Data Collection Support Webinar

2. Data Collection Support Webinar MetaStar, Inc. March 21, 2007 Candi Davis Carol Ferguson Pam Clemens

3. AnnouncementsQuarter 3 2006 Validation Case Selection • Record requests are late this quarter, should be mailed soon • Run “Case Selection” report available on www.qualitynetexchange.org • Click on “Hospital Validation Reports” • Choose Quarter 3 2006

4. AnnouncementsQuarter 3 2006 Validation Case Selection • Encourage HIM department to copy medical records promptly • Review the copies for completeness • Make sure any EHR documents you utilized during abstraction are part of the paper copy • Send to the CDAC in the timeframe allowed

5. Announcements Quarter 2 2006 Validation Results • Validation has been completed for all WI hospitals • Very high failure rate this quarter: • 10 Critical Access Hospitals • 5 PPS Hospitals

6. Announcements Quarter 2 2006 Validation Results • Failures due to: • “Invalid Record Selection” mismatches (6) • Pneumonia working diagnosis (5) • Miscellaneous mismatches

7. Announcements Quarter 2 2006 Validation Results • Miscellaneous mismatches across all topics • Missing documents from paper medical record copy • Abstraction staff changes • Using wrong version of data definitions • Not following guidelines/abstractor missed information

8. Announcements Quarter 2 2006 Validation Results • Invalid Record Selection Reasons: • Patient not admitted to acute care • Date of birth • Swing bed admission • Admission/discharge date (3)

9. What makes a record an “Invalid Record Selection”? • Wrong patient – Date of birth on cover sheet does not match the record • Wrong dates of stay – Provider submits a different admission than what was requested on the coversheet

10. What makes a record an “Invalid Record Selection”? • Wrong admission or discharge date – Dates on the coversheet do not match the documentation in the record • Wrong type of admission – Stay is not acute care admission

11. “Invalid Record Selection” • Information on the green coversheets and case selection listing is from the abstracted data the hospital or its vendor submits to the warehouse • Information on the green coversheets must match the documentation in the medical record • It is extremely important that the patient’s date of birth and admission/discharge dates are entered correctly

12. “Invalid Record Selection” • It is also very important that the stay is an acute care admission when submitting data • The CDAC is not permitted to make changes or assume data entry errors • During abstraction and after submission, double check admission date, discharge date and date of birth • Do not assume the UB-92 download information is correct. If the abstractor determines through their chart review that the UB-92 information is incorrect, they should correct and override the downloaded value

13. “Invalid Record Selection” • From the HRP QIOSC: • “The numbers of Invalid Record Selections has risen nationally, so this is not a Wisconsin issue. The majority of errors I have seen are due to the provider abstracting the date of service to include the observation stay or a SNF/Hospice discharge. Providers need to be reminded that abstracting medical records for CMS is not the same as billing. CMS requests that only Acute Inpatient levels of care be abstracted and submitted to the warehouse.”

14. “Invalid Record Selection”Example 1 • Patient arrives to ED 2/10, placed in observation • On 2/11 physician writes an order for admission • Patient discharged 2/13 • Dates of service that is submitted to the warehouse should be 2/11- 2/13 • If the provider submitted the dates of service as 2/10 - 2/13 this would be listed as an “Invalid Record Selection” since the admission date does not match the medical record documentation

15. “Invalid Record Selection”Example 2 • Patient arrives to ED 2/15, physician writes an order for admission • On 2/20 physician writes an order to transfer patient to inpatient SNF or hospice • Patient discharged 2/25 • Dates of service that is submitted to the warehouse should be 2/15-2/20 • If the provider submitted the dates of service as 2/15-2/25 this would be listed as an “Invalid Record Selection” since the date the patient was discharged from Inpatient acute level of care does not match the information submitted to the warehouse

16. “Invalid Record Selection” • Information about “Invalid Record Selection” can be found on www.qualitynet.org • Under the “Hospitals” tab • Click on “Data Validation” • Click on “Data Validation Overview” • See also, “Specifications for Calculating Hospital Data Validation Results” pages 7-8 • See also Quest # 55830 for guidance on readmissions

17. Most Common Abstraction ErrorsHeart Failure (n=296) • Discharge Status – 25 (8%) • Abstractor missed information ** – 20 • Abstractor answer not in record – 5 ** “Information is present in the medical record in the approved locations, but was not abstracted. This is an error of omission.”

18. Most Common Abstraction Errors Heart Failure (n=296) • LVF Assessment– 23 (9%) • Abstractor missed information - 8 • Abstractor answer not found in record - 8 • Not following abstraction instructions - 7 • Contraindications ACE/ARB – 25 (24% of n=105) • Fail parent element (LVF Assmt) – 10 • Abstractor missed information - 4 • Abstractor answer not found in record - 4 • Not following abstraction instructions - 7

19. Most Common Abstraction Errors Heart Failure Discharge (n=181) • Discharge Instructions • Medications – 31 • Symptoms worsening – 17 • Activity – 12 • Diet – 11 • Weight – 11 • Follow-up - 10

20. Most Common Abstraction Errors Heart Failure Discharge • Discharge Instructions (n=181) • Medications – 31 • Not following abstraction instructions – 17 • Abstractor missed information – 6 • Abstractor answer not found in record – 5 • Parent element mismatch (discharge status?) - 3

21. Most Common Abstraction Errors Heart Failure Discharge • What are the themes to the errors? • What can you change (“by next Tuesday”) in your abstraction process? • Next month, we’ll look at pneumonia and AMI

22. Survey Results(refer to documents sent with agenda) • Keeping current • What themes do you see? • Can your hospital afford to slight this continuing education need? • Anything you might add to your process? • Training new abstractors • Any themes here? • What is the cost to your hospital of inadequately trained abstractors?

23. Facts You Can Work With • “ACE-inhibitor and ARB Contraindication/ Intolerance” for discharges effective April 1, 2007 • Fact Sheet: “Reperfusion Performance Measures for AMI” January 2007

24. Useful Resources on MedQIC • “Facts You Can Work With” • Found on www.medqic.org • Click on “Hospital” tab • Click on “Other Resources” • Scroll down

25. Facts You Can Work With • Coming soon on www.medqic.org • “Pneumonia Frequently Asked Questions (FAQs) February 2007

26. Facts You Can Work With • Comments from listeners who have used the fact sheets • Who are they useful for?

27. April 2007 Changes(refer to documents sent with agenda) • Summary of AMI and HF Measure Changes – 4/1/07 Discharges • SCIP Changes for 4/1/07 Discharges • Pneumonia Select Changes for 4/1/07 Discharges

28. Alignment of CMS & JCAHO • Missing data policy change becomes effective for hospital inpatient discharges on April 1, 2007 • See Release Notes version 2.2 released on December 1, 2006 • Primary reason for the policy is to improve data quality

29. Alignment of CMS & JCAHO • Abstractors must “touch” and provide an answer to every data element that is applicable per the combined skip logic of all of the measures in the measure set • If after due diligence, the abstractor determines that a value is not documented or is not able to determine the answer value, the abstractor must select “Unable to Determine” (UTD) as the answer

30. Responses to Submitted Questions • Question: I do not have time to access and search the MedQIC website. Is there any easy way to know what is available and retrieve information? • Answer: The MedQIC web site has recently added a new feature called: “New Content” • www.MedQIC.org • Under “Latest News” Click on “New Content” • Download spreadsheets for either 2006 or 2007 for a comprehensive overview of content posted to MedQIC

31. Questions/Feedback

32. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320 www.metastar.com This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-53