Data Quality Section, PASBA September 2009. Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs

Data Quality Section, PASBA

September 2009

Regulatory Guidance Program Management Organizational Factors System Inputs,

Processes, and Outputs CHCS ADM MEPRS/EAS TPOCS MEWACS

Patient Records Accountability

Coding Audits Sampling Size and

Techniques Inpatient Records Outpatient Records

Workload Comparison System Security System Design,

Development, Operations, and Education and Training

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Department of DefenseDepartment of Defense

INSTRUCTIONINSTRUCTION

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DIRECTIVEDIRECTIVE

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DIRECTIVEDIRECTIVE

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DIRECTIVEDIRECTIVE

Data Quality Manager Data Quality Assurance Team Intermediate Command DQ Manager Service Data Quality Manager DQMC Review List Commanders Monthly Data Quality

Statement (internet based)

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Composite Health Care System (CHCS) Armed Forces Health Longitudinal

Technology Application (AHLTA) Ambulatory Data Module (ADM) Medical Expense and Performance

Reporting System (MEPRS) / Expense Assignment System (EAS)

MEPRS Early Warning and Control System (MEWACS)

Defense Medical Human Resources System –Internet (DMHRS-i)

Third Party Outpatient Collection System (TPOCS)

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Written Procedures Current Versions Upgrades & Updates Rejected Records End of Day Processing

Percentage of Clinics Percentage of Appointments

Timely Coding Completion

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Q. 1. What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.)

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Q. 2. In accordance with legal and medical coding practices, have all of the following occurred: a) What percentage of Outpatient Encounters,

other than APVs, have been coded within 3 business days of the encounter? (B.6.(a))

b) What percentage of APVs have been coded within 15 days of the encounter? (B.6.(b))

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Q. 2. In accordance with legal and medical coding practices, have all of the following occurred: c) What percentage of Inpatient records have

been coded within 30 days after discharge? (B.6.(c))

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EAS Financial Reconciliation Inpatient and Outpatient Workload

Reconciliations MEWACS Review Timely Data Transmittal Workload Comparison

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Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.)

a) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission?

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b) Were the data load status, outlier/variance, WWR-EAS IV, and allocations tabs in the MEWACS document reviewed and explanations provided for flagged data anomalies?

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c) For DMHRS-i, what is the percentage of timecards submitted by the suspense date?

d) For DMHRS-I, what is the percentage of approved timecards by the suspense date?

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CHCS Duplicate Records Timely Data Transmittal

Standard Inpatient Data Record (SIDR) Worldwide Workload Report

Inpatient Records Accountability Documentation Coding SIDRs completed (in a “D” status)

Workload Comparison

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Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).

a) MEPRS/EAS (45 calendar days)

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- b) SIDR/CHCS (5th and 20th calendar day of the month)

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- c) WWR/CHCS (10th calendar day following month)

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Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).

d) SADR/ADM (daily)

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A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF inpatient medical records for the audit data month.

A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%.

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Coding DRG Codes Related Data Elements (C.5)

All Diagnoses Any Procedures Sex Age Discharge/Disposition

Percentage of SIDRs Completed (D-Status)

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Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j)

- a) What percentage of inpatient records

whose assigned DRG codes were correct?

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- b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct?

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- c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct?

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- d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct?

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- e) What percentage of completed and current (signed within the past 12 months) DD Form 2569s are available for audit?

-f) What percentage of available, current and complete DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

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ADM Timely Data Transmittal

Standard Ambulatory Data Record (SADR) Error Logs Workload Comparison

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Sample Size Accountability

Percentage Located or Properly Checked Out Checked-out Over 30-Days?

DD Form 2569 (Third Party Insurance Information)

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Q.6. Outpatient Records. (c.6.a,b,c,d,e,f)

a) Is the documentation of the encounter selected to be audited available? Documentation includes documentation in medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA?

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E&M Codes ICD-9 Codes CPT Codes

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Q. 6. Outpatient Records.

b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.)

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c) What is the percentage of ICD-9 codes deemed correct?

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d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.)

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e) What percentage of completed & current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit?

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- f) What percentage of available, current and completed DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS?

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Question 7 Ambulatory Procedure Visits (C.7.a,c,d,e,)

Questions 7.a,c,d,e, are the same as Questions 6.a,c,d,e,

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Q. 8. Comparison of reported workload data (C.9). a) # SADR Encounters (count only visits / #

WWR visits b) # SIDR Dispositions / # WWR Dispositions c) # EAS Visits / # WWR Visits d) # EAS Dispositions / # WWR Dispositions e) # IPSR SADR encounters (FCC=A***)/#

Sum WWR (Total Bed Days + Total Dispositions)

Note: Question e, FY09 Goal is 80%.

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Q.8a SADR Visits / WWR Visits Should have an equal number of visits. Encounters – Omit Appt. Status of “No-

Shows,” “Canceled,” and Disposition Code “Left Without Being Seen”

Encounters – Include Appt. Status “TelCon” Only SADR Records Marked with an Appt.

Status of “C” (complete) Are To Be Included

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Q.8b SIDR Dispositions / WWR Dispositions Must Match Only SIDRs With a Disposition of Status of “D”

Are To Be Included SIDRs – Exclude Carded for Record Only (CRO)

and Absent Sick Records

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Q. 8cEAS Visits / WWR Visits Must Match Include MEPRS Functional Cost Code B**

(Outpatient) and FBN (Hearing Conservation) Include APVs

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Q. 8dEAS Dispositions / WWR Dispositions Must Match Only SIDRs with a Disposition Status of “D”

are to be included

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• IPSR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions)

Note: FY10 Goal is 80% • Insure WWR calculation includes live births

(section 01) and Bassinet Days (section 00).

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Q.9. - System Design, Development, Operations and Education/Training (E.4.c).

- # AHLTA SADR encounters/# of Total SADR encounters

Note: FY09 compliance goal is 80%.. (* It is understood that not all clinical

modules are deployed in the current version of AHLTA.)

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Q.10.- CHCS software used during the data month to identify duplicate patient registration records. (C.2a)

- What was the number of potential duplicate records in the reporting month?

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Q.11.- Provide the number of incomplete and non-transmitted SIDRs for the month.

Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA.

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Q.12.a.- Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record.


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Q.12.b.- Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record, 30 days after an active duty soldier has retired or separated from the service.


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Q. 13. – I am aware of data quality issues identified by the completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility.

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Are there internal controls and procedures in place to approve and manage assignment of security key privileges?

Have all security key holders been identified and their need for security key privileges validated by the CIO or designee?

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System Administrator Appointed In Writing for Each System

Training and Education Procedures and Documentation

System Change Request Process System Incident Report Routine Maintenance Points of Contact for Equipment Failure

Issues Contingency Plans Trouble tickets

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Chief DQ Section PASBATim Bacon, [email protected]

North Atlantic Regional Medical CommandMs. Tama Oringderff, 210-295-9289Tama.Oringderff @us.army.mil

Southeast Regional Medical Command, European Regional Medical Command,Western Regional Medical CommandMr. Joe Alley, [email protected]

Great Plains Regional Medical Command,Pacific Regional Medical CommandMr. Dwayne Mentis, [email protected]

mailto:[email protected]

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BACKUP SLIDES

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METRIC MANIA

Department of Army

Strategic Readiness System(SRS)

Review &

Analysis

TMA metrics

BALANCED SCORECARD

- Promote, Sustain and Enhance Soldier Health- Train, Develop and Equip a Medical Force that Supports Full Spectrum Operations - Deliver Leading Edge Health Services to Our Warriors and Military Family to Optimize Outcomes

For more information go to: https://ke2.army.mil/bscThis is a dynamic, living document

America’s Premier Medical Team Saving Lives and Fostering Healthy and Resilient PeopleArmy Medicine…Army Strong!

Pat

ien

t/C

ust

om

er/

Sta

keh

old

er CS 6.0 Inspire Trust in

Army Medicine

CS 4.0 Responsive Battlefield

Medical Force

CS 1.0 Improved Healthy and Protected

Families, Beneficiaries and

Army Civilians

CS 3.0 Improved Healthy and Protected Warriors

CS 5.0 Improved Patient and Customer

Satisfaction

IP 10.0 Optimize Medical

Readiness

IP 13.0 Build Relationships and Enhance Partnerships

LG 18.0 Improve Training and Development

IP 11.0 Improve Information

Systems

CS 2.0 Optimized Care and Transition of Wounded, Ill, and

Injured Warriors

IP 12.0 Implement

Best Practices

IP 14.0 Improve Internal and

External Communication

LG 20.0 Improve Knowledge

Management

LG 17.0 Improve Recruiting and

Retention of AMEDD Personnel

Inte

rna

l Pro

cess

Le

arn

ing

a

nd

Gro

wth

LG 19.0 Promote and Foster a

Culture of Innovation

Maximize Value in Health Services

Provide Global Operational Forces Build the Team Balance Innovation

with StandardizationOptimize Communication and

K nowledge Management

Fee

db

ack

Ad

jus

ts R

eso

urc

ing

De

cisi

on

s

IP 8.0 Improve Quality,

Outcome-Focused Care and Services

IP 7.0 Maximize Physical and Psychological

Health Promotion and Prevention

IP 9.0 Improve Access and Continuity of

Care

IP 16.0 Synchronize

Army Medicine to Support Army

Stationing & BRAC

R 21.0 Optimize

Resources and Value

R 22.0 Optimize Lifecycle Management

of Facilities and Infrastructure

R 23.0 Maximize

Human Capital

EN

DS

ME

AN

SW

AY

S

Re

sou

rce

IP 15.0 Leverage Research,

Development and Acquisition

= CofS Accountability

OTSG

Command Management System(CMS)

Why should you care? What can you do to help?

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MEDCOM STRATEGY MAP

GOALS:

• Improve overall health & wellness of enrolled beneficiaries.

• Improve patient access and satisfaction.

• Improve effectiveness of peacetime direct care system.

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KEYS TO SUCCESS

• Improve Data Quality Efforts

• Cultural Change

• Improve Access to Care

• Tie Financing to PerformancePBAM – Performance Based Adjustment Model

Army Health System

MedicalGreen-Suit

Military

Total MEDCOMDHP Human Resources

WT Population ~ 12,000

Population Requiring Healthcare (Demand)

MEDCOM Capacity (Human Capital)

MEDCOM direct care capacity cannot meet the Healthcare demand of the around 3 million eligible beneficiaries (MEDCOM cares for 1.414 million enrolled & 300K users)

Reasons include: -Population dispersion (especially among Retirees & their Families) -Efficiency demands (numerous small population centers) -Military structure supports Readiness – not peacetime healthcare

AD

ADFM

65+

Ret/RetFM (<65)

Army Health System

23% 63% 1%24% 67% 7%24% 63% 11%24% 65% 9%25% 66% 6%26% 67% 7%27% 62% 9%27% 61% 9%28% 63% 8%28% 65% 6%28% 61% 9%30% 59% 9%30% 62% 6%31% 61% 7%32% 61% 6%33% 60% 7%33% 59% 7%33% 58% 7%35% 61% 4%38% 58% 4%

47% 48% 4%61% 36% 3%Tricare/military

Kaiser PermanenteAARP

MedicareMedicaid

BCBS of MichiganCare first BCBS

PacifiCare/ SecureHumana

Medicare and Part DOther health plan

AnthemHighmark

Blue Cross & Blue ShieldWellPoint

UnitedHealthecare-NetBCBS of Illinois

CoventryAetnaCigna

Health Care Services CorpUnitedHealcare

Highly satisfied Satisfied Dissatisfied Highly dissatisfied

Overall satsfation with health plan

Overall Satisfaction With Health Plans

“And the Winner is…” Managed Care Magazine, September 2008 pp 41-46

Data -Wilson Health Information LLC Annual Survey Jan-Feb 2008

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DATA QUALITY

• Increased emphasis on MTF submissions

• Improved reporting timeliness

• Improved accuracy SIDRs

SADRs

MEPRS

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•Combines Multiple Data Systems•Current Enrollment (ECM)- Assumes Historical Space-A work•Potential Enrollment (MTF Business Plans)•EBSM- Forecast population changes•Ops- UNCLASSIFIED Deployments and Redeployments by location by month•ARTS- Deployed personnel from MTF

•Provides Adjusted Enrollment for those Active duty deployed, and redeploying

•Adjusts MTF enrollment capacity based on deployed PCMs (1000/Per deployed PCM)

•Future Development to include:•Adjustments for Backfilling PCMs from another MTF•Forecast ARTS deployments- (Pending Deployments)•Deployment to CMS

Enrollment Capacity Forecast Model (ECFM)

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USE OF THE DATA

TMA = Gospel

“Garbage In, Garbage Out”

OTSG = Disaster

MTF = Nuclear Fire Storm

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• The data matter

• Cultural shift

• Use the CMS

• Ask: What are we asking our staff to do?

Priorities

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Standardize Core R&A for Medical Treatment Facilities

• No standard R&A approach in MEDCOM

• MTF Cdrs create their own “TOC”

• MTF’s spend a lot of time designing/developing

the “TOC”

• Cdrs and staffs learn together at the expense of

Organizational Performance

• R&A provides the Azimuth….critical to direction

and success

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Core Measures for MTFs

•Enrollment

•Productivity

•Access

•Patient Satisfaction

•Coding Accuracy

•Prevention/HEDIS

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End-of-Day (EOD) Processing MTF staff will determine the status of each appointment as accurately as possible. EOD processing will be correctly completed at the end of each business day.

Pending: The MTF appointment information system assigns this initial status for an appointment that has been booked for a patient for a future date or time. All pending appointments must be changed to one of the final encounter statuses in order to complete End-of-Day processing.

Kept: The patient has a booked appointment, arrives at the MTF/clinic, and is treated by provider.

Walk-in: The patient does not have a scheduled appointment, arrives at the clinic, and is assigned a time to see the provider the same day. This status will not be changed at End-of-Day processing.

Sick Call: An Active Duty member arrives at a clinic for a pre-arranged block of time for care. This status will not be changed at End-of-Day processing.

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End-of-Day (EOD) ProcessingPatient Cancellation: A patient with a scheduled appointment notifiesThe MTF in accordance with local procedures that they will not keep the appointment.

No-Show: A scheduled appointment that the patient does not keep. Determinations of no-shows will be in accordance with local procedures.

Facility Cancellation: The MTF cancels an available/open appointmentor cancels a patient’s scheduled appointment.

Left Without Being Seen: The patient has a booked appointment, arrivesat the clinic, and is checked in, but decides to leave without seeing the provider.

Admin: The admin status is used on appointments or telephone consultsthat do not represent actual contact with a patient. The status must beAssigned in End-of-Day processing. A transaction with this status will not bepassed to ADM or AHLTA and will not be coded or included in SADR.

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End-of-Day (EOD) Processing

Occasions of Service: This status on a patient appointment indicates nomedical decision was made by a privileged provider who is directly Responsible for the management of care for the patient. This status willno longer be used on telephone consults. This transaction will pass fromCHCS to the Ambulatory Data Module (ADM), is always non-count, and maybe used to assess level of effort. ADM and AHLTA do not recognize this status as an appointment for completion. Therefore this status will NOT prompt the provider to code the encounter and will avoid generating a Standard Ambulatory Data Record (SADR).Telephone Consultation: When a provider answers a telephone consult inAHLTA, the provider will be asked by the system, “Does this meet the out-patient visit criteria?” If the provider is a technician, nurse, or other non-count provider or the clinic is a non-count clinic, the workload type responsewill be defaulted to No (non-count) and cannot be changed in AHLTA. If the provider is a privileged provider and the clinic is a count clinic, the defaultwill be Yes (count). The provider should change the response to No if it does not meet the visit criteria.

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Walk-ins 1. A walk-in is a patient who seeks care without a scheduled appointment,Arrives at the clinic, and is assigned a time to see the provider the same day.

2. There is no ATC Standard for walk-in appointments.

3. Walk-ins are not designed for use as a schedulable event.

4. High utilization of walk-ins can create data quality challenges for the MTF and make the process of measuring/explaining access, and assessing demand more complex.

5. High rates of walk-ins may also make business plan targeting difficult since theyare unplanned events.

6. Excessive walk-in activity can reduce the appointments available to patientsrequesting care on the telephone.

7. However, if clinics utilize the walk-in function to get patients seen in a manner that is more timely/convenient for the patients, this is recognized as good customerservice from the patient’s perspective.

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Medical Expense and Performance Reporting System (MEPRS)

1. The DoD Manual 6010.13-M, MEPRS for Fixed Medical and Dental TreatmentFacilities. Provides a definition of MEPRS codes (also know as functional costcodes, FCC).

2. Define your CHCS File-and-Build Hospital Locations so that each clinic has only one associated MEPRS code.

3. Ensure that each MEPRS code has the four characteristics of: a. A defined physical space (e.g., square footage) b. Associated expenses (e.g., supplies) c. Associated personnel time (e.g., work hours) and d. Associated workload (e.g., visits, procedures, etc.)

4. Manual provides definition and criteria of a visit (count vs. non-count)

5. Defense Medical Human Resources System – internet (DMHRS-i) is still a Significant issue for the Army. Missing , incomplete, incorrect time-cards.

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Documents

Data Quality Section, PASBA September 2009. Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs