04-16-2008 DCS Presentation

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04-16-2008 DCS Presentation Powered By Docstoc
					Data Collection Support

MetaStar, Inc.
April 16, 2008
Pam Clemens
Candi Davis

A new Measure Comparison document has
been released
  New title: “Inpatient Hospital Quality
  The purpose: “To provide a reference guide on
  submission and Hospital Compare details for
  QIOs and Providers for the National Inpatient
  Quality Measures.”

  Under the “Hospitals – Inpatient” tab
  Click on either HQA or RHQDAPU
  Click on “Measure Comparison”
  Click on “Inpatient Hospital Quality Measures”

Submission Deadlines
  Public Reporting Deadlines/ICD Population &

Validation Schedule/Deadlines
      Hospital Compare Updates

The March 2008 release will have new features
  HCAHPS patient survey results
     Time period: 4Q06 – 2Q07
  Medicare Payment and Volume
     Previously displayed on CMS web site
     Includes the elective DRGs and other DRGs of high utilization
     for a total of 44 DRGs
     Based on hospital discharges from FY 2006
     Hospital Compare Updates

The 30-day Mortality Outcome Measures
will not change for this release
  Time period: 3Q05 – 2Q06
The current hospital performance data for
Clinical Process Measures will be updated
     Mortality Measure Education

Watch for information about upcoming national
hospital conference calls to be held end of April –
Purpose will be to educate hospitals about changes
to the reporting format and model changes
  Changes include hospice exclusions and pneumonia
Information will be posted to
        Quality Net Education

QualityNet Enhancement Overview for All
  Found on
  Under “Training,” click on “QualityNet
  Under “For All Users,” click on “QualityNet
  Enhancement Overview for All Users”
  Length: 28 minutes
      OPPS CART Application

Deployed 4/3/08
Available on
For use with CART v 4.4
      Updates: Abstraction Tools

Topic-specific documents for use in conducting
manual abstraction have been created for your use,
effective for April 1, 2008, through September 30,
2008, discharges are now available on QualityNet:
from the following link:
      Updates: Abstraction Tools

Or by going to
  Under “Hospitals-Inpatient”, click on “Specifications
  Manual Version 2.4b”
The updated tools are located in the upper right
corner for:
  Acute Myocardial Infarction
  Heart Failure
  Surgical Care Improvement Project
     Updates: Abstraction Tools

In order to accommodate multiple
abstraction tools, the data elements are
arranged in alphabetical, rather than tool
specific order
They are provided in Word format to allow
providers to modify to meet their individual
     Updates: Abstraction Tools

For information specific to the data
elements and abstraction guidelines, please
refer to the Alphabetical Data Dictionary
for The Specifications Manual for National
Hospital Quality Measures for discharges
effective April 1, 2008
          Updates: Validation

Quarter Two 2007 validation for Wisconsin
hospitals has been completed
  4 PPS hospitals failed
  11 Critical Access Hospitals
          Updates: Validation

Most common mismatches:
  7 Chest X-ray
  5 Antibiotic Dose
  5 Admission Source
  4 Invalid Record Selection
          Updates: Validation

Quarter Three 2007 validation
  Week #3
  Results have been posted for 13 Wisconsin
  5 PPS passed
  8 CAH passed
  No failures
  Updates: Revised Quest Answers

See attached for Quest revisions for
February and March
A total of 3,007 questions were processed in
The Hospital Public Reporting QIO has
been receiving many concerns about Quest
  These have been forwarded to CMS
  Updates: Revised Quest Answers

CMS is working on an upgrade to the Quest
platform that should improve its
Some archiving has been done, but this is a
very slow process
Watch for a future upgrade that will allow
searching by data element
Hot Topics: Beta-Blocker Current Medication

 Based on recent feedback from the SCIP
 Listserve and Quest, an abstraction
 clarification has been issued by the SCIP
 Clinical Measures group
 Abstractors are to consider beta-blockers as
 current medications only if the patient was
 on a beta-blocker prior to admission
Hot Topics: Beta-Blocker Current Medication

 During 4Q07 and 1Q08, guidance was provided
 through Quest that may be in conflict with this
 Cases that have already been abstracted DO NOT
 need to be re-abstracted
 In the event a case is selected for validation and a
 mismatch occurs for Beta-Blocker Current
 Medication, special consideration will be given
Hot Topics: Beta-Blocker Current Medication

 Effective immediately, the performance
 measure will be limited to those cases that
 list a beta-blocker as a medication taken
 prior to admission only
 Future Quest questions will be answered
Hot Topics: Beta-Blocker Current Medication

 The primary intent of the SCIP-Card-2
 measure and the accompanying data
 elements is to identify those patients who
 routinely take beta-blockers and to
 determine whether the medication was
 continued during the perioperative period,
 unless a contraindication is documented
Hot Topics: Beta-Blocker Current Medication

 After consideration, beta-blocker therapy
 started AFTER admission and prior to
 surgery will NOT be considered current
 beta-blocker therapy
 Responses to Submitted Questions

Question: “What is the point of origin for a
patient who comes to the ER from farming?
He is a farmer. He was shoveling grain and
got chest pain.”
 Responses to Submitted Questions

Answer: “For 10/01/2007 discharges, the
point of origin would be ‘7’ – emergency
room as it is assumed the patient presented
from home. Although “farming” may be
considered his work, it is also considered
his home.”
(Reference: Quest #153139)
 Responses to Submitted Questions

Question: What does “PREV REC” mean
when it is listed next to a validation case
found on my Case Selection report?
 Responses to Submitted Questions

Answer: “The record appears to have been
previously requested by the CDAC for another
project that they are working on. Since the list
does state “PREV REC” then you should not
recopy and send the record; they will use the
record they already have in-house. If you do send
another copy they will consider it a duplicate and
Reference Quest # 116711
 Responses to Submitted Questions

Question: Medical records has received a
request for two medical records. The cover
sheet says they are for surveillance for the
“Patient Safety Monitoring System.” What
does this mean?
 Responses to Submitted Questions

Answer: See link for article regarding the
“Medicare Patient Safety Monitoring
System” (MPSMS)
MPSMS is a national surveillance project
aimed at identifying rates of specific
adverse events within the Medicare
 Responses to Submitted Questions

Answer cont:
  The hospital records from an annual random national
  sampling of more than 40,000 Medicare inpatient fee-
  for-service discharges are sent to two CDACs
  An adverse event is defined as an unintended harm,
  injury, or loss that is more likely associated with a
  patient’s interaction with the health care delivery
  system than from an attendant disease process
Contact Information:

MetaStar, Inc.
2909 Landmark Place
Madison, WI 53713

(608) 274-1940 or (800) 362-2320
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-08-28.

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