TMA CHCS DQ COURSE CY 08

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TMA CHCS DQ COURSE CY 08 Powered By Docstoc
					   COMPOSITE HEALTH CARE SYSTEM

“Data Quality Tools You Can Use” (Part 1)
     Charlene Colon, Clinical Data Analyst


    Womack Army Medical Center, Fort Bragg, NC
                   February 2008
             Agenda
 Part 1 – CHCS
  - CHCS Data Quality “Check Points”
  - CHCS “Secrets Revealed”
  - CHCS Data Quality “Radar” Screener
 Part 2 – Ambulatory Data Module (ADM)
  - Encounter Data “Tune Up”

  Course Notes:
  - Hyperlinks can only be accessed from Slideshow Mode
  - Imbedded Icons can only be accessed from Normal View
  - See Notes View for Additional Details and Business Rules
  - The data is real, only the names have been changes to ensure
    compliance with HIPAA Protected Health Information (PHI)
  - Re-use of any charts, graphics or animations – Encouraged!

                                                                   2
           Course Objectives

   Understand DQ Building Blocks in CHCS
   Highlight capabilities that support DQ
   Identify processes and that impact DQ
   Provide DQ Tools You Can Use
   Where to locate Information Resources…




                                             3
               Why the Focus?
   Standardize data collection methods
   Compare workload and productivity
   Measure efficiency per Provider FTE
   Forecast demand for services
   Establish performance benchmarks
   Identify trends and utilization
   Calculate costs of services
   Assess and improve quality of services:
    - Standard of Care
    - Population Health
    - Clinical Practice Guidelines


                                              4
       Data Capabilities

           Quality
                                   Population
         Indicators




  Clinical                                  TRICARE
Performance                                  Access




                       Practice
                      Management
                                                      5
                  Since 1992…
 CHCS has been the primary operational clinical system
  supporting DoD and US Coast Guard facilities world-wide:
   - 100+ Individual Platforms world-wide supporting over 500 MTFs

 Interfaces with more than 40 Clinical & Administrative systems:
   -   AHLTA – Department of Defense Electronic Medical Record
   -   Beneficiary Eligibility - Defense Eligibility & Enrollment System (DEERS)
   -   Resources - Expense Assignment System (EAS)
   -   Billing - Third Party Outpatient Collections System (TPOCS)
   -   Pharmacy - Pharmacy Data Transaction System (PDTS)

 Standard tables for data consistency:
   -   ICD-9-CM (Inpatient/Outpatient Diagnosis and Inpatient Procedures)
   -   CPT/HCPCS (Outpatient Procedures and Services/Supplies)
   -   HIPAA Provider Taxonomy
   -   NATO STANAG (2050), Federal and DoD standard tables
   -   Site defined tables for MTF operations
        • Hospital/Clinic Locations
        • Providers/Provider Class
        • Clinic Schedules

                                                                                   6
It’s Not Easy Being Green!




                         7
            It Takes a Team!

1. Workload and Coding Compliance Review/Audit
2. ADM/AHLTA/CCE Interface Error Management
3. Data Needed for Operational Assessments and DQMC Review
4. Training, User Feedback and Staff Assist Visits




                                                         8
                     Integrated Capabilities
                                              Graphic Interface

               CHCS Registration
                DEERS Eligibility                       Wellness
                 Patient Merge                        Immunizations
                                          I
                                          N
                  Appt Scheduling/
                       Visits             T           Questionnaires

                                          E
                     Radiology
                                          R           Encounter Notes
                                          F
                                          A
                      Pharmacy                        Appt List Display
                                          C
                                          E
                                                     Scanned Images
                     Laboratory
                                                     T-CONS/Consults


                     Ambulatory           T          Encounter Coding      AHLTA          Clinical Data
                     Data Module
                                          O                               Clinical Data       Mart
                                                                           Repository        (CDM)
                    Order Entry           O            Order Entry
                                                      Results Review
                                                                           (CDR)
                   Results Review         L
                                          S
                      Inpatient                   AHLTA captures patient data and clinical
                                                 documentation from MTFs world-wide into
                                                     a single, global patient database
CCE - Coding         SIDR/SADR (CAPER),
 Compliance           WWR, MEPRS/EAS &                                                            9
   Editor                   TPOCS
                                        DQ Building Blocks
                                                            DMIS Group Parent
                                                                (DMIS ID)



      Treatment MTF Division                              Treatment MTF Division                       Treatment MTF Division
            (DMIS ID)                                           (DMIS ID)                                    (DMIS ID)
     Department/Service/Product Line                      Department/Service/Product Line              Department/Service/Product Line


4th Level         4th Level            4th Level      4th Level             4th Level          4th Level         4th Level          4th Level
  FCC               FCC                  FCC            FCC                   FCC                FCC               FCC                FCC



   Hospital             Hospital              Hospital             Hospital             Hospital           Hospital           Hospital
   Locations            Locations             Locations            Locations            Locations          Locations          Locations


        Military Treatment Facility Workload is captured and reported by:
             -   Group Parent Defense Medical Information System (DMIS ID)
             -   Treatment MTF DMIS ID
             -   4th Level MEPRS Code - Functional Cost Code (FCC)
             -   Department/Service (Product Line) and Hospital Location
        Hospital Locations “Places of Care” support MTF activities/services such as:
             - Managed Care (Primary Care Manager) Teams
             - Wards, Clinics, Ambulatory Procedure Units, Ancillary Services, File Rooms, External Locations, etc. 10
                        Hospital Location
   Used by AHLTA to map Assigned Clinic Locations
    with Appointment List Displays
   Multiple Hospital Locations may be linked to the
    same 4th level FCC
GRP    MTF    FCC    CHCS DEPT/SERVICE/LINE     CLINIC LOCATION NAME      WKLD TYPE   FCC DESCRIPTION
0089   0089   BGAA   FAMILY MEDICINE SERVICES   FAMILY PRACTICE T-CON     NON-COUNT   WAMC FAMILY MEDICINE
0089   0089   BGAA   FAMILY MEDICINE SERVICES   WFM SPORTS MEDICINE       COUNT       WAMC FAMILY MEDICINE
0089   0089   BGAA   FAMILY MEDICINE SERVICES   WFM-TEAM DUTY             COUNT       WAMC FAMILY MEDICINE
0089   0089   BGAA   FAMILY MEDICINE SERVICES   WFM-TEAM HONOR            COUNT       WAMC FAMILY MEDICINE
0089   0089   BGAA   FAMILY MEDICINE SERVICES   WFM-TEAM INTEGRITY        COUNT       WAMC FAMILY MEDICINE
0089   0089   BGAA   FAMILY MEDICINE SERVICES   WFM-TEAM RESPECT          COUNT       WAMC FAMILY MEDICINE
0089   7286   BGAN   FAMILY MEDICINE SERVICES   JHC-BLUE TEAM             COUNT       JOEL HEALTH CLINIC
0089   7286   BGAN   FAMILY MEDICINE SERVICES   JHC-RED TEAM              COUNT       JOEL HEALTH CLINIC
0089   7286   BGAN   FAMILY MEDICINE SERVICES   JHC-WHITE TEAM            COUNT       JOEL HEALTH CLINIC
0089   7286   BGAN   FAMILY MEDICINE SERVICES   JOEL AFTER HOURS CLINIC   COUNT       JOEL HEALTH CLINIC
0089   7286   BGAN   FAMILY MEDICINE SERVICES   JOEL T-CON                NON-COUNT   JOEL HEALTH CLINIC




                                                                                                           11
               Hospital Location
CHCS Menu Path
---------
 DAA     Data Administration Menu
  CFT     Common Files and Tables Management Menu
     CFM    Common Files and Tables Maintenance Menu
  ->> HOS     Hospital Location File Enter/Edit

HOSPITAL LOCATION: DQ FAMILY PRACTICE                     DOD HOSP LOCATION EDIT
                          NAME: DQ FAMILY PRACTICE
                        ABBREV: DQFP
                   DESCRIPTION: DQ FAMILY PRACTICE
                 LOCATION TYPE: CLINIC
                       SERVICE: FAMILY PRACTICE
                      DIVISION: DIV A - TRAINING HOSPITAL
                      FACILITY: WALTER REED AMC WASHINGTON DC
                    MEPRS CODE: BGAI/0037
                COST POOL CODE:

 PROMPT FOR REQUESTING SERVICE: YES
              ENROLLEE LOCKOUT: YES
                  TYPE OF CARE: BOTH SPECIALTY AND PRIMARY CARE
                                                       Sets relationship between
 Select CLINIC SPECIALTY:
                                                       Hospital Location, FCC and
 FAMILY PRACTICE/PRIMARY CARE
                                                              MTF DMIS ID
 Select DUPLICATE CHECKING ORDER TYPE:

 INACTIVE FLAG:
                                                                                    12
            Clinic Profile
 Establishes Workload Type for the Clinic:
  - Count
  - Non-Count
 Non-Count Locations cannot have Count Visits:
  - Immunization Clinic
  - Nurse T-CON Clinic
 Establishes Appointment Types for the Clinic:
  - Count (ACUT/ACUT$, WELL/WELL$, ROUT/ROUT$, T-CON*, etc.)
  - Non-Count (RN T-CON Clinic Location)
 AHLTA supports the Workload Flag set by CHCS by:
  - Clinic Type
  - Appointment Types within the Provider Profile (PPRO^)


                                                            13
                    Linking It All Together
                                       DMIS Group Parent
                                           (DMIS ID)



                 CHCS MTF Division                               CHCS MTF Division
                    (DMIS ID)                                       (DMIS ID)



   4th Level         4th Level       4th Level              4th Level     4th Level       4th Level
     FCC               FCC             FCC                    FCC           FCC             FCC



 Hospital            Hospital         Hospital                           Hospital         Hospital
 Locations           Locations        Locations                          Locations        Locations


                                     Clinic Profile
Clinic Profile     Clinic Profile                                       Clinic Profile   Clinic Profile
                                       (^CPRO)

                                                           Appt Type
                                           Provider
   Provider             Provider
                                            Profile
    Profile              Profile
                                           (^PPRO)

                                                                                                      14
15
               Provider File
 Key Elements:
  - Provider ID (Short Name)
       • Can be changed upon Provider Name change
       • Typically 5 characters of Last Name plus 1-2 Characters of First Name
  - National Provider ID
  - Enterprise Provider ID
  - Provider Class
       • Locally defined Provider Type
  - Provider Signature Class
       • Establishes Provider Privileges for Ancillary Order Entry
       • AHLTA uses the Signature Class = NURSE to support RN T-CONS
  -   Medical Specialty->HIPAA Taxonomy->CMAC Class
  -   Default Ancillary Order Requesting Location
  -   Associated Clinic Locations (Where they see patients)
  -   Active AHLTA Account (Yes/No)
  See Notes View for Provider File Business Rules
                                                                                 16
               Provider File Elements
CHCS Menu Path
---------
 DAA     Data Administration Menu                       • Provider Class determines
  CFT     Common Files and Tables Management Menu         Ancillary Order Entry
     CFM    Common Files and Tables Maintenance Menu      Privileges (based on mapping
  ->> PRO     Provider File Enter/Edit                    to Signature Class)
PROVIDER:  QUIRT,RICHARD                                            DA PROVIDER EDIT
                      Name: QUIRT,RICHARD
                                                        • AHLTA uses the Signature
             Provider Flag: PROVIDER                      Class = NURSE to support RN
               Provider ID: QUIRTR                        T-CONS are assigned an E&M
           Provider Class: PHYSICIAN                      Code of 99499 “Placeholder”
                       SSN: 123-45-9999
Select PROVIDER SPECIALTY:
  FAMILY PRACTICE PHYSICIAN (001)
  FAMILY PRACTICE/PRIMARY CARE (923)
Primary Provider Taxonomy: 207Q00000X
      CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY
Select PROVIDER TAXONOMY:
  207Q00000X
                  Location: DQ FAMILY PRACTICE Direct Care Providers MUST have a
                                            • All
               HCP SIDR-ID: 001289
                                              Direct Care Medical Specialty <=905
        Branch of Service: MARINE CORPS
                      Rank: CAPTAIN
   Active CHCS II Account: YES              • FY 07 data requires a valid Medical
                                              Specialty to be Relative Value Units to
Select ASSOCIATED CLINIC:                     be “credited”
  DQ FAMILY PRACTICE
                                                                                        17
  MEDICAL EXAMINATION CLINIC
                   <=905 and >910 - Explained
CHCS Fileman View: (FM->IFE->PROVIDER)

Below is how CHCS “sees” the Provider Specialty entries and uses them in the SADR. CHCS
will populate the SADR with the 1st entered Specialty, rather than the one that
represents Direct Care (Specialties <905).

When entering Provider Specialties enter the lower number 1st. (The one <=905). Then
the correct Specialty will be in the SADR and sent to M2. Then enter the Specialty
>910 to support Health Care Finder/Managed Care.

NAME: MORTNNNNNN,MNNN E
CLASS: NURSE PRACTITIONER           PROVIDER ID: MORTMARE
LOCATION: CLARK TEAM          CLINIC ID: CLARK TEAM
DEPARTMENT ID CODE: FAMILY PRACTICE DEPT
PROVIDER SPECIALTY(S): 923
PROVIDER SPECIALTY(S): 604                      • This resulted in the Provider NOT being
HIPAA TAXONOMY: 363LP2300X                        credited with RVU until updated in CHCS
                                                • Enter the lowest Provider Specialty FIRST!
NAME: PLATNNN,KYNNNN E                          • Establish an MTF process to identify and
LOCATION: OBSTETRICS-WAMC           CLINIC ID: OBSTETRICS-WAMC
                                                  correct in CHCS:
DEPARTMENT ID CODE: OB/GYN DEPT
PROVIDER SPECIALTY(S): 964                           • Use the M2 DQ report
PROVIDER SPECIALTY(S): 927                           • Update Provider Profile in CHCS
PROVIDER SPECIALTY(S): 154                           • Edit/Update ADM Encounter and HIPAA
HIPAA TAXONOMY: 207V00000X                              Provider Taxonomy


                                                                                               18
                  Provider File “Team”
   IMD/Data Admin:
     -   Creates CHCS User Account
   Credentials:
     -   Creates Provider File Entry in CHCS
     -   Enters Provider Medical Specialty/HIPAA Taxonomy
     -   Enters Provider Class/Signature Class
   Clinical/Operations:
     -   Enters/Updates RN & Tech Provider Records
   MCP Network Manager:
     -   Sets PCM Flag
     -   Manages PCM Capacity
   Clinic Managers/Appointment Supervisors:
     -   Clinic Profile Entry/Updates (^CPRO)
     -   Provider Profile Entry/Updates (^PPRO)
           • Assigned Clinic Locations needed for AHLTA
   IMD (System Admin, Security and Training)
     -   Security Clearance
     -   Network Access
     -   CHCS/AHLTA Account Transfer and Training
   MEPRS/UCAPERS
     -   Provider Type->Skill Type
     -   Name Match with CHCS (Based on DEERS/CCQAS Provider Name)
     -   Pay Grade
     -   Location Assigned
   Locally Developed Form(s) designed and utilized to standardize processes
                                                                               19
“Secrets Revealed”




                     20
           Best Kept Secret! - OLUM
 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 (Scroll Down for Data Admin and
    Ad-Hoc Users Guides)
  - Browse or Find topic of interest such as “Monthly” or
    “Hospital Location”
 Link to OLUM.wmv

                                                        21
                Patient Registration
 Patient MUST be registered in the CHCS Host Platform to be
  able to be used in AHLTA
 Performs checks to help prevent creation of duplicate patients
   - Double entry to confirm Sponsor SSN
 Requires the Fileman “&” (Ampersand) key to enter new
  patients
 Performs DEERS query to obtain Enterprise Person ID,
  Eligibility Status and “Lock Down” key person identifiers
   - Enterprise Person ID is key to correlating patient data in AHLTA
 Allows Pseudo-Individual SSNs (800-YY-MDDD)
   - Assign responsibility or focus on updating Pseudo SSNs
 Allows users with Full or Mini-Registration access to update:
   -   Address and Contact Information
   -   Outpatient Medical Records Location
   -   Patient Category – to identify beneficiary relationship to the MHS
   -   Station/Unit ID – MTFs can create locality specific Unit ID Table

   Tools you can use: (See Patient Registration)
   http://www-nmcp.med.navy.mil/EduRes/CompMedia/chcs/nuggets.asp
                                                                            22
                    Mini-Registration




   Key person identifier elements “synched” with DEERS are “Locked Down”
   MTF Staff responsible for Patient Category updates
   Updates to Demographics and Contact Information must be made in CHCS
   CHCS entered Demographics and Contact Informatin updates will update AHLTA
   Consider using Home Phone as Preferred Method of Contact
   Link to DEERS Mini-Reg.wmv                                                   23
                     DEERS Address Updates
 Do not use % * ~ ? [ ] { } in the address field
 Enter complete Phone Number including Area Code
 Rules for CHCS/DEERS Address Updates:
   - CHCS requests eligibility data from DEERS, for NEW Registrations.
   - Address information obtained from DEERS is downloaded into CHCS.
   - A date/time stamp is associated with the address update.
   - If the patient is found in DEERS, the DEERS Patient Identifier is downloaded
     to the CHCS patient file.
   - When the address is updated on CHCS, a message is generated for the
     patient and sent to DEERS, ONLY IF there is a DEERS Patient Identifier in
     CHCS - without this ID DEERS can't make a match and update contact data.
   - When DEERS receives update message, it compares the address update
     date/time to whatever date/time is on file in DEERS. If the message from
     CHCS isn't "fresher" than the data on file, it is dropped.
   - After the initial registration, CHCS does not update address data from
     DEERS unless the user specifically uses the "Demographics" action on the
     DEERS Eligibility Request option, and chooses to update the data.


                                                                                               24
       Source: SAIC Fieldservices Informational of November 2004 and New DEERS Release Notes
                       Duplicate Patients
   CITPO/AHLTA Advisory (July 2007) identified duplicate patients in CHCS as a
    key concern, requiring a Risk Mitigation Strategy
   MHS policy is being developed to delineate accountability through actionable
    data-quality metrics
   Merge processing in CHCS is critical to support the AHLTA Clinical Data
    Repository (CDR)
   Frequent causes for Duplicate Patients in CHCS:
     -   Newborns
     -   Typographical and/or Transcription Errors (Can’t read handwritten registration form)
     -   Name & Sponsor Changes
     -   Pseudo-SSNs (John Doe Registrations)
     -   Mail-In Labs (Creates Pseudo Patient Name)
     -   Lack of Dual Eligibility Patient Indicator in DEERS/CHCS
   CHCS Potential Duplicate Patient Search identifies potential duplicates for
    DQMC Review List Item C.2.
   CHCS User Registration Report identifies users requiring additional training to
    support DQMC Review List C.2. Items a) to d)
   Dedicated MTF POC needed to investigate duplicates and perform patient
    merges on CHCS
   MHS Trouble Ticket then required to process duplicate patients in AHLTA

   Patient Registration SOP (See Back-Up Materials)
                                                                                                25
                Risk and Prevention
 Potential Risk to Patient Safety!
   - CHCS cannot perform Drug-Allergy checks across duplicate records
   - PDTS may miss critical Drug-Drug checks
   - Important clinical history may not 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”
 Train Patient Look-Up Processes:
   -   CAC Card Look-Up (Bar Code Scanner)
   -   Verify against Military ID Card/CAC Card
   -   First Initial of Last Name + Last 4 Sponsor SSN –> C1234
   -   Partial Name –> COLON,C
   -   Last Name+Last 4 (Excellent for Validating Unit Rosters)
   -   Full SSN –> 123-44-1234
   -   Hyphenated Last Names (No Hyphen)
                                                                        26
           Enrollment Processing
 Interface between CHCS/DEERS supports
  Enrollment processing
 Data errors impact successful updates:
  - New Enrollments
  - Enrollment Transfers
 See TRICARE Ops Center for the number of
  Enrollment Errors that may be impacting
  patients at your MTF
 http://mytoc.tma.osd.mil/#


                                           27
NED Error Reporting




                      28
              Other Health Insurance
 DEERS interfaces with CHCS to provide
  Other Health Insurance (OHI):
  -   Used to bill for both Inpatient and Outpatient services
  -   Primary, Secondary and Tertiary benefit coverage
  -   New and Updated Demographics and OHI sent to TPOCS daily
  -   OHI cannot be entered for Active Duty and Civilian Patient
      Categories
 Daily transfer of the DD2569 to the UBO!
  - Entry/Validation of OHI in CHCS within 3 calendar days
    required to prevent manual back-billing or erroneous Third Party
    Billing



                                                                 29
                           Synchronizing Processes
   Date of           1->                    2->                      3->                                                                                      MSA/TPOCS
   Service                                                                                                                                                      Billing
                     Billing HOLD           Billing HOLD             Billing HOLD
                     Services in CHCS       Services in CHCS         Services in CHCS
                     OIB Suspense File      OIB Suspense File        OIB Suspense File
                     Update OHI             Update OHI               Update OHI


                                                                                                                                                             MANUAL RE-WORK
                                             Enter Coding into
 Annual Update of
                       File/Track Annual     CHCS ADM/AHLTA                                                                                                  Manually Bill for Prior
     DD2569
                        DD2569 Update                                Coding Audit Review                                                                      Covered Services

                                                                                                                                                              If OHI is for DD7A
                                                                                                                                                             Billable Beneficiary,
                                                                                                                                                                 Exclude DD7A
                                                                                                                                                               Charges in MSA



                       Verify Insurance    If new OHI - Check for    Enter/Update OHI in
Send DD2569 to UBO
                          Coverage         Prior Billable Services     CHCS->DEERS
                                                                       08 May 2002@1534              For Official Use Only                      Page    1



    DD 2569                                                            0035
                                                                                                     Ambulatory Data Module

                                                                              NAVAL AMBULATORY CARE CENTER GROTON


                                                                       AARPST,MOD82 DISPLAY
                                                                                                     ADM Patient Encounter

                                                                                                         20/800-40-0401
                                                                                                                                                COMPLETE


                                                                                                                                                 Age:62Y


       Other
                                                                       --------------------------------------------------------------------------------
                                                                        Appt Date/Time: 07 May 2002@1805             Type: NEW            Status: WALK-IN
                                                                                Clinic: BBA5 GEN SURG APU                                MEPRS: BBA5
                                                                         In/Outpatient: OUTPATIENT                    APV: Yes     Work Related: No
                                                                         Appt Provider: CASEY,KATHLEEN MAURA (MD)


       Health
                                                                       2nd Provider #1: SINCLAIR,YVONNE J (MD)               Role: ATTENDING
                                                                       ================================================================================
                                                                       E&M Code Description                               Mod1 Mod2 Mod3 Dx Level Units
                                                                       --------------------------------------------------------------------------------
                                                                       99499     UNLISTED E&M SERVICE                                       1            1


     Insurance
                                                                       ================================================================================
                                                                       CPT/HCPCS Description                              Mod1 Mod2 Mod3 Dx Level Units
                                                                       --------------------------------------------------------------------------------
                                                                       00140     ANESTH, PROCEDURES ON EYE                AA                1            1
                                                                       66820     INCISION, SECONDARY CATARACT             50    82          1            2
                                                                       66983     REMOVE CATARACT/INSERT LENS              82                1            2
                                                                       65093     REVISE EYE WITH IMPLANT                  82    50          1            2




      Encounters Completed AFTER 3 Business Days Will Still Be Sent to Billing - If OHI is on File
                                                                                                                                                                                30
                Visit Criteria ???
 MEPRS Workload Reporting guidelines establish
  the definition for:
  - "Count" Visits
  - “Non-Count" Visits

 A “COUNT” VISIT requires 3 Key Elements to =
  Workload:
  1. Interaction between patient and healthcare provider
  2. Independent judgment/assessment of patients condition, to
     accomplish one or more of the following:
      •   Examination
      •   Diagnosis
      •   Counseling
      •   Treatment
  3. Documentation
   Focus Shifting from Counting “Visits” to Measuring Work/Services Provided
                                                                               31
                               MTF Workload Comparison

                                               Family Medicine (BGA*) Comparison (FY 07)
                                                   (MEPRS Cost Visit - Workload Flag "COUNT")
                    35,000


                    30,000


                    25,000


                    20,000
         # Visits




                    15,000


                    10,000


                     5,000


                        0

                             Oct-06   Nov-06              Dec-06            Jan-07              Feb-07   Mar-07   Apr-07

Womack AMC - 0089            27,858   27,871              25,289            30,173              25,809   27,527   26,984
Darnall ACH - 0110           17,380   16,346              15,175            18,796              19,014   18,849   18,599
Dew itt ACH - 0123           14,484   13,771              13,814            15,449              12,978   16,941   14,977
Eisenhow er AMC - 0047       11,617   10,467              12,479            12,685              10,479   11,645   11,010
Martin ACH - 0048            10,698   9,499                9,670            10,198              9,691    11,042   10,638
Blanchfield ACH - 0060       8,500    8,592                7,262             9,692              8,486    9,735    8,709




Source: MEWACS http://www.tricare.mil/ebc/rm_home/meprs/mol3/
                                                                                                                           32
                                   MTF Workload Comparison

                                              Optometry (BHC*) Comparison (FY 07)
                                               (MEPRS Cost Visit - Workload Flag "COUNT")


                   5,000

                   4,500

                   4,000

                   3,500

                   3,000
        # Visits




                   2,500

                   2,000

                   1,500

                   1,000

                     500

                      0

                           Oct-06    Nov-06        Dec-06            Jan-07            Feb-07   Mar-07   Apr-07

Womack AMC - 0089           882       866            983              1,069            1,043    1,280    1,419
Darnall ACH - 0110         1,431     1,315          1,194             1,568            1,404    1,380    1,666
Dew itt ACH - 0123         1,098     1,091           997              1,239            1,036    1,572    1,239
Eisenhow er AMC - 0047      980       964            763              1,017             744     1,029     846
Martin ACH - 0048          3,310     3,119          3,823             4,405            3,388    4,010    3,298
Blanchfield ACH - 0060     1,511     1,699          1,252             1,671            1,489    1,626    1,418




Source: MEWACS http://www.tricare.mil/ebc/rm_home/meprs/mol3/
                                                                                                                  33
               Workload Assignment
 Workload Capture Elements:
  - DMIS ID Group Parent
  - Treating MTF DMIS ID
  - 4th Level MEPRS Code (FCC):
     •   Inpatient – “A” Level FCCs (Admissions/Dispostions and Occupied Bed Days)
     •   Outpatient – “B” Level FCCs and FBN* (Dental – “C” Level FCCs)
     •   Ancillary – “D” Level FCCs
     •   Special Programs – “F” Level FCCs (FBN* Hearing Conservation)
  - Clinic Type (Only COUNT Visits are reported as Workload):
     • World-Wide Workload Report
     • WAM/EAS ->MEWACS
  - Patient Category (Rolls up to Beneficiary Category)
  - Patient Status (Inpatient/Outpatient)
  - Appt Status (KEPT, S-CALL, WALK-IN or T-CON)
     • Occ-Svc, Admin, Cancels and No-Shows not reported as Workload
  - Requesting/Performing Location (Ancillary Services)
                                                                             34
              Monthly Clinic Statistics
 CHCS Monthly Clinic Statistical Report
  (MSR) provides Visit Accountability:
  -   Hospital Location
  -   4th Level FCC
  -   Provider
  -   Patient Category
  -   Inpatient/Outpatient Visits
  -   Count/Non-Count Visits
  -   Appointment Type
  -   Division Summary
 Excellent tool for Visit Workload and
  Provider FTE Reporting Reconciliation
                                           35
FTE Reconciliation




                     36
                   MSR Outpatient Visits
      WOMACK ARMY MEDICAL CENTER                           05 Feb 2008@1348    Page 684
                             MONTHLY STATISTICAL REPORT by GROUP
                                From: Jan 2008    To: Jan 2008
      ================================================================================
        MEPRS/DMIS                         |    COUNT WORKLOAD    | NON-COUNT WORKLOAD
        Code       Description             |   # In # Out Total | # In # Out Total
      ================================================================================
      ***DIVISION SUMMARY***

      Division: CLARK HEALTH CLINIC
      -----------------------------
        BAAI/7294 INTERNAL MED - CLARK           0     124     124    0      6      6
        BDAI/7294 PEDIATRICS - CLARK             0     592     592    2      5      7
        BEDI/7294 CHIROPRACTIC - CLARK           0     343     343    0      0      0
        BFBI/7294 PSYCHOLOGY - CLARK             0      52      52    0      0      0
        BGAI/7294 CLARK HEALTH CLINIC            8   10577   10585    1    670    671
        BHCI/7294 OPTOMETRY - CLARK              1     275     276    0    148    148
        BHDI/7294 AUDIOLOGY - CLARK              0      12      12    0      0      0
        BJAI/7294 FLIGHT MEDICINE - CLAR         0      43      43    0     63     63
        FBNI/7294 CLARK - HEARING CONSER         0     456     456    0      0      0
      Division Total:                            9   12474   12483    3    892    895




 Includes both COUNT and NON-COUNT Visits
 COUNT Visits reported in the WWR and WAM
 BOTH COUNT and NON-COUNT included in the SADR                                           37
                             Worldwide Workload
CLARK HEALTH CLINIC                          WORLDWIDE WORKLOAD REPORT - SECTION I.A.2                 06 Feb 2008 0704    Page 70
DMIS ID: 7294 (Roll-up Report)                       Reporting Period: Jan 2008
                                                    Calculated: 05 Feb 2008 1719
                                     TOTAL WORKLOAD BY PATIENT CATEGORY WITHIN 4TH LEVEL MEPRS
                                                                                                            Item 00 = Basic
TYPE OF REPORT (CHECK BOX): ()Initial (X)Monthly ()Final ()Corrected                                        Item 01 = Live Birth
------------------------------------------------------------------------------------------------------------------------------------
Item   MEPRS/DMIS    Clinic Service                 Admissions       Bed         Sick       Inpatient     Outpatient    Ambulatory**
         PATCAT                                                      Days        Days       Visits        Visits        Proc Visits
------------------------------------------------------------------------------------------------------------------------------------
       BGAI/7294     CLARK HEALTH CLINIC                  -             -           -            [8]        [10540]             -

         A00   USA DECEASED SPONSOR                      -             -            -             -              1             -
         A11   USA ACTIVE DUTY                           -             -            -             3           4167             -
         A12   USA AD RES                                -             -            -             -             50             -
         A15   USA NATIONAL GUARD                        -             -            -             -              8             -
         A22   USA RES INACT DUTY TRG                    -             -            -             -              2             -
         A25   USA FAM MBR FAD-TRANS ASSIST A            -             -            -             -              1             -
         A31   USA RET LOS                               -             -            -             1            558             -
         A32   USA RET PDRL                              -             -            -             -             14             -
         A41   USA FAM MBR AD                            -             -            -             3           4477             -
         A43   USA FAM MBR RET                           -             -            -             -            712             -
         A45   USA FAM MBR DECEASED AD                   -             -            -             1             31             -
         A47   USA FAM MBR DECEASED RETIRED              -             -            -             -            202             -
         A48   USA UNREMARRIED FRM SPOUSE                -             -            -             -             37             -
         R72   NATO RECIP AGREE                          -             -            -             -              1             -
         R73                Only includes Count Visits
               NATO RECIP AGREE - FAM MBR                -             -            -             -              2             -

*Fourth level MEPRS Codes are not standardized above the MTF level. Comparisons of fourth level data between MTFs are not valid.
**Ambulatory Procedure Visits are INCLUDED in the Outpatient Visits Columns by B Level MEPRS Code, as of CHCS Version 4.5.
  Ambulatory Procedure Visits are included in item code 14 in the Worldwide Workload Report ASCII file, as of CHCS Version 4.6.




                                                                                                                               38
                              WAM Outpatient Visits
UIC: W2L6AA   CLARK HEALTH CLINIC                                                                                  06 Feb 2008 0703
DMIS ID: 7294                                                                                                            Page:   23
                                                      DATA SET WORKLOAD REPORT
                                                    Month: Jan       Year:  2008                       (Last Data Gen 02/05/08@1701)
------------------------------------------------------------------------------------------------------------------------------------
 DATA   Perform    Request DMIS CPT CODE    | *CAT | *CAT | *CAT | *CAT | *CAT | *CAT |      Raw Amt    Wgt Amt   Raw Amt   Wgt Amt
 SET    FCC/DMIS   FCC      ID   Lab & Rad |     1 |   2   |   3   |    4 |   5   |   9 |    Sys-Gen    Sys-Gen    Edit     Edit
------------------------------------------------------------------------------------------------------------------------------------
 OUT    OUTPATIENT VISITS
                   BAAI/7294                   3      55      28       38       0      0       124       0.00          0      0.00
                   BDAI/7294                   0     590       0        2       0      0       592       0.00          0      0.00
                   BEDI/7294                 343       0       0        0       0      0       343       0.00          0      0.00
                   BFBI/7294                   4      48       0        0       0      0        52       0.00          0      0.00
                   BGAI/7294                4237    4507     674     1069     53       0     10540       0.00          0      0.00
                   BHCI/7294                 265      10       0        0       0      0       275       0.00          0      0.00
                   BHDI/7294                   9       2       0        1       0      0        12       0.00          0      0.00
                   BJAI/7294                  43       0       0        0       0      0        43       0.00          0      0.00
                   FBNI/7294                 453       1       1        1      0       0       456       0.00          0      0.00
                                -------   ------- ------- ------- ------- ------- ------- --------- --------- --------- ---------
                                Totals:     5357    5213     703     1111     53       0     12437       0.00          0      0.00

 *CAT is Beneficiary Category: 1=ACTIVE DUTY, 2=FAM MBR OF ACTIVE DUTY, 3=RETIRED, 4=FAM MBR OF RETIRED, 5=OTHER, 9=NOT REPORTED.




  Includes only COUNT Visits
  Patient Category is use to Roll Up to Beneficiary Category
  Sent to EAS using the WAM Interface


                                                                                                                                39
             Reconciling Clinic Visits
 End of Day-> “Every Clinic – Every Day”:
  - Evening Clinics and ER -> Next morning
 Process Cancels and No-Shows – As they occur:
  - Cancel by Patient (^CBP) option allows appointment to be re-used
 Duplicate Same Day/Same Clinic Visits:
  - Patient seen in AM returns in the PM is a single visit
  - Patient seen by Nurse/Tech and the Provider (Same day/Same Clinic)
    is also a single visit
  - Join Option in CHCS requires Appointments to be adjoining
 CHCS Tools You Can Use:
  - CHCS PAS End of Day Report
  - CHCS Ad-Hoc



                                                                       40
             Same Day/Same Clinic Visits

 CHCS Ad-Hoc report to identify Same
  Day/Same Clinic Appointments
 Generates an ASCII File for import into Excel
 See your CHCS Administrator, to import the
  Ad-Hoc query and create CHCS Menu Option
 CHCS System Administrator Instructions:
  - Convert to Text File before Import
  - Set any CHCS Internal Entry Numbers (IENs) for Hospital
    Locations to be excluded



    Thank you to our WAMC DBA John Rehder for his DQ support   41
Time to Break…




                 42
                Inpatient Visits
                                WALK-IN SEARCH CRITERIA
  Patient: HEALTHE,YOU                             FMP/SSN: 30/800-11-2255
  Clinic: QQQCHCSIITESTBRAGG CLINIC/WAMC           ATC Category:
  Clinic Phone:                                    Appt Type: ACUTE APPT
  Provider: QQQCHCSIITEST,BRAGGDOCA                Duration:
  Detail Codes:                                    Srv Type:
  Time Range: 0950 to 0950                         Days of Week:
  Dates: 14 Feb 2005 to 14 Feb 2005
  ------------------------------------------------------------------------

  ------------------------------------------------------------------------
  This is an inpatient.
  Are you from the attending service? No//


 Both CHCS and AHLTA will prompt:
   - (CHCS) Are you from the attending service? No//
   - (AHLTA) Related to Inpatient Stay?:
 Allied Health Providers-> Accept CHCS default of “NO”
 Consulting Providers-> Accept CHCS default of “NO”
 Only the Attending Clinical Staff of the Same Clinical Service should
  answer “YES”:
   - Then the Visit will be a Non-Count
   - Visit will have an “A” Level FCC based on the inpatient Clinical Service 43
         AHLTA Inpatient Visits

                        AHLTA entered Walk-Ins for a
                         Consulting Provider
                        AHLTA will sometimes indicate
                         the patient is an inpatient, even
                         though the patient is not currently
                         admitted, if AHLTA does not
                         receive the CHCS Disposition
                         Update. MHS Trouble Ticket
                         recommended to remove Inpt Flag
                        Click NO to ensure that
                         encounter is assigned to a “B”
                         Level FCC of the Consulting
                         Provider
Leave Blank




                                           Click NO
                                                        44
Lost Workload !!




                   45
              Inpatient Administration
 CHCS is the source system for Inpatient
  Admissions, Transfers and Dispositions:
  - Assigns OBDs at the Census Hour, to the current Clinical Service
  - Current Clinical Service used as the Requesting Location for Inpatient
    Ancillary Services
  - Current Attending Provider and Clinical Service used to create
    Inpatient Professional Services Record (IPSR RNDS*) encounters
 Correction Management allows corrections to:
  - Clinical Service, OBDs and Disposition Date/Time
  - Patient Category used for Workload and Billing
  - Recalculates OBDs for SIDR, WWR and Inpatient MSA billed charges
 Inpatient Coding:
  - ICD-9 Codes used to capture Diagnosis and Inpatient Procedures
  - NATO STANAG (2050) for Cause of Injury Coding
  - Diagnosis Related Grouping (DRG Encoder/Grouper->Inpatient CCE)

                                                                        46
                  Corrections Management
     Patient: BXXXX,XXXXXX                                                      VIEW ADT
     FMP/SSN: 20/XXX-XX-XX22       DOB: XXFebXX       PATCAT: A31    Sex: M
     ==========================================================================
     TYPE   DATE   TIME RMEPRS MEPRS WARD       RM-BD  DAYS

       ADM 14Aug07 2030   AAAA   AAHA   ICU2W            3   Reg# 1306883 (T) ERA
       WRD 17Aug07 1316          AAAA   4SMED            3   Interward transfer
       DSP 20Aug07 1340                                      Disp type: HOME
                                                             Bed days=6
                                                             Sick days=6




 Corrections Management ONLY supports Inpatient data:
  - Patient correctly admitted to AAAA with the system transfer to an ICU (AAHA)
    Bed
  - AAAA is the Referring MEPRS (R-MEPRS) for OBDS
  - SIDR and WWR will contain OBDs for “A” Level ICU FCCs, however WAM/EAS
    will include these OBDs within the R-MEPRS
  - Corrections Management does NOT support correcting Inpatient Ancillary Order
    Requesting Locations, Ancillary or Ambulatory data
  - Check for Dispositions with an “A” Level ICU FCC and coordinate with PAD for
    ICU Dispositions (Happens most often with NICU Dispositions)
                                                                                           47
                 SIDR Data
 The Standard Inpatient Data Record (SIDR) is an ASCII
  file transmission of patient level Inpatient data,
  generated monthly by CHCS:
  - Army MTFs also create in interim monthly SIDR – “D” Records Only
 Key SIDR data elements include:
  -    Treatment MTF DMIS ID
  -    Admission/Disposition Dates
  -    Source of Admission/Type of Disposition
  -    ICD-9-CM Diagnosis & Procedure Codes
  -    Assigned DRG and Weight
  -    Patient Demographics (including Patient Category and Enrollment)
  -    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
      See Notes view for SIDR Record Status Flags                         48
               DQ - Where to Start ??
1. Training – Attend CHCS Training offered at your
   MTF - If none are offered, explore options:
     MedLearn
     NMC Portsmouth for CHCS Nuggets and AHLTA SOPs
     PASBA Coding VTC (Click on Coding->Coding VTC)
2. Coordinate with Provider/Nursing Champion and
   IMD to establish a CHCS/AHLTA Users Forum
3. Understand your MTF Business Processes:
       Provider In/Out-Processing
       CHCS/AHLTA Support and Training Team
       Coding Support and Provider Feedback
       Business Plan Targets
       Special Programs – New Initiatives
       MTF unique systems and Ad-Hoc reports
       MTF staff responsible for key DQ processes

                                                       49
                          DQ Process Area Review

                                                                     Cost/Performance &
                                                                           Billing
                                                                      (CHCS/ADM/EAS/M2)
                                        Clinical
                                  (CHCS/ADM & AHLTA)               12. Ancillary File Maintenance

     Enrollment,                 7. Clinic & Provider              13. Common File
                                    Profiles (Specialties &            Synchronization Across
Demographics & Other
                                    Workload Flags)                    Systems (Personnel and
  Health Insurance                                                     Clinical)
   (CHCS/DEERS)                  8. Individual Check-In/End
                                    of Day Processing              14. Synchronization of
1. Patient Registration                                                Workload Reporting
                                 9. Correct assignment of              (SIDR/SADR, WWR,
2. Duplicate Patients               Inpatient Attending                WAM/EAS)
3. NED Error Processing             Provider and Service
                                                                   15. Accurate data to study
4. CHCS/DEERS Sync               10. Coding Accuracy and               Access to Care, Quality
                                     Timely Completion                 Improvements, Business
5. Eligibility Verification
                                 11. Ancillary Order                   Planning and Market Share
6. OHI Capture (DD 2569)                                               Analysis
                                     Requesting Locations


                Be Prepared for the “Duration”… Data Quality is not at One-Time Effort…

                                                                                                    50
 Questions??




Information Sources on the Web   51
                    Tri-Service Web Sites
  WEB SITE                               LINK (Verified as of 6 Feb 2008)
  CHCS Courses & Downloads               https://mhslearn.satx.disa.mil/ilearn/en/learner/jsp/d
   Web Based & Virtual Classroom        efault.htm
  CHCS Data Management*                  http://www.chcs-dm.com/DM4CHCS/default.html
   User Guides, Release Notes
   Interface Documentation
  TMA Data Quality Management            http://tricare.osd.mil/ocfo/mcfs/dqmcp/training.cfm
  Control Program Training
  Post Deployment Health Toolbox         http://www.pdhealth.mil/guidelines/toolbox.asp
   Algorithms & Coding Guides
  TRICARE Operations Center              http://mytoc.tma.osd.mil/#
   Access to Care Template Analysis
   Enrollment Status Reports
  MEPRS Early Warning and Control        http://www.tricare.osd.mil/ebc/rm_home/meprs/me
  System (MEWACS)                        wacsxls.cfm
  Uniform Biostatical Utility            http://www.tricare.osd.mil/org/pae/ubu/default.htm
   Coding Guidelines and Updates
  MHS Population Health Portal           https://pophealth.afms.mil/tsphp/login/login.cfm
   HEDIS Measures/Action Lists
                                                                                          52
* See your CHCS Administrator for Access – Password Required
                   Service Web Sites
WEB SITE                             LINK (Link Verified as of 6 Feb 2008)
Army Knowledge On-Line*:             Log On to AKO & Follow Link:
 AHLTA Updates & Template Team      https://www.us.army.mil/suite/page/406
 Links to AF AHLTA Site
OTSG Decision Support*:              https://ke2.army.mil/otsg/main.php?cid=57
 Portal to All AMEDD Metrics/Data
Army PASBA:                          https://pasba3.amedd.army.mil
 DQ Metrics & Coding Support        (AKO login required)
 Coding VTC Presentations

Army MEPRS Program Office:           http://ampo.amedd.army.mil/
 All things MEPRS and FAQs

NMC Portsmouth “Nuggets”             http://www-
 CHCS & AHLTA “How To’s” & SOPs     nmcp.med.navy.mil/EduRes/CompMedia/chcs/nug
 Must See!!                         gets.asp




* Password Required                                                              53
                   Best of the Web
WEB SITE                            LINK (Verified as of 6 Feb 2008)
American Medical Association CPT    https://catalog.ama-
Code Look-Up                        assn.org/Catalog/cpt/cpt_search.jsp?checkXwho=
 Look-Up by Code or Keyword        done
 Includes Medicare RVU & Payment
 Lists CPT Assistant References
ICD-9 Flash Coder/ICD-9 On-Line     http://www.icd9coding1.com/flashcode/home.jsp
 ICD-9 Code Look-Up
 Related DRGs                      http://icd9cm.chrisendres.com/index.php?action=
 Billable Indicator                contents
Physician Practice Tools            http://www.physicianspractice.com/index/fuseacti
 E&M Coding Benchmarks             on/tools.main.htm


Sample Size Calculator              http://www.custominsight.com/articles/random-
 Confidence Intervals              sample-calculator.asp




                                                                                 54
           VT 400 Terminal Emulation                                                                                                                      Graphic User Interface
                                                                                                                                                                                       Data Mart
                                                                                                       Application Architecture
                                                   ADM Patient Encounter
                    MSA,BILLABLE CIVILIAN                  20/800-44-7976                  AGE:53y
                  ==============================================================================
                    Appt Date/Time :05 Mar 2002@1800       Type: APV             Status: WALK-IN
                             Clinic: GEN SURG APU GR                             MEPRS : BIAE
                      In/Outpatient: Outpatient             APV: Yes      Work Related: Yes
                      Appt Provider: CASEY,KATHLEEN MAURA MD              Injury Date : 05 Mar 2002
                    2nd Provider #1: GLUCK,ERIC S MD
                    2nd Provider #2: SINCLAIR,YVONNE J DDS
                        Disposition: ADMITTED
                    Chief Complaint: 925.1
                                                                          Role: ASSISTING
                                                                          Role: ASSISTING

                                                CRUSHING INJ OF FACE AND SCALP
                    ==============================================================================
                                                                                                                                                                                         CDM
                      ICD-9      Dx Description                                Priority
                    ------------------------------------------------------------------------------
                      925.1      CRUSHING INJ OF FACE AND SCALP                   1
                      802.29     MULT FX MANDIBLE-CLOSED                          2
                      E880.0     FALL ON/FRM STAIR/STEP, ESCLTR                   3
                  ==============================================================================
                   CPT Cd Description                                  Dx Lvl Mod1 Mod2 Mod3 Units
                    ------------------------------------------------------------------------------

ELIGIBILITY &       D7820 CLOSED TMP MANIPULATION
                    D7610 MAXILLA OPEN REDUCT SIMPLE
                    13121 REPAIR OF WOUND OR LESION
                    00190 ANES,FACIAL BONE/SKULL;NOS
                                                                          123
                                                                          123
                                                                          123
                                                                          123
                                                                                 80
                                                                                 AA
                                                                                      51
                                                                                                1
                                                                                                1

                                                                                                1
                                                                                                 3                                                                                       CDR
ENROLLMENT          21125 AUGMENTATION, LOWER JAW BONE
                    21275 REVISION, ORBITOFACIAL BONES
                                                                          123
                                                                          123
                                                                                 80
                                                                                 80
                                                                                                1
                                                                                                2




                                                                                                                                                                                     CLINICAL DATA
                                                                                                                                                                                     REPOSITORY

                                          CHCS Host Patient Database
  Standard Files and Tables (DMIS, ICD-9, CPT/HCPCS, DRG, HIPAA Taxonomy, National Drug Codes, Zip Code)
       Site Defined Files and Tables (Hospital Locations, Providers, Users, Formulary, Tests/Procedures)
                                            Application Business Rules


     Inpatient Admissions and                                                                                   Outpatient Appointment Scheduling                Ambulatory Data
        Dispositions (PAD)                                                                                      Managed Care Program (PAS/MCP)                    Module (ADM)


                      Clinical Order Entry and Results Reporting


Laboratory                        Radiology                                                           Pharmacy                          Nursing                                 Workload
                                                                                                                                                       Medical Services
                                                                                                                        Consults                       Accounting (MSA)
                                                                                                                                                                           Assignment Module
  (LAB)                             (RAD)                                                               (PHR)                            Orders                                  (WAM)



                CHCS Generic Interface Specification (GIS) for (HL7) and Electronic Transfer Utility (ETU)
                                                                                                                        HL7, M/OBJECTS, OR CUSTOM INTERFACES              FTP DATA TRANSFERS
LAB INSTRUMENTS                  DIN-PACS                                                             PDTS
CO-PATH                          VOICE RAD                                                            ATC                                                                     TRICARE OPS CTR
LAB-INTEROP                                                                                           BAKER CELL     AHLTA               TRANSPORTABLE CPR                     SIDR/SADR
DBSS                                                                                                  PYXIS          ICDB                TRAC2ES                                 EAS EXTRACT
HIV                                                                                                   VOICE REFILL   EI/DS               CAC (Patient Look-Up)                     WWR
                                                                                                                                                                                     MEPRS-EAS
                                                                                                                     DoD/VA SHARE        NMIS
                                                                                                                                                                                      TPOCS
                                                                                                                     CIS/ESSENTRIS       CODING EDITOR (CCE)                           SVC AD-HOCS
                                                                                                                     AUDIO CARE                                                         55

                                                                                                                                                                                   February 2007

				
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