CHCS and ADM

1. CHCS and ADM Achieving Data Quality Success

2. Agenda • Part 1: CHCS, Presented by Ms. Kiefer • Part 2: Ambulatory Data Module (ADM), Presented by Mr. Kavanaugh

3. COMPOSITE HEALTH CARE SYSTEM

4. CHCS Agenda • Information Resources • Data Quality Building Blocks • Provider File • Patient Registration • Workload Assignment • Inpatient Visit Information • DQ Process Key Points

5. CHCS Information resources

6. Why Focus on CHCS? • CHCS: Primary clinical application and data source for the Military Health System (MHS) to: • Capture and report services provided • Measure productivity & efficiency • Forecast demand for services • Establish performance benchmarks • Identify trends and utilization • Assess and improve quality of services

7. Achieving DQ Success • Attend CHCS Training: • CHCS Virtual Classroom:https://fieldservices.leidos.com/Report.aspx?Id=506 • Army MAPS Program:http://www.youtube.com/user/ArmyMAPSProgram/videos?shelf_index=0&view=0&sort=dd • AFMOA DQ Documents:https://kx2.afms.mil/kj/kx2/DataQuality/Documents/Forms/ShowFolders.aspx • Navy CHCS Nuggets:http://www-nmcp.med.navy.mil/EduRes/CompMedia/chcs/nuggets.asp • Establish CHCS and AHLTA Users Forum • Learn MTF Business Processes: • Provider & Staff In and Out-Processing • CHCS & AHLTA Support and Training Team • Coding Support and Provider Feedback • Performance Plan Targets & Balanced Scorecard Objectives • Special Programs • MTF Unique Processes • MTF CHCS, AHLTA & Essentris Super Users

8. Application Capabilities • Interfaces and shares data with numerous Clinical & Administrative Applications: • AHLTA, HAIMS, iEHR, Essentris, CCE • DEERS • EASi • TPOCS, ABACUS, etc (Service Specific) • PDTS • CHAS ICDB • Standard tables for data consistency: • ICD • CPT • HIPAA Taxonomy • CMAC • Site defined files and tables • Standard and ad-hoc reporting capabilities

9. It Takes A Team! • Service & Region DQ Points of Contact (POCs) • MTF DQ Manager • DQ Assurance Team • Information Management or Systems • Coders & Auditors • Clinic Managers & Administrators • Everyone!

10. OLUM: Best Kept Secret! • CHCS On-Line Users Manual (OLUM) • Electronic documentation and index of CHCS Functions and Reports • Accessible by ALL CHCS Users: • Type OLUM from any Menu display in CHCS • Select IND to access the OLUM Index • Select CHCS Sub-System (Arrow Down to view additional topics) • Browse or Find topic of interest such as “Monthly” or “Hospital Location” • Does not include recent CHCS updates

11. CHCS Data quality Building blocks

12. Integrated Capabilities Graphic User Interface CHCS Patient Registration DEERS Eligibility Enrollment Patient Merge Wellness Immunizations INTERFACE TOOLS 1 Questionnaires Appt Scheduling Walk-In Visits Encounter Notes Radiology Services 1 Patient Merge Appt List Display Walk-In Visits Pharmacy Services Scanned Images T-CONS & Consults Laboratory Services 2 2 Encounter Data Ambulatory Data Module (ADM) AHLTA Clinical Data Repository (CDR) Order Entry Results Review Order Entry Results Review CCE - Coding Compliance Editor AHLTA captures patient data and clinical documentation from MTFs world-wide into a single, global clinical database and the DoD Electronic Health Record (EHR) Inpatient Admissions CarePoint (CHAS) DoD VA SHARE (BHIE)

13. Building Data Quality • MTF Managed Files • User • Patient and Enrollment • Provider • Hospital Locations • Templates & Schedules • Patient Appointments • Pharmacy Files • Laboratory Files • Radiology Files • Consults

14. MTF Managed Files • User File • CHCS and AHLTA Access • Defined by • Menus • File Manager Access Codes • Security Keys

15. MTF Managed Files • Patient File • Unique person identification • Allow DEERS to auto-register new enrollees

16. MTF Managed Files • Provider File • Includes Both Internal and External Providers • Data accuracy impacts: • Billing and Potential Reimbursements • Patient Enrollment • Templates and Schedules • Appointing • Clinical Order Entry • Highlighted Fields • Proper Naming Convention • National Provider ID (NPI) • Provider Specialty - HIPAA Taxonomy • Signature Class • Primary Hospital Location (MEPRS) • DEA and or License • EDI_PN

17. MTF Managed Files • Hospital Location File • Identifies types of services provided and where they are performed: • Inpatient Wards • Ambulatory Procedure Units (APUs) • Outpatient Clinics • Ancillary Services Locations (LAB, RAD and Rx) • Admin Areas and File Rooms • Linked to Functional Cost Codes (FCC) and Defense Medical Information System (DMIS) ID

18. MTF Managed Files • PAS Profile Template File • Clinic Schedule Templates • Schedulable Entity File • Clinic Appointment Schedules • Data purged from CHCS every 60-120 Days, depending on site parameters

19. MTF Managed Files • Patient Appointment File • Clinic Appointments, Ambulatory Procedure Visits (APVs), RNDS* and Radiology (RAD*) • Sends Scheduled Appointments to AHLTA • Captures key elements for Workload Reporting

20. MTF Managed Files • KG ADC Data File • Captures Encounter Coding • Provides data to identify services and measure performance

21. Clinic Profile • Establishes Clinic Workload • Identifies Clinic Appointment Types • Includes security keys to ensure designated clinic and central appointment personnel can appoint • Determines appointment times and parameters

22. Linking It All Together DMIS Group Parent (DMIS ID) CHCS MTF Division (DMIS ID) CHCS MTF Division (DMIS ID) 4th Level FCC 4th Level FCC 4th Level FCC 4th Level FCC 4th Level FCC 4th Level FCC Hospital Locations Hospital Locations Hospital Locations Hospital Locations Hospital Locations Clinic Profile Clinic Profile Clinic Profile (CPRO) Clinic Profile Clinic Profile Appt Type Provider Profile Provider Profile Provider Profile (PPRO) Provider Profile identifies Clinic Locations where the Provider sees Patients and valid Appointment Types

23. CHCS Provider file

24. Provider File Elements • Provider ID (Short Name) • First 4 letters of Last and First Names • DO NOT include any portion of the Provider SSN • National Provider ID (NPI) • CMS identifier for health care providers • Provider Class • Locally defined; attached to the Signature Class file • Physician, Resident, Pharmacist, Clinical Nurse, Student, Technician, etc. • Establishes Provider Privileges for Order Entry (3, 4, 99 are HCP classes) • Medical Specialty->HIPAA Taxonomy->CMAC Class • CHAMPUS Maximum Allowable Charge (CMAC) Class used to calculate billing rate for Outpatient Itemized Billing • Multiple Specialties and HIPAA Taxonomies may be assigned • EDI_PN • Uniquely identifies each provider within the Department of Defense • Added after providers are updated via the EWPD • Once attached, provider information can no longer be modified • MEDCOM uses this to link DMHRSi availability to CHCS appointing

25. Provider File Maps Provider Signature Class • 1 - NURSE • 2 - PROVIDER W COUNTERSIGNATURE • 3 - HCP • 4 - COUNTERSIGNING HCP • 0 - CLERK WITH LIMITED ORDERING • 99 - OUTSIDE PROVIDER Provider Class Locally Defined by Staff Function • NAME SIGNATURE CLASS • ------------------------------------------------------------------------------- • EARLY INTERVENTION SPEC (NURS) NURSE • EKG TECHNICIAN NURSE • EMERGENCY PHYSICIAN HCP • ENDOCRINOLOGIST HCP • EXTERNAL PROVIDER OUTSIDE PROVIDER • FAMI.PRACT.PHYSICIAN RESIDENT HCP • FAMILY PRACTICE PHYSICIAN HCP • GENERAL MEDICAL OFFICER HCP Medical Specialty • (000) GENERAL MEDICAL OFFICER • (001) FAMILY PRACTICE PHYSICIAN • (003) FAM PRAC RESIDENT&INTERN W LICENSE • (004) EMERGENCY PHYSICIAN • (600) NURSE, GENERAL DUTY • (900) CORPSMAN TECHNICIAN • (901) PHYSICIAN ASSISTANT • Provider Signature Class is a key • field in the Provider Class Table. • Signature Class determines • Ancillary Order Entry Privileges CMAC Provider Class • 01 MEDICAL DOCTOR&DOCTOR OSTEOPATHY • 02 MENTAL HEALTH PROVIDER • 03 ADDITIONAL MENTAL HEALTH PROVIDER • 04 ADDITIONAL MEDICAL PROVIDER HIPAA Taxonomy Map • Code: 207Q00000X • PRIVILEGE ASSIGNED: PRIVILEGED • PROVIDER SPECIALTY CODE: 001

26. Provider File Management Recommendations • IMD, Systems or Data Admin: • Creates CHCS User Account per clinic leadership • Network Access • AHLTA Account Transfer • CHCS and AHLTA Training (contract permitting) • Non-Privileged Provider File Entry in CHCS • Credentials: • Privileged Provider File Entry in CHCS • Clinic, Operations or MCP Network Manager: • Sets PCM Flag and Manages PCM Capacity • Clinic Managers and Appt Supervisors: • Clinic Profile Entry and Updates (CPRO) • Provider Profile Entry and Updates (PPRO)

27. CHCS Patient registration

28. Patient Registration • Patient MUST be registered in the local CHCS host • Registration fail safes • Double entry to confirm Person Identifier • Automated DEERS check during registration • Automated duplicate search • Effective June 2011, the SSN Administration began assigning area numbers (800 – 899) as real SSN • Allows users to update various levels of demographic data in full or mini-registration

29. Patient Registration Flow DEERS Updates AHLTA Clinical Data Repository DEERS CHCS Synchronize Patient Data • DEERS is the “gold” standard • When a new person is added to CHCS, DEERS downloads data into CHCS • Security Keys prevent users from by-passing DEERS matching • Fileman “&”, DG ADD PATIENT, DG REG SYNCH

30. Duplicate Patients • Duplicate patient prevention and merge processing is critical to ensure a single electronic medical record for all inter-related systems • CHCS Potential Duplicate Patient Search Report identifies potential duplicates • CHCS User Registration Report identifies users requiring additional training • Dedicated MTF POC must investigate duplicates and perform patient merges on CHCS • Weekly updates of CHCS Patient Merges submitted to MHS Help Desk for merge processing in AHLTA • AFMOA ePatient Data Integrity contractors correct registration errors, resolve CHCS duplicate patients, troubleshoot HAIMS duplicates, and submit AHLTA incidents

31. Duplicate Patient Risk • Potential Risk to Patient Safety! • CHCS cannot perform Drug-Allergy checks across duplicate records • Pharmacy Data Transaction System (PDTS) may miss critical Drug-Drug checks • Important clinical history may not readily visible in CHCS, DoD VA SHARE and AHLTA • Implications for Orders entered in AHLTA – Appears to the Provider as “Orders NOT Writing Back to CHCS”

32. Duplicate Pt Prevention • Train Patient Look-Up Processes: • CAC Card Look-Up (Bar Code Scanner) • Verify against Military ID or CAC Card (DoD ID#) • Patient Name – Enter patient’s last and first name • Partial Name – Enter shorter version of name to find spelling variations • DOD Identification number (DOD ID) if available • Person identifier • Sponsor person identifier (current or historical) – enter the sponsor’s person identifier at the patient name prompt • Confirm with DOB and gender

33. Patient Enrollment • Interface between CHCS and DEERS supports Managed Care Enrollments for MTF Enrollees • When key data elements do not match between CHCS and DEERS, an error or discrepancy will be reported • Enrollment data errors potentially impact successful updates: • New Enrollments • Enrollment and PCM Transfers • Family Member Enrollments • Enrollment errors may result in delays in Network Referrals being processed – impacting Patient Care

34. CHCS Workload assignment

35. Workload Assignment • Workload Reports: • Monthly Statistical Report (MSR) • WAM EAS • Workload Assignment: • DMIS ID Group Parent->Treating MTF DMIS ID • Only COUNT Visits are reported as Visit Workload • 4th Level MEPRS Code (Functional Cost Center - FCC): • Inpatient – “A” Level FCCs: # Admissions & Dispositions and Occupied Bed Days • Outpatient – “B” Level FCCs and (Dental – “C” Level FCCs) • Special Programs – “F” Level FCCs (FBN* Hearing Conservation) • # COUNT Visits • Patient Category (Rolls up to Beneficiary Category) • Patient Status (Inpatient and Outpatient) • Appointment Status (KEPT, S-CALL, WALK-IN or T-CON*)

36. CHCS Inpatient information

37. AHLTA Inpatient Prompt 1. 5. • Patient found as Inpatient (MEPRS YYYA) • Leave Blank • Pop Up Message will then be displayed • Click No – “The Visit is NOT associated with the inpatient stay…” • NOTE: If you click YES, the workload will inappropriately be set as INPATIENT. It will cause an ADM Writeback error and you will not receive proper credit for this encounter. It will also be difficult to correct without assistance from Systems/IMD personnel. • Visit or Encounter will then be credited to Assigned “B” Clinic 2. 3. 4.

38. Inpatient Admissions • Admissions, Transfers and Dispositions: • Assigns Occupied Bed Days (OBDs) at the Census Hour, to the current clinical service • Day of Admission is equal to an OBD, even if Admission is less than 24 Hours, unless patient is same day Transfer In and Out • Day of Discharge is not counted as an OBD for Workload or Billing • Current Clinical Service is Requesting Location for Ancillary Services • Inpatient Coding: • ICD Codes used to capture Diagnosis and Procedures • NATO STANAG (2050) for Cause of Injury Coding • Diagnosis Related Grouping (Inpatient CCE – MS-DRG Grouping)

39. Attending RNDS* • Current Attending Provider and Clinical Service is used to create Inpatient Professional Services Record (IPSR RNDS*) in Ambulatory Data Module (ADM) • Ancillary workload (i.e., Radiology, Pathology, Pharmacy) will be credited to the appropriate A*** CAPER • RNDS* encounter is used to capture Inpatient Professional Services of the Attending Provider • RNDS* encounters are completed in ADM • RNDS* encounters not completed within 30 days are automatically cancelled by CHCS

40. SIDR • Inpatient data is reported in Standard Inpatient Data Record (SIDR) • The SIDR is an extract file of patient level Admissions data. It is generated monthly. • Army MTFs also create an interim monthly SIDR – “D” Records Only • “D” Records contain a Final Assigned DRG • Key SIDR data elements include: • Treatment MTF DMIS ID • Admission and Disposition Dates • Source of Admission and Type of Disposition • Diagnosis & Procedure Codes • MS-Diagnosis Related Group (DRG) and Weight • Patient Demographics • Age at Admission • Occupied Bed Days per Clinical Specialty (4th Level FCC) • Intensive Care Unit (ICU) Days • MEPRS Code of the Referring Clinical Specialty for ICU Care

41. DQ Process Key Points Cost, Performance & Billing (CHCS, ADM, EAS, M2) Clinical (CHCS ADM & AHLTA) • Ancillary File Maintenance • Common File Synchronization Across Systems (Personnel and Clinical) • Synchronization of Workload Reporting (SIDR, CAPER, WWR, WAM EAS) • Accurate data to study Access to Care, Quality Improvements, Business Planning and Market Share Analysis Enrollment, Demographics & Other Health Insurance (CHCS & DEERS) • Clinic & Provider Profiles (Specialties & Workload Flags) • Individual Check-In & End of Day Processing • Correct Assignment of Inpatient Attending Provider and Service • Coding Accuracy and Timely Completion • Ancillary Order Requesting Locations • Patient Registration • Duplicate Patients • NED Error Processing • CHCS DEERS Sync • Eligibility Verification • OHI Capture (e2569) Be Prepared for the “Duration”… Data Quality is not at One-Time Effort…

43. ADM Agenda • Business Rules • Encounter Data Flow • Encounter Example • Data Extracts • Coding Compliance Reports

44. ADM Business rules

45. Coding Table Updates • CPT – Updated per Calendar Year • Effective 1 Jan • MTF updates synchronized for AHLTA, CHCS and CCE • CPT automatically sent to TPOCS from CHCS • Use CHCS or M2 to identify Obsoleted Codes used - to identify impact and reduce “Obsolete” ICD-9 Code Write-Back errors • Coordinate with Ancillary Areas (LAB & RAD) to update CHCS LAB & RAD Site Defined files and Radiology Procedure Groups • ICD-9 – Updated per Fiscal Year • Effective 1 Oct • MTF updates must be coordinated for AHLTA, CHCS, CCE and TPOCS • Use CHCS or M2 to identify obsoleted codes used - to identify impact and reduce “Obsolete” coding AHLTA Write Back errors ADM software supports ICD-9 and CPT Coding validation, based on Date of Service - needed for Billing and CCE encounter coding updates

46. Capturing Clinical Services Capacity Workload Services Performance Schedules Appointments Encounters RVU • Frozen • Open • Booked • Pending • Cancelled • Kept • Walk-In&Sick-Call • T-CONS • LWOBS • No-Show • Cancelled (Patient) • Cancelled (MTF) • Cancelled (TOL) • Occ-Svc • Admin • Open (Not Coded) • Complete • Diagnosis • Procedures&Services • Documentation • Quality of Services • Population Health • Outcomes • Practice Profiles • Research • Simple Work Relative Value Units (RVU) • Enhanced RVU • Enhanced Work RVU • Enhanced Practice Expense RVU • Average RVU & Encounter • RVU, Provider FTE, Day • Provider Aggregate RVU Focus Shifting from “Counting Visits” to Measuring Work & Services Provided

47. Encounters vs Visits • An encounter captures services provided: • Reason for seeking care • Where the services were provided • Level of Medical Decision Making and Complexity • Clinical services provided • Identifies Staff (By Name) providing the services • Provider Seen • Clinical Service • Provider Medical Specialty and HIPAA Taxonomy

48. Encounter Data Elements • ICD-9-Coding – Why was Patient seen? • Chief Complaint and Diagnoses • CPT Coding – What was done to address the patient problem? • Provider Services and Procedures supports capture of RVU • Modifiers (explain additional details about the Service or Procedure) • Units of Service • HCPCS Coding - What additional services and supplies were provided? • Evaluation & Management Coding: • Setting • Office, (New or Established), Inpatient Professional Services (IPSR), Emergency Room, Preventive Service (New or Established), etc. • Level of Services • Complexity (Minimal, Low, Moderate, or High) • Age Band • Preventive Services and Wellness • Encounter data stored in CHCS KG ADC DATA file

49. Additional Details • HIPAA standard data elements: • Cause of Injury and associated elements • Geographic Location of Injury (Motor Vehicle Accidents) • Pregnancy Related and associated elements • HIPAA Provider Taxonomy • Secondary Providers • Additional E&M Codes (up to 2 Additional E&M Codes) • Diagnosis Code Priority (Links Procedure to Dx 1, 2, 3 or 4) • CPT Code Units of Service (per CPT Code) • CPT Code Modifiers (up to 3 – per CPT Code) • Military Unique ICD-9 Codes (ICD-9 Code Extenders) • Encounter Disposition (Inpatient Services and Ambulatory Disposition Types)

50. ADM Encounter data flow