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Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013

Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013. Carmela Estrada Bondad, MPH Hospital Engagement Network Health Research & Educational Trust American Hospital Association. Objectives. Gain understanding of what information is provided in the CDS Reports

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Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013

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  1. Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013 Carmela Estrada Bondad, MPH Hospital Engagement Network Health Research & Educational Trust American Hospital Association

  2. Objectives • Gain understanding of what information is provided in the CDS Reports • Learn how to interpret and use your data to determine progress on the HEN project

  3. Agenda • Review HEN Data Needs • Overview of Reports Available in CDS (Live Demo) • Individual Measures Reports • All Measures Report • Comparative Measures Report • Hospital Dashboard • Interpreting and Using your Data • Cynosure/HRET Improvement Calculator • Questions?

  4. HEN Overview • ACA considerable focus on quality • Created the CMS Innovation Center • Public-private partnership • Set 40/20 goal • Tool: Hospital Engagement Networks • 26 contracts awarded • Contracted with 34 state and regional hospital associations • 1,600 + hospitals Hospital HAC Teams Clinicians & Front Line Staff THE PATIENT

  5. What is Data Management in HEN? • Surgical Site Infection (SSI) • Obstetrical Adverse Events/EED • Injuries from Falls & Immobility • Pressure Ulcers • VTE Preventable Readmissions Adverse Drug Events (ADEs) CAUTI CLABSI Ventilator-Associated Pneumonia (VAP)

  6. Why collect & report data? • To demonstrate hospitals have reduced their Hospital Acquired Conditions and Readmissions over the 2 year period • To monitor that interventions are working • Part of the PDSA cycle • Measures are used to assess the impact of changes • To identify areas of strengths, weaknesses, and challenges – guide your improvement efforts

  7. Data Requirements For each of the ten clinical topics, submit: • 1 process measure (how we know our interventions are actually implemented) • 1 outcome measure (how we know our interventions are actually working)

  8. Data Timeframes • Baseline Data • Prior to January 2012 • Start/End date determined by user • One aggregate numerator/denominator • Monitoring Data • January 2012 – December 2013 • One numerator/denominator for each month

  9. More data submission?! • Things to consider… • What are you already measuring? • What are you planning to measure? • What other data sources exist? • Identify Existing Measures • Are they in the Encyclopedia of Measures? • If not, there is an option to add user-defined measures.

  10. Data Needed Patient Level Data PHI

  11. Comprehensive Data System • HRET’s project data collection system • Web-based • Secure • Flexible • https://www.hretcds.org

  12. Live CDS Demonstration • Logging in • Measure “enrollment” • Organization-defined measures • Data entry • Reports • Individual Measure • All Measures • Comparative Measures Report • Hospital Dashboards

  13. What type of report do I need? • Data and Run Chart for your hospital’s performance on a single measure? • Individual Measure Report • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance? • Measure Comparison Report • Data only for all Measures and data entered for your hospital? • All Measures Report

  14. What type of report do I need? • List of who has CDS access/type of access? • Organizational User* • Dashboard Report on data submission status, outcome measure results, and run charts for all EOM measures? • Hospital Dashboard

  15. Individual Measure Report • The Individual Measure Report allows you to see a selected measure for a selected hospital across time. • Includes: • Timeframe (Baseline or Monitoring) • Start and End Date • Numerator and Denominator values • The rate for all timeframes where the data has been submitted.

  16. Individual Measure Report

  17. Individual Measure Report • Click on the ‘Reports’ tab • Then select ‘Individual Measure’

  18. Individual Measure Report • By selecting the ‘Chart’ tab after selecting a measure in the ‘Data’ section, you can see a run chart of the selected measure.

  19. Individual Measure Report – Sample Run Chart

  20. Individual Measure Report • To export:

  21. All Measures Report • The All Measures Report is a report that allows you to see all measures across all topics where data has been submitted. • Includes: • Organization name • Topic • Measure Name • Timeframe (Baseline or Monitoring) • Start and End Dates • Numerator and Denominator Definitions • Numerator and Denominator Values • The rate for that timeframe • The date the data was last updated • The city and state • Medicare ID Number • HRET_MeasureID (Our designated ID for the measure) • Measure Type (Outcome or Process)

  22. All Measures Report

  23. All Measures Report • Click on the ‘Reports’ tab • Then select ‘All Measures’

  24. All Measures Report • The circled area shows the different elements you can use to filter the data • For example, if you only wanted to view Falls Data, you could use the dropdown menu for ‘Topic’ as pictured below.

  25. All Measures Report • It can be filtered by any of the listed elements that are included • The full report can be exported to Excel • Filtered data can also be exported to Excel • Note: Depending on the amount of data you have, the All Measures Report may take longer to load

  26. All Measures Report • To export:

  27. Comparative Measures Report • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance • Only Available for EOM and State-defined measures

  28. Measure Comparison Report • Measure Comparison Report—CHART view

  29. Measure Comparison Report • The data used in the CHART can be found by clicking the DATA tab. • The variables included in the DATA view are • HRET_OrganizationID—the unique HRET identifier for your organization • HRET_MeasureID—the unique measure identifier • Measure-the measure name • Timeframe– Baseline (pre-2011) or Monitoring (2012-forward) • StartDate– timeframe start date. For BASELINE, this is YOUR organization’s start date • EndDate– timeframe end date. For BASELINE, this is YOUR organization’s end date • Numerator—your organization’s numerator • Denominator—your organization’s denominator • Rate– your organization’s rate • All State Hosps Rate—the rate for all hospitals in your state reporting this measure • # State Hosps—the number of hospitals in your state reporting this measure • All Project Hosps Rate—the rate for all hospitals in the project reporting this measure • # Project Hosps—the number of hospitals in the project reporting this measure • MeasureType—Outcome or Process

  30. Organization User Report • List of who has CDS access/type of access • Only Available for Data Administrators

  31. Organization User Report

  32. What is the Hospital Dashboard? • The Hospital Engagement Network Hospital Dashboard is a monthly report that contains data and information related to your hospital’s • Data submission status • Outcome measure results • Readmission Race data • Early Elective Delivery/Hard Stop Policy information • Run charts depicting your hospital’s progress towards the goal of reducing harm by 40% and reducing readmissions by 20% by the end of 2013. • Canned Monthly Report • Available for download under CDS Resources

  33. Data Sources

  34. Update Process

  35. Hospital A

  36. Hospital Hospital Hospital Hospital

  37. Hospital Hospital Hospital Hospital

  38. Hospital Hospital Hospital Hospital

  39. Hospital Hospital Hospital Hospital

  40. Interpreting and Using Your Data and Reports • Using data to answer your questions • “Now that I have all of this data, what do I do with it?” • “What does my data mean?” • “Am I reaching my improvement goals?”

  41. Interpreting and Using Your Data and Reports • Preparing data for analysis • What question are you trying to answer? • What is the best way to present the data? • Who is your audience for your analysis? • Do you have any outliers or strange data? • Run chart points that are clearly out of line with others • Missing data points

  42. Interpreting and Using Your Data and Reports • Preparing data for analysis • What question are you trying to answer? • What is the best way to present the data? • Who is your audience for your analysis? • Do you have any outliers or strange data? • Run chart points that are clearly out of line with others • Missing data points

  43. Interpreting and Using Your Data and Reports • Run the analysis • Pull the data from CDS • Run chart • Export raw data from CDS and copy/paste into excel to create your own graphs • Assess trends • Draw conclusions • Quality Checks on your Results • Present your final results • Ensure that your graphs and data are understandable to your audience • Be creative!

  44. Tools for Interpreting and Using Your Data • Cynosure/HRET Improvement Calculator • Developed to help translate data into Harms prevented and Estimated Costs Savings • Available for download in CDS Resources (excel file) or in Data tab of www.hret-hen.org • Live Demo

  45. Click on L4; Enter # of 30-day all cause readmissions for baseline period

  46. Click on M4; Enter # of discharges for baseline period

  47. Click on L5; Enter % reduction for goal (only if you want to change from 20% default)

  48. Click on L6; Enter cost (only if you want to change from default)

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