or two words you want to use as inclusions or exclusions.
For example. Maybe you are answering data element Initial ECG Interpretation and you want to know if ST Depression is enough to say yes to this data element...type in “Initial ECG Interpretation ST depression...Then click on the little gray “submit” button....a new window opens.
Enter a few key words. I find entering the name of the data element you are trying to answer along with one or two words you want to use as inclusions or exclusions.
For example. Maybe you are answering data element Initial ECG Interpretation and you want to know if ST Depression is enough to say yes to this data element...type in “Initial ECG Interpretation ST depression...Then click on the little gray “submit” button.
8. 8 The page refreshes with a list of questions containing those terms.
You can search by Relevance (that is, the number of words that match) or by ID number or alphabetically by question or by the publication date simply by clicking on the word in the skinny gray header bar.
As you review the questions don’t forget to scan the “published” date and the text of the Q&A to be sure the answer relates to the proper discharge quarter.
Once you find a question you like you click on the small magnifying glass icon to the far right.The page refreshes with a list of questions containing those terms.
You can search by Relevance (that is, the number of words that match) or by ID number or alphabetically by question or by the publication date simply by clicking on the word in the skinny gray header bar.
As you review the questions don’t forget to scan the “published” date and the text of the Q&A to be sure the answer relates to the proper discharge quarter.
Once you find a question you like you click on the small magnifying glass icon to the far right.
9. 9 ...and a new window opens with the full Q&A.
You have the option to print or email this Q&A from this screen.
If you use this advise to answer your question I advise you do save it in one form or another just in case you do have a low validation score and this is one of the mismatched elements you wish to appeal....here’s your appeal argument right here....and a new window opens with the full Q&A.
You have the option to print or email this Q&A from this screen.
If you use this advise to answer your question I advise you do save it in one form or another just in case you do have a low validation score and this is one of the mismatched elements you wish to appeal....here’s your appeal argument right here.
10. 10 Moving on.
We’re going to spend some time in ‘My Quality Net’ so I’m going to skip over it for a second and give you a peek at the MedQIC tab.
This site offers performance improvement tools in the form of paper order sets, and pathways as well as posters and chart reminder stickers and the like. It also offers a number of recorded educational sessions and provider recordings sharing process change experiences in a variety of topics...a great method for sharing lessons learned and it can save you from making the same initial missteps.
If you would like to share something you’ve done click on the “Submit A Tool To MedQIC” link.
In the left hand bubbles you see a number of provider types listed. When you click on ‘hospital’ the page refreshes and the left hand bubbles then contain links to hospital specific performance improvement topics, heart care, MRSA transmission reduction, immunization, etc.
I’ll leave it to you to investigate this area further. There is a search engine in the upper right that can be helpful.
Also, for those of you involved with developing EHRs, there is a link to Dr. Blumenthal’s blog discussing HIT issues. See “Health IT Buzz”
But we are going to spend the remainder of our time together in My Quality Net.
Moving on.
We’re going to spend some time in ‘My Quality Net’ so I’m going to skip over it for a second and give you a peek at the MedQIC tab.
This site offers performance improvement tools in the form of paper order sets, and pathways as well as posters and chart reminder stickers and the like. It also offers a number of recorded educational sessions and provider recordings sharing process change experiences in a variety of topics...a great method for sharing lessons learned and it can save you from making the same initial missteps.
If you would like to share something you’ve done click on the “Submit A Tool To MedQIC” link.
In the left hand bubbles you see a number of provider types listed. When you click on ‘hospital’ the page refreshes and the left hand bubbles then contain links to hospital specific performance improvement topics, heart care, MRSA transmission reduction, immunization, etc.
I’ll leave it to you to investigate this area further. There is a search engine in the upper right that can be helpful.
Also, for those of you involved with developing EHRs, there is a link to Dr. Blumenthal’s blog discussing HIT issues. See “Health IT Buzz”
But we are going to spend the remainder of our time together in My Quality Net.
11. 11 When you click on the ‘My Quality Net’ tab you are taken to the log in page.
This area is password protected because it contains hospital data.
If you’re not already registered for Quality Net I can help you get a user ID and password.
Enter your user ID and password.When you click on the ‘My Quality Net’ tab you are taken to the log in page.
This area is password protected because it contains hospital data.
If you’re not already registered for Quality Net I can help you get a user ID and password.
Enter your user ID and password.
12. 12 This is the ‘My Quality Net’ home page.
It varies by user because the content here is determined for the specific roles you are assigned, roles give you access to specific areas.
This is all I get so that’s what I’m showing you. Many of you will have much more including Administrative functions like edit users and vendor assignments and outpatient data.
I want to show you the three areas depicted above. Exchange Files, Reports, Manage Measures.
Let’s start with the Exchange files.
Click on Send/Receive
This is the ‘My Quality Net’ home page.
It varies by user because the content here is determined for the specific roles you are assigned, roles give you access to specific areas.
This is all I get so that’s what I’m showing you. Many of you will have much more including Administrative functions like edit users and vendor assignments and outpatient data.
I want to show you the three areas depicted above. Exchange Files, Reports, Manage Measures.
Let’s start with the Exchange files.
Click on Send/Receive
13. 13 This box appears for a few seconds while the applet is loaded.This box appears for a few seconds while the applet is loaded.
14. 14 And then the page refreshes with a view of your inbox.
Click on the name of the mail you want to open, it will then be highlighted in yellow.
And in the middle section also yellow where you see From, Subject and Date Received this is where any free text shows up like an email.
You have the option then to forward it on or delete it.
Below that in the bottom section you see the files available for download.
You cannot open those files from here, you must download it first.
Click on the square box next to it then click download
And then the page refreshes with a view of your inbox.
Click on the name of the mail you want to open, it will then be highlighted in yellow.
And in the middle section also yellow where you see From, Subject and Date Received this is where any free text shows up like an email.
You have the option then to forward it on or delete it.
Below that in the bottom section you see the files available for download.
You cannot open those files from here, you must download it first.
Click on the square box next to it then click download
15. 15 This box appears
Click OKThis box appears
Click OK
16. 16 Select the folder you want to save this file toSelect the folder you want to save this file to
17. 17 A confirmation appears
Click OK – then you can go off line to your files and open it from there
Unlike email – you can’t open the message from the inbox.
To send a file to someone else – for example a validation appeal request to me – click on the ‘New’ button (upper left)A confirmation appears
Click OK – then you can go off line to your files and open it from there
Unlike email – you can’t open the message from the inbox.
To send a file to someone else – for example a validation appeal request to me – click on the ‘New’ button (upper left)
18. 18 There are five steps – all aligned in order on this form
First click on the ‘To’ button to select a recipientThere are five steps – all aligned in order on this form
First click on the ‘To’ button to select a recipient
19. 19 A new box appears
Select the radio button for ‘Organization Type’
Select QIO
Click on go and a list of QIOs shows up
Select Masspro
Click ‘Go’A new box appears
Select the radio button for ‘Organization Type’
Select QIO
Click on go and a list of QIOs shows up
Select Masspro
Click ‘Go’
20. 20 and the list of Masspro employees appears below
Scroll down to the intended recipient and click on the check off box
Then click Add and the recipients name appears to the right
You can select as many people as you want
Went the list of recipients is complete click on the ‘Save’ buttonand the list of Masspro employees appears below
Scroll down to the intended recipient and click on the check off box
Then click Add and the recipients name appears to the right
You can select as many people as you want
Went the list of recipients is complete click on the ‘Save’ button
21. 21 You are taken back to the new message box with the recipients name at the top.
Now you move down to the subject and message sections. These are free text areas not required but available for you to use.
And a neat little option called the Notification Date.
This comes in handy when you are sending time sensitive material – like a validation appeal request – and you want to be forewarned if the deadline is approaching and the recipient hasn’t opened the file yet.
Then, last step, click on the ‘Attach File’ box to select the file you wish to send.You are taken back to the new message box with the recipients name at the top.
Now you move down to the subject and message sections. These are free text areas not required but available for you to use.
And a neat little option called the Notification Date.
This comes in handy when you are sending time sensitive material – like a validation appeal request – and you want to be forewarned if the deadline is approaching and the recipient hasn’t opened the file yet.
Then, last step, click on the ‘Attach File’ box to select the file you wish to send.
22. 22 your browser opens
Select the file you wish to send and click ‘Open”your browser opens
Select the file you wish to send and click ‘Open”
23. 23 You then see the ‘Processing file…” message appear in the New message box
This takes five or ten seconds actually it depends on the size of the file.You then see the ‘Processing file…” message appear in the New message box
This takes five or ten seconds actually it depends on the size of the file.
24. 24 Then you will see the file listed here
Click ‘Send”
Then you will see the file listed here
Click ‘Send”
25. 25 A built in safety check appears – do you want to send this file to this recipient
If yes click on yesA built in safety check appears – do you want to send this file to this recipient
If yes click on yes
26. 26 You will be informed that the message was sent
Click OKYou will be informed that the message was sent
Click OK
27. 27 You will then be taken back to your inbox
You can select the ‘Sent’ section to see this and any other file you have sent.
You can also ask for a notification to be sent to your regular email informing you when a file has been loaded here for you.
Go to Notification Preferences (upper right)
That’s an introduction to the File Exchange.
Let’s go back out to the Home Page by clicking on ‘Back To My Tasks’ and take a look at Reports.You will then be taken back to your inbox
You can select the ‘Sent’ section to see this and any other file you have sent.
You can also ask for a notification to be sent to your regular email informing you when a file has been loaded here for you.
Go to Notification Preferences (upper right)
That’s an introduction to the File Exchange.
Let’s go back out to the Home Page by clicking on ‘Back To My Tasks’ and take a look at Reports.
28. 28 Back on the Home Page In the reports section select ‘Run’Back on the Home Page In the reports section select ‘Run’
29. 29 The default page offers two Annual Payment Update reports but if you click on the drop down box...The default page offers two Annual Payment Update reports but if you click on the drop down box...
30. 30 You’ll see a variety of report types to chose from.
Hcahps reports, the quarterly preview report, validation reports and clinical reports.
We’ll take a look at the Annual payment update reports first.You’ll see a variety of report types to chose from.
Hcahps reports, the quarterly preview report, validation reports and clinical reports.
We’ll take a look at the Annual payment update reports first.
31. 31 These two reports are designed to inform you of your status for participation in the IQR program.
The provider participation report keeps you abreast of your quarterly data submissions and the Confidence Interval Report gives you your annual validation score....this report is available only once a year because the final validation score with the Confidence Interval applied is determined annually.
The provider participation report is a key report.
You have to pull this report every quarter a week or two before HCAHPS deadline and then again a week or so prior to the clinical data submission deadline, and assess your submissions to make sure you do not under-submit.
Let’s take a look at it.
Click on RHQDAPU Provider Participation report.
The report is still listed as RHQDAPU even though the program has changed its name to IQR.These two reports are designed to inform you of your status for participation in the IQR program.
The provider participation report keeps you abreast of your quarterly data submissions and the Confidence Interval Report gives you your annual validation score....this report is available only once a year because the final validation score with the Confidence Interval applied is determined annually.
The provider participation report is a key report.
You have to pull this report every quarter a week or two before HCAHPS deadline and then again a week or so prior to the clinical data submission deadline, and assess your submissions to make sure you do not under-submit.
Let’s take a look at it.
Click on RHQDAPU Provider Participation report.
The report is still listed as RHQDAPU even though the program has changed its name to IQR.
32. 32 You will be taken to a Parameters page.
Each report type has different parameters you can set to customize the report a little bit.
This report only allows you to select your hospital and the calendar year you are interested in.
I can see all MA hospital data so I have to select from among you. You will only have your hospital name listed here.
You still need to click on it to highlight it.
The calendar year is the current calendar year by default.
Click on Request reportYou will be taken to a Parameters page.
Each report type has different parameters you can set to customize the report a little bit.
This report only allows you to select your hospital and the calendar year you are interested in.
I can see all MA hospital data so I have to select from among you. You will only have your hospital name listed here.
You still need to click on it to highlight it.
The calendar year is the current calendar year by default.
Click on Request report
33. 33 The page refreshes with this message informing you your request has been submitted.
Now click on the View Reports tab.The page refreshes with this message informing you your request has been submitted.
Now click on the View Reports tab.
34. 34 The view reports tab will provide a list of all reports requested within the last 7 days.
Following from left to right
You get the date and time requested followed by the report name
To the far right there is a status column communicating whether to not the report is ready. It will say either complete, when it is ready, processing, when it is imminent, or pending when there may be a wait. If it is pending the Size column will provide a fraction like 127 out of 234....this tell you there is a long queue and you can sign out and sign back in later to view the report. It won’t go away.
Once complete you can select one of the three gray icons on the last three columns. The small magnifying glass opens the report in a new window. You can view it, download it or print it from there.
The downward arrow allows you to download it for viewing and/or sharing off line later, and the trash can is to delete it.
If you want to run more reports you just go back to the Run Reports tab.
The view reports tab will provide a list of all reports requested within the last 7 days.
Following from left to right
You get the date and time requested followed by the report name
To the far right there is a status column communicating whether to not the report is ready. It will say either complete, when it is ready, processing, when it is imminent, or pending when there may be a wait. If it is pending the Size column will provide a fraction like 127 out of 234....this tell you there is a long queue and you can sign out and sign back in later to view the report. It won’t go away.
Once complete you can select one of the three gray icons on the last three columns. The small magnifying glass opens the report in a new window. You can view it, download it or print it from there.
The downward arrow allows you to download it for viewing and/or sharing off line later, and the trash can is to delete it.
If you want to run more reports you just go back to the Run Reports tab.
35. APU/RHQDAPU Provider Participation Report This is the Provider Participation Report. This is actually the old version I don’t have a mock report in the new format. The new report is cleaner, no blue bar for instance just the title top center, but the content format is similar, I’ll show you a close up of the data on the current form in a second but I wanted you to get oriented to the whole page.
The title top center.
Note this is a four page report for a calendar year. Page 1 is quarter one, page two quarter two and so on.
The quarter is now provided top center just under the title. Worth eyeballing it when you open the report to make sure you are looking at the right quarter of data. Just below the title section you see two columns. In the left you’ll find your hospitals Medicare provider ID, name and other demographics. This section also lists IQR program requirements with a little yes or no next to them to indicate whether or not you have met the requirement for the year. Another section worth eyeballing each time you pull the report. Currently listed are Active Quality Net Administrator, the notice of participation date, CEO name, data accuracy acknowledgement and Structural Measures questions answered. Let me know if the CEO name is incorrect and I’ll update the CMS data base.
Below those two columns – the data.
Lets go now to a close up of the data in its current format...This is the Provider Participation Report. This is actually the old version I don’t have a mock report in the new format. The new report is cleaner, no blue bar for instance just the title top center, but the content format is similar, I’ll show you a close up of the data on the current form in a second but I wanted you to get oriented to the whole page.
The title top center.
Note this is a four page report for a calendar year. Page 1 is quarter one, page two quarter two and so on.
The quarter is now provided top center just under the title. Worth eyeballing it when you open the report to make sure you are looking at the right quarter of data. Just below the title section you see two columns. In the left you’ll find your hospitals Medicare provider ID, name and other demographics. This section also lists IQR program requirements with a little yes or no next to them to indicate whether or not you have met the requirement for the year. Another section worth eyeballing each time you pull the report. Currently listed are Active Quality Net Administrator, the notice of participation date, CEO name, data accuracy acknowledgement and Structural Measures questions answered. Let me know if the CEO name is incorrect and I’ll update the CMS data base.
Below those two columns – the data.
Lets go now to a close up of the data in its current format...
36. 36 Clinical data is represented in the section with the gray and white stripes. Each pt population [AMI, HF, PN and SCIP] have there own row and must be assessed individually. This review requires a lot of cross referencing. There are no short cuts. That being said once you do it once or twice it doesn’t take any time at all.
You need this report and you need the minimum sample size tables from each measure information form in the Spec manual. One for AMI one for HF one for PN and one for SCIP. They all differ, you need them all.
Now the columns.
The first column ‘Total Medicare Claims’ lists the number of Medicare claims CMS has received in that pt population this quarter. The Total Cases Accepted To Date column tell you how many cases CMS has successfully received from you in that pt population for the quarter. Skip the next one for now. Then you see Total Inpatient Population. This is populated with the numbers you, or your vendor on your behalf, has entered in the Population and Sample section in my quality net. The Total Sample Size and your sampling frequency comes from there as well.
To assess the data first compare the Total Medicare Claims in the first column with the Total Inpt Population in the fourth column. Now, the Total Inpt population should be equal to or greater than the Total Medicare count because it is all payor. The day will come when you will have to correct that, for now there are no financial consequences. So for now just look at the two numbers and use the higher of the two.
Take the higher of the two and compare it to the Minimum Sample Size tables you pulled from The Spec Manual Measure Information Form for that pt population.
If you are sampling monthly you must use the monthly minimum sample size table, if you are sampling quarterly you must use the quarterly minimum sample size table and if you have indicated you are not sampling you are still (for now) only held accountable for submitting the minimum QUARTERLY sample size so use that table.
Okay, I’ll repeat. Use the Minimum Quarterly sample size tables if you are sampling quarterly or not sampling at all. Use the Minimum monthly sample size if you are sampling monthly.
Now that you know your minimum sample size compare it to The Total Cases Accepted To Date.
The Total Cases Accepted To Date must be at least your minimum sample size.
If it is your all set. If it’s not that means you are under-submitted and the hospital is at risk for a financial loss. When you find you’re under submitted you’ll have to do a little trouble shooting and we’ll do that next.
But before we move on I want to show you the final component of this report.
Just below the clinical data section is the HCAHPS survey data section. The hcahps data is submitted quarterly but broken down monthly. The unverified Files Accepted To Date is actually the CMS way of saying were surveys submitted for this quarter? And for each month you need to see a Yes. If there is No look to the right under the Verified zero-cases information accepted to date column. That’s CMS’s way of saying did you tell me you have no cases for this month? If the files accepted for July reads No the zero cases for July needs to say yes. If both say no you have under-submitted. Troubleshooting here requires contacting your hcahps vendor.
That’s how you use this report and I repeat, you should be doing this every quarter a couple of weeks before deadline so you have time to troubleshoot if necessary.
So, if you do find you’ve under-submitted some clinical cases, what do you do?Clinical data is represented in the section with the gray and white stripes. Each pt population [AMI, HF, PN and SCIP] have there own row and must be assessed individually. This review requires a lot of cross referencing. There are no short cuts. That being said once you do it once or twice it doesn’t take any time at all.
You need this report and you need the minimum sample size tables from each measure information form in the Spec manual. One for AMI one for HF one for PN and one for SCIP. They all differ, you need them all.
Now the columns.
The first column ‘Total Medicare Claims’ lists the number of Medicare claims CMS has received in that pt population this quarter. The Total Cases Accepted To Date column tell you how many cases CMS has successfully received from you in that pt population for the quarter. Skip the next one for now. Then you see Total Inpatient Population. This is populated with the numbers you, or your vendor on your behalf, has entered in the Population and Sample section in my quality net. The Total Sample Size and your sampling frequency comes from there as well.
To assess the data first compare the Total Medicare Claims in the first column with the Total Inpt Population in the fourth column. Now, the Total Inpt population should be equal to or greater than the Total Medicare count because it is all payor. The day will come when you will have to correct that, for now there are no financial consequences. So for now just look at the two numbers and use the higher of the two.
Take the higher of the two and compare it to the Minimum Sample Size tables you pulled from The Spec Manual Measure Information Form for that pt population.
If you are sampling monthly you must use the monthly minimum sample size table, if you are sampling quarterly you must use the quarterly minimum sample size table and if you have indicated you are not sampling you are still (for now) only held accountable for submitting the minimum QUARTERLY sample size so use that table.
Okay, I’ll repeat. Use the Minimum Quarterly sample size tables if you are sampling quarterly or not sampling at all. Use the Minimum monthly sample size if you are sampling monthly.
Now that you know your minimum sample size compare it to The Total Cases Accepted To Date.
The Total Cases Accepted To Date must be at least your minimum sample size.
If it is your all set. If it’s not that means you are under-submitted and the hospital is at risk for a financial loss. When you find you’re under submitted you’ll have to do a little trouble shooting and we’ll do that next.
But before we move on I want to show you the final component of this report.
Just below the clinical data section is the HCAHPS survey data section. The hcahps data is submitted quarterly but broken down monthly. The unverified Files Accepted To Date is actually the CMS way of saying were surveys submitted for this quarter? And for each month you need to see a Yes. If there is No look to the right under the Verified zero-cases information accepted to date column. That’s CMS’s way of saying did you tell me you have no cases for this month? If the files accepted for July reads No the zero cases for July needs to say yes. If both say no you have under-submitted. Troubleshooting here requires contacting your hcahps vendor.
That’s how you use this report and I repeat, you should be doing this every quarter a couple of weeks before deadline so you have time to troubleshoot if necessary.
So, if you do find you’ve under-submitted some clinical cases, what do you do?
37. 37 Go back to the Run reports section and select clinical warehouse feedback reports from the drop down box.
Go back to the Run reports section and select clinical warehouse feedback reports from the drop down box.
38. 38 There are two reports here that prove to be very useful.
The first is the Case Status Summary Report. We’ll take a look at this one first. It’s a simple report that will show you if you have any cases rejected. If you do have cases rejected you will then need to look at the Data Submission detail report to identify which case or cases were rejected and why so that you can correct your data entry and resubmit before deadline.
Okay, so first, the case status summary report. Click on the name.
There are two reports here that prove to be very useful.
The first is the Case Status Summary Report. We’ll take a look at this one first. It’s a simple report that will show you if you have any cases rejected. If you do have cases rejected you will then need to look at the Data Submission detail report to identify which case or cases were rejected and why so that you can correct your data entry and resubmit before deadline.
Okay, so first, the case status summary report. Click on the name.
39. 39 The parameter page opens up.
You will again highlight your hospitals name. It will be the only one listed for you.
Then you have to manually enter the first and last dates of the quarter in a two digit month/two digit day/four digit year format.
You can select the measure set you want to look at. Let’s say when you reviewed your Provider Participation Report you identified an under-submission in your HF population. You could just select HF and that’s the only population that will show up on this report.
This is a simple one page report so you can skip over the select measures section and the report will give you information for all four measure sets by default.
Skip submitter. Even if you have more than one vendor you need to assess all submissions for rejections.
Finally click on the gray ‘request report’ button.The parameter page opens up.
You will again highlight your hospitals name. It will be the only one listed for you.
Then you have to manually enter the first and last dates of the quarter in a two digit month/two digit day/four digit year format.
You can select the measure set you want to look at. Let’s say when you reviewed your Provider Participation Report you identified an under-submission in your HF population. You could just select HF and that’s the only population that will show up on this report.
This is a simple one page report so you can skip over the select measures section and the report will give you information for all four measure sets by default.
Skip submitter. Even if you have more than one vendor you need to assess all submissions for rejections.
Finally click on the gray ‘request report’ button.
40. 40 The report looks like this.
See, it’s not a whole lot of information to weed through. A nice simple report.
The first column lists the patient populations.
The second column lists the number of cases submitted in each population.
The third column lists the number of cases accepted in each population and the final column tells you the number of cases rejected.
This report only lists measure sets submitted. So if you had not submitted any AMI cases the AMI category would not even show up listed here.
If you have identified and under-submission and see that you have no rejected cases that means you have a case or cases that you have not yet abstracted. You need to work with your vendor first and ask them to help you identify missing cases.
If the vendor reports don’t help you identify the missing case(s) you need to turn to your billing and Medical Records departments for assistance.
You need to know what cases are in the population and what cases have already been abstracted.
If, on the other hand, you do see the case or cases were rejected your next move is to pull the Data Submission Detail report.
Return to the ‘Run Reports’ section.
The report looks like this.
See, it’s not a whole lot of information to weed through. A nice simple report.
The first column lists the patient populations.
The second column lists the number of cases submitted in each population.
The third column lists the number of cases accepted in each population and the final column tells you the number of cases rejected.
This report only lists measure sets submitted. So if you had not submitted any AMI cases the AMI category would not even show up listed here.
If you have identified and under-submission and see that you have no rejected cases that means you have a case or cases that you have not yet abstracted. You need to work with your vendor first and ask them to help you identify missing cases.
If the vendor reports don’t help you identify the missing case(s) you need to turn to your billing and Medical Records departments for assistance.
You need to know what cases are in the population and what cases have already been abstracted.
If, on the other hand, you do see the case or cases were rejected your next move is to pull the Data Submission Detail report.
Return to the ‘Run Reports’ section.
41. 41
This time select the Case Submission Detail report
This time select the Case Submission Detail report
42. 42 Again, here is the parameters page
Select your hospital
Enter the first and last dates of the quarter you are interested in.
Leave submitter blank
Scroll down...Again, here is the parameters page
Select your hospital
Enter the first and last dates of the quarter you are interested in.
Leave submitter blank
Scroll down...
43. 43
Select Upload Status is not as helpful as it appears. Once a case is rejected it will always show up on the ‘rejected’ report, even if a case that was previously rejected was resubmitted by your vendor and accepted on resubmission it will still show up on the rejected report. You want to identify the currently rejected cases so just skip the Select Upload Status section and the report will pull all cases.
Select Measures. This is helpful because the report is a detail report it contains a lot of information and can get rather large. In the interest of limiting the amt of info you must wade through just highlight the population to populations you are interested in.
Skip Select Action Code
Skip Select A Message Type
Then click on the little radio button for the format you want the report in PDF or excel.
Finally click on Request Report.
Select Upload Status is not as helpful as it appears. Once a case is rejected it will always show up on the ‘rejected’ report, even if a case that was previously rejected was resubmitted by your vendor and accepted on resubmission it will still show up on the rejected report. You want to identify the currently rejected cases so just skip the Select Upload Status section and the report will pull all cases.
Select Measures. This is helpful because the report is a detail report it contains a lot of information and can get rather large. In the interest of limiting the amt of info you must wade through just highlight the population to populations you are interested in.
Skip Select Action Code
Skip Select A Message Type
Then click on the little radio button for the format you want the report in PDF or excel.
Finally click on Request Report.
44. Data Submission Detail Report This, once again, is an old report because I don’t have a mock report in the new format. The new format is a little sleeker but the body of the report with all the data is the same. You can now see what I meant when I said this report contains a lot of information to wade through. At first glance it’s pretty much a nightmare but I’m going to walk you through the information found here so you can more easily identify the information that you need.
Centered, just below the tile Data Submission Detail Report are the dates and the pt populations, aka topics, that you chose to look at. Just eyeball this to make sure you have the correct and complete dates and populations.
Just below that is a line that contains Batch ID, discharge date, admit date, submission date, status and submitter name. These headers are associated with the information found below, in the body of the report .
The dark blue bar will contain your hospitals name
The dark gray bar will contain the population, and everything under that dark gray bar relates to that population until you get to the next dark gray bar with a different population.
The light gray bar contains a patient identifier. Everything in the white section under that light gray bar is associated with that patient. Until you get to the next light gray bar with the next patient identifier.
The Batch ID. In the column under the batch ID there are two different number sets. One set of numbers are 7 digits long, those are the batch ID numbers. The other set of numbers are 6 digits in length. The 6 digit numbers are associated with the measures. For instance you see AMI-1 is always # 21100. But you get a different batch ID number every time your vendor submits data for you. Each time the vendor submits even one AMI case they automatically re-submit all AMI cases. That’s just how it works. They don’t submit individual cases, they submit individual populations.
Okay, back on track. Scan to the last batch for each patient. Next to the batch ID is the Discharge and Admit dates in that order followed by the date it was submitted followed by the status.
That’s what you’re looking for, the status of the last submission. Here it will read either Accepted or Rejected.
To save time, when you open the report it opens with an adobe reader. Use the ‘search’ field at the top of the reader to search for the word ‘Rejected’.
Locate the rejected cases. Beneath that, where all the measures are listed you will see ‘Critical Error (I don’t have an example here I’m sorry, but instead of seeing AMI-1 for instance, you would see the words Critical Error). That’s followed by the reason for the critical error. It will tell there what data element was entered incorrectly then using that information go back to your data abstraction software and make the necessary changes. Then resubmit the case to your vendor and, especially if your closing in on the data submission deadline, give your vendor a call and let then know you’ve corrected and resubmitted that case or cases.This, once again, is an old report because I don’t have a mock report in the new format. The new format is a little sleeker but the body of the report with all the data is the same. You can now see what I meant when I said this report contains a lot of information to wade through. At first glance it’s pretty much a nightmare but I’m going to walk you through the information found here so you can more easily identify the information that you need.
Centered, just below the tile Data Submission Detail Report are the dates and the pt populations, aka topics, that you chose to look at. Just eyeball this to make sure you have the correct and complete dates and populations.
Just below that is a line that contains Batch ID, discharge date, admit date, submission date, status and submitter name. These headers are associated with the information found below, in the body of the report .
The dark blue bar will contain your hospitals name
The dark gray bar will contain the population, and everything under that dark gray bar relates to that population until you get to the next dark gray bar with a different population.
The light gray bar contains a patient identifier. Everything in the white section under that light gray bar is associated with that patient. Until you get to the next light gray bar with the next patient identifier.
The Batch ID. In the column under the batch ID there are two different number sets. One set of numbers are 7 digits long, those are the batch ID numbers. The other set of numbers are 6 digits in length. The 6 digit numbers are associated with the measures. For instance you see AMI-1 is always # 21100. But you get a different batch ID number every time your vendor submits data for you. Each time the vendor submits even one AMI case they automatically re-submit all AMI cases. That’s just how it works. They don’t submit individual cases, they submit individual populations.
Okay, back on track. Scan to the last batch for each patient. Next to the batch ID is the Discharge and Admit dates in that order followed by the date it was submitted followed by the status.
That’s what you’re looking for, the status of the last submission. Here it will read either Accepted or Rejected.
To save time, when you open the report it opens with an adobe reader. Use the ‘search’ field at the top of the reader to search for the word ‘Rejected’.
Locate the rejected cases. Beneath that, where all the measures are listed you will see ‘Critical Error (I don’t have an example here I’m sorry, but instead of seeing AMI-1 for instance, you would see the words Critical Error). That’s followed by the reason for the critical error. It will tell there what data element was entered incorrectly then using that information go back to your data abstraction software and make the necessary changes. Then resubmit the case to your vendor and, especially if your closing in on the data submission deadline, give your vendor a call and let then know you’ve corrected and resubmitted that case or cases.
45. 45 That is all for data submission for now. It is a lot of information, but that is the process necessary to avoid under-submission and with use you will become very comfortable with it.
Let’s go back to the ‘Run Reports’ page and look at some other report types.
Select Hospital Validation reports from that drop down box.
Click go to refresh the page.
If you are one of the hospitals chosen to participate in inpatient validation you will have two reports available to you, Case Selection and Case Detail. If you are not currently participating in validation you will only have one report available to you, Case Selection.
I don’t have any mock validation reports so I’ll just give a quick run down of what you’ll see. You can pause this recording, pull your own reports and follow along, that may be helpful.
The second report listed here, the Case Selection report, list the cases you must submit to the CDAC. It provides you with the population the case is in one or two pt identifiers, the date the request was made for the record, the date it is due to CDAC and the final column will contain an ‘N’ or a ‘Y’. Yes or NO. Once the CDAC receives your records they communicate that with a Y in the final column. So, Prior to deadline you want to pull this report and see if there are all Y’s in the final column. If not just check in with Medical Records to make sure they are or will be sent in time.
The first report listed here is the Case Detail Report. This becomes available once the CDAC re-abstracts the records. This provides details about each case listing all the data elements with a comparison of how the hospital answered with how the CDAC answered. If there’s a mismatch there is an explanation provided as well. The first page for each submitted case will list the measures the case was abstracted for and whether abstraction resulted in exclusion, passing or failing the measure. Theses are the match rates that are reflected in the score.
The “Overall Reliability” score, located in the upper left on the Case Detail report, is your validation score for the quarter.That is all for data submission for now. It is a lot of information, but that is the process necessary to avoid under-submission and with use you will become very comfortable with it.
Let’s go back to the ‘Run Reports’ page and look at some other report types.
Select Hospital Validation reports from that drop down box.
Click go to refresh the page.
If you are one of the hospitals chosen to participate in inpatient validation you will have two reports available to you, Case Selection and Case Detail. If you are not currently participating in validation you will only have one report available to you, Case Selection.
I don’t have any mock validation reports so I’ll just give a quick run down of what you’ll see. You can pause this recording, pull your own reports and follow along, that may be helpful.
The second report listed here, the Case Selection report, list the cases you must submit to the CDAC. It provides you with the population the case is in one or two pt identifiers, the date the request was made for the record, the date it is due to CDAC and the final column will contain an ‘N’ or a ‘Y’. Yes or NO. Once the CDAC receives your records they communicate that with a Y in the final column. So, Prior to deadline you want to pull this report and see if there are all Y’s in the final column. If not just check in with Medical Records to make sure they are or will be sent in time.
The first report listed here is the Case Detail Report. This becomes available once the CDAC re-abstracts the records. This provides details about each case listing all the data elements with a comparison of how the hospital answered with how the CDAC answered. If there’s a mismatch there is an explanation provided as well. The first page for each submitted case will list the measures the case was abstracted for and whether abstraction resulted in exclusion, passing or failing the measure. Theses are the match rates that are reflected in the score.
The “Overall Reliability” score, located in the upper left on the Case Detail report, is your validation score for the quarter.
46. 46 The HCAHPS section also offers you a quick glance status summary report and a detailed submission report. The Provider Participation Report is also linked here, a redundancy built in for convenience, it’s the same Provider Participation report we looked at earlier.The HCAHPS section also offers you a quick glance status summary report and a detailed submission report. The Provider Participation Report is also linked here, a redundancy built in for convenience, it’s the same Provider Participation report we looked at earlier.
47. 47 Prior to posting data to Hospital Compare for public access CMS makes a preview report available to hospitals so you can see what the public is going to see before they see it.
You can change very little if anything but you at least know ahead of time what is going out there.
This preview report is called the HQA Preview report and it is available once each quarter for the month before Hospital Compare is refreshed.
Need help? – this handy little link brings you to a document explaining what will be posted to hospital compare for that time period.Prior to posting data to Hospital Compare for public access CMS makes a preview report available to hospitals so you can see what the public is going to see before they see it.
You can change very little if anything but you at least know ahead of time what is going out there.
This preview report is called the HQA Preview report and it is available once each quarter for the month before Hospital Compare is refreshed.
Need help? – this handy little link brings you to a document explaining what will be posted to hospital compare for that time period.
48. 48 if you try to select this report when it’s not available you’ll just be informed that it’s not availableif you try to select this report when it’s not available you’ll just be informed that it’s not available
49. Hospital Quality Alliance (HQA) Preview Report This is what the report looks like – sort of. Once again there have been changes but I do not yet have a mock report available to me in the new format.
As of the Q209 preview report they no longer provide quarterly data here, just the aggregate of the four most recent quarters of data. That’s what gets posted to Hospital Compare the aggregate of four quarters of clinical data.
What you’ll now see is this.
The first column will still list the measures moniker AMI-1, AMI-2 etc, with the full name in the second column.
The third column provides your hospitals performance aggregate followed by three columns of comparable data. The top ten percent nationally, the state average and the national average. The comparable data are aggregates of the same four quarters.
Q110 preview was available Jan 11th through Feb 9th.
Q210 preview will be available in April.This is what the report looks like – sort of. Once again there have been changes but I do not yet have a mock report available to me in the new format.
As of the Q209 preview report they no longer provide quarterly data here, just the aggregate of the four most recent quarters of data. That’s what gets posted to Hospital Compare the aggregate of four quarters of clinical data.
What you’ll now see is this.
The first column will still list the measures moniker AMI-1, AMI-2 etc, with the full name in the second column.
The third column provides your hospitals performance aggregate followed by three columns of comparable data. The top ten percent nationally, the state average and the national average. The comparable data are aggregates of the same four quarters.
Q110 preview was available Jan 11th through Feb 9th.
Q210 preview will be available in April.
50. 50 That’s a lot of information to absorb; you may want to pause this and go refresh your coffee then we’ll take a look at the Manage Measures Section of Quality Net before I wrap up.
Go to View/Edit Measures Designation in the Hospital Inpatient section.That’s a lot of information to absorb; you may want to pause this and go refresh your coffee then we’ll take a look at the Manage Measures Section of Quality Net before I wrap up.
Go to View/Edit Measures Designation in the Hospital Inpatient section.
51. 51 To tell you the truth I’m not sure what you see here.
I have to select the hospital. You may have to highlight your hospitals name or you may not get this screen at all. If you do get this screen just click on your hospitals name to highlight it and then click on ‘Continue’
To tell you the truth I’m not sure what you see here.
I have to select the hospital. You may have to highlight your hospitals name or you may not get this screen at all. If you do get this screen just click on your hospitals name to highlight it and then click on ‘Continue’
52. 52 The screen refreshes with a list of measures by topic.
Under each topic there are two columns. In the left hand column are all the measures you intend to submit to CMS. All IQR required measures are automatically chosen for you so that they don’t get overlooked.
Once a measure is in this column CMS will be expecting it and if you submit a case without the data associated with that measure the case is rejected and that will put you at risk for under submission.
The measures listed in the right hand column are voluntary measures that you have the option to submit. If you see them in the right hand column you are not submitting them.
You cannot change your measure selections once you have submitted even one case for that quarter so, if you plan to change your measure selections do so before any data submission for that quarter. You do not have to make measures selections every quarter. These will automatically carry over quarter to quarter. You just need to go here if you are changing your measure selections.
You want to make sure the measures selection you communicate to your vendor (a separate electronic process controlled by your vendor) make sure those measure selections match the measure selections found here.The screen refreshes with a list of measures by topic.
Under each topic there are two columns. In the left hand column are all the measures you intend to submit to CMS. All IQR required measures are automatically chosen for you so that they don’t get overlooked.
Once a measure is in this column CMS will be expecting it and if you submit a case without the data associated with that measure the case is rejected and that will put you at risk for under submission.
The measures listed in the right hand column are voluntary measures that you have the option to submit. If you see them in the right hand column you are not submitting them.
You cannot change your measure selections once you have submitted even one case for that quarter so, if you plan to change your measure selections do so before any data submission for that quarter. You do not have to make measures selections every quarter. These will automatically carry over quarter to quarter. You just need to go here if you are changing your measure selections.
You want to make sure the measures selection you communicate to your vendor (a separate electronic process controlled by your vendor) make sure those measure selections match the measure selections found here.
53. 53 Another feature worth noting while we’re here is the View History button. When measure selection changes are made this view history button appears next to the measures affected. Click on it to see who entered the change and when.Another feature worth noting while we’re here is the View History button. When measure selection changes are made this view history button appears next to the measures affected. Click on it to see who entered the change and when.
54. 54 Next we’re going to the Population & Sampling section for Hospital Inpatients.Next we’re going to the Population & Sampling section for Hospital Inpatients.
55. 55 This data does have to be submitted quarterly and has its own data submission deadline. The requirements will be reviewed in part III of this series. Each population is listed, including individual sections for each of the surgical strata.
Every box must contain a number even if that number is zero for the data to be considered complete.
Looking at pneumonia. For each month you will tell CMS how many pneumonia patients you had that carried any Medicare benefit. For these purposes CMS is not looking for how many Medicare claims you have but rather how many pneumonia patients had any Medicare benefit at all even if there was no claim to Medicare. Perhaps the pt has part D or a Medicare HMO that was not billed, count all those patients as Medicare.
Then enter how many pneumonia patients you had that month with no Medicare benefit. The totals will tally automatically. The total number of patients for the quarter is what shows up in the ‘Total Initial Patient Population’ column on your Provider Participation Report.
Next you have to enter the Medicare and Non-Medicare counts for the cases you submitted in your sample. For those of you not sampling this will be the same numbers as the initial population, for those of you sampling these numbers could be lower. Again the totals tally automatically and the total sample size is found in the box in the lower right. This number shows up on your Provider Participation Report in the ‘Total Sample Size’ column.This data does have to be submitted quarterly and has its own data submission deadline. The requirements will be reviewed in part III of this series. Each population is listed, including individual sections for each of the surgical strata.
Every box must contain a number even if that number is zero for the data to be considered complete.
Looking at pneumonia. For each month you will tell CMS how many pneumonia patients you had that carried any Medicare benefit. For these purposes CMS is not looking for how many Medicare claims you have but rather how many pneumonia patients had any Medicare benefit at all even if there was no claim to Medicare. Perhaps the pt has part D or a Medicare HMO that was not billed, count all those patients as Medicare.
Then enter how many pneumonia patients you had that month with no Medicare benefit. The totals will tally automatically. The total number of patients for the quarter is what shows up in the ‘Total Initial Patient Population’ column on your Provider Participation Report.
Next you have to enter the Medicare and Non-Medicare counts for the cases you submitted in your sample. For those of you not sampling this will be the same numbers as the initial population, for those of you sampling these numbers could be lower. Again the totals tally automatically and the total sample size is found in the box in the lower right. This number shows up on your Provider Participation Report in the ‘Total Sample Size’ column.
56. 56 The final Manage Measures sub-section I want to review with you to today is the Structural Measures section for the Hospital Inpatients.
Click on this
The final Manage Measures sub-section I want to review with you to today is the Structural Measures section for the Hospital Inpatients.
Click on this
57. 57 I get this screen but I’m not sure if you do. If you do you need to enter your 6 digit Medicare #, it begins with 22
Then Click ‘Find’
The screen is not available at this time it only becomes available during the period in which you can enter data July 1st through August 15th.
But you would see a screen that lists answered questions on the left and unanswered questions on the right.
You’ll be able to click on the unanswered questions on the right, answer them, save them and you’re done.
As this period approaches for answering the questions about what data registries you use you can be sure you will receive more direction from me. I just want you to know where it is so you can at least recognize it when you have to go back to it later this year. This data is entered in July and August each year.
I get this screen but I’m not sure if you do. If you do you need to enter your 6 digit Medicare #, it begins with 22
Then Click ‘Find’
The screen is not available at this time it only becomes available during the period in which you can enter data July 1st through August 15th.
But you would see a screen that lists answered questions on the left and unanswered questions on the right.
You’ll be able to click on the unanswered questions on the right, answer them, save them and you’re done.
As this period approaches for answering the questions about what data registries you use you can be sure you will receive more direction from me. I just want you to know where it is so you can at least recognize it when you have to go back to it later this year. This data is entered in July and August each year.
58. QualityNet My Tasks Vendors for transmitting data to CMS are authorized in the ‘My Quality Net’ section as well.
Quality Net Administrators and those basic users who have been assigned the Vendor Authorization role will see this bubble as another option when you sign into My Quality Net.
You select the data type you are authorizing a vendor for. Inpatient, outpatient or HCAHPS for hospitals.
Vendors for transmitting data to CMS are authorized in the ‘My Quality Net’ section as well.
Quality Net Administrators and those basic users who have been assigned the Vendor Authorization role will see this bubble as another option when you sign into My Quality Net.
You select the data type you are authorizing a vendor for. Inpatient, outpatient or HCAHPS for hospitals.
59. Vendors currently authorized
You are brought to a screen that provides a list of vendors you currently authorize to submit data on your behalf.
From here you can either Update the authorization (most likely selected when you end a relationship with a vendor) or you can add a new vendor by clicking on one of the two gray buttons seen toward the bottom of the page.
Both screen sets are similar, we’ll go into add new vendor authorization.
Click on that
You are brought to a screen that provides a list of vendors you currently authorize to submit data on your behalf.
From here you can either Update the authorization (most likely selected when you end a relationship with a vendor) or you can add a new vendor by clicking on one of the two gray buttons seen toward the bottom of the page.
Both screen sets are similar, we’ll go into add new vendor authorization.
Click on that
60. Add a new vendor to authorized vendor list When the screen refreshes you will see a drop down box from which you will select a new vendor – all authorized vendors are listed here.
You then have to enter two different dates.
One the ‘Encounter Date’ tell CMS the first day of the quarter you are allowing this vendor to submit data for. For instance if this vendor will begin submitting Q111 data you will enter 01/01/2011 in this box.
Next you have to tell CMS on which date this vendor is allowed to begin submitting data on your behalf that is called the Data Transmission date.
If the vendor is starting with Q1 2011 data that data cannot be submitted until after the deadline for Q410 data. The deadline for Q410 data is May 1st 2011 for outpatient (considering that’s the screen we’re looking at) so with the deadline for Q410 data being 05/01/2011 you would enter 05/02/2011 as the Data Transmission date.
The day after the data submission deadline for the previous quarter.
Do this for each patient population.
Do not enter ends dates until you are ending your relationship with this vendor. Leave them blank until then.
Select the Continue buttonWhen the screen refreshes you will see a drop down box from which you will select a new vendor – all authorized vendors are listed here.
You then have to enter two different dates.
One the ‘Encounter Date’ tell CMS the first day of the quarter you are allowing this vendor to submit data for. For instance if this vendor will begin submitting Q111 data you will enter 01/01/2011 in this box.
Next you have to tell CMS on which date this vendor is allowed to begin submitting data on your behalf that is called the Data Transmission date.
If the vendor is starting with Q1 2011 data that data cannot be submitted until after the deadline for Q410 data. The deadline for Q410 data is May 1st 2011 for outpatient (considering that’s the screen we’re looking at) so with the deadline for Q410 data being 05/01/2011 you would enter 05/02/2011 as the Data Transmission date.
The day after the data submission deadline for the previous quarter.
Do this for each patient population.
Do not enter ends dates until you are ending your relationship with this vendor. Leave them blank until then.
Select the Continue button
61. Approve new or changed vendor authorizations You’ll see a confirmation page
Review the data entered
Select the Edit button to go back to modify dates
Or enter you’re ‘My Quality Net’ password & select the Submit button to saveYou’ll see a confirmation page
Review the data entered
Select the Edit button to go back to modify dates
Or enter you’re ‘My Quality Net’ password & select the Submit button to save
62. Vendor authorization complete This is the acceptance page
The authorization is complete
Select the Print button if you wish to print a copy for your recordsThis is the acceptance page
The authorization is complete
Select the Print button if you wish to print a copy for your records
63. Quality Net Roles Basic Access – to view QNet content
APU Role – to view APU Dashboard
CART Role– to enter data into the CART tool
QIO Clinical Warehouse Feedback Reports Role
File Exchange and Search Role
HCAHPS Feedback Role
HCAHPS Online Data Entry Role
HCAHPS Vendor Authorization Role
ICD Population Sample Read Role
ICD Population Sample Update/Edit Role
Measure designation Read Role
Measure Designation Update/Edit Role
63 The last point I want to make today is that there are a vast number of ROLES you can be authorized for as a QNet User.
One of the Quality Net Administrators from your hospital can give you any one of them
The Admin logs into QNet goes to the Administrative section under Edit user
The admin selects you from the list and then selects the role he/she would like to add and okays it
You then have access to that area of QNet when you next sign in.
Those listed here are specific to inpatient data collection
I emboldened those I think every QNet user should have if you have a hand in the inpatient data collection process.
FYI the Measure Designation Update/Edit Role allows you to answer the Structural measures questions as well as update the measures selection.The last point I want to make today is that there are a vast number of ROLES you can be authorized for as a QNet User.
One of the Quality Net Administrators from your hospital can give you any one of them
The Admin logs into QNet goes to the Administrative section under Edit user
The admin selects you from the list and then selects the role he/she would like to add and okays it
You then have access to that area of QNet when you next sign in.
Those listed here are specific to inpatient data collection
I emboldened those I think every QNet user should have if you have a hand in the inpatient data collection process.
FYI the Measure Designation Update/Edit Role allows you to answer the Structural measures questions as well as update the measures selection.
64. Quality Net Roles HOPQDRP Data Upload Role
HOPQDRP Feedback Reports Role
HOPQDRP Population Sample read
HOPQDRP Population Sample Update/Edit
HOPQDRP Submission Reports Role
HOPQDRP Vendor Authorization Role
64 There are also a number of roles available to you specific to outpatient data collectionThere are also a number of roles available to you specific to outpatient data collection
65. 65 That is all for today. There is a great deal to absorb but with increased familiarity these reports and QNet data entries will become second nature and, as always, I am available to assist you in accessing and utilizing any of this information.That is all for today. There is a great deal to absorb but with increased familiarity these reports and QNet data entries will become second nature and, as always, I am available to assist you in accessing and utilizing any of this information.
66. 66 Questions ? QIO contacts
Beth McConville
emcconville@maqio.sdps.org
781-419-2887
Chris Richards
crichards@maqio.sdps.org
781-419-2757
Matt Kennedy (for Quality Net Access)
mkennedy@maqio.sdps.org
781-419-2807
Quality Net Help Desk
E-mail: qnetsupport@ifmc.sdps.org
Phone: (866) 288-8912
Fax: (888) 329-7377
Here is my contact information along with my colleague Chris Richards. I also give you the contact info for Matt Kennedy he is available here at Masspro to assist you with Quality Net access as well.
He’s actually the person you process the paper work through when you are initially registering for a QNet password.
I hope you found this information helpful and clear. And I hope that you will join me in part III of this series to review the specific Inpatient Quality Reporting requirements for FYs 2012, 13 and 14.
Have a great day.Here is my contact information along with my colleague Chris Richards. I also give you the contact info for Matt Kennedy he is available here at Masspro to assist you with Quality Net access as well.
He’s actually the person you process the paper work through when you are initially registering for a QNet password.
I hope you found this information helpful and clear. And I hope that you will join me in part III of this series to review the specific Inpatient Quality Reporting requirements for FYs 2012, 13 and 14.
Have a great day.
