DATA COLLECTION GUIDE Direct Data Submission Optimal Diabetes Care 2013 (01/01/2012 to 12/31/2012 Dates of Service) Notice about Physician Quality Reporting System (PQRS): If your medical group will be using MNCM’s program to submit PQRS and DDS data (total population) at the same time, you must follow a different set of instructions. The guide for submitting PQRS/DDS data can be downloaded from the MNCM Data Portal (Resources tab), or please contact [email protected]. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 1 TABLE OF CONTENTS Measure Specifications ....................................................................................... 3 Summary of Changes .......................................................................................................... 4 Table 1: ICD-9 Diagnosis Codes for Identifying Diabetes Mellitus ..................................... 6 Table 2: ICD-9 Diagnosis Codes for Identifying Ischemic Vascular Disease ........................ 7 Table 3: ICD-9 Diagnosis Code for Identifying Major Depression or Dysthymia ................ 9 Table 4: ICD-9 Diagnosis Codes for Identifying Pregnancy for Patients with Diabetes Mellitus .................................................................................. 10 Measure Logic/Flow Chart for Patients who DO NOT HAVE IVD ..................................... 11 Measure Logic/Flow Chart for Patients who HAVE IVD ................................................... 12 Data Elements and Field Specifications ............................................................. 13 Summary of Changes ........................................................................................................ 14 Direct Data Submission Instructions ................................................................. 25 Summary of Changes ........................................................................................................ 26 About Direct Data Submission; Required Reporting ........................................................ 26 Health Care Homes ........................................................................................................... 26 DDS Participation Requirements ...................................................................................... 27 Confidentiality and HIPAA for DDS ................................................................................... 28 Overview of Process and Timeline .................................................................................... 29 Resources to Get You Started ........................................................................................... 30 Step 1: Registration and Preparations .............................................................................. 31 Step 2: Identifying the Patient Population (Denominator) .............................................. 32 Step 3: Data Collection...................................................................................................... 40 Step 4: Data Quality Checks .............................................................................................. 44 Step 5: Data File Creation (.csv) and Data Submission ..................................................... 49 Step 6: MNCM Validation of Submitted Data ................................................................... 55 Step 7: Direct Data Submission Results ............................................................................ 57 Appendices ...................................................................................................... 58 Appendix A: About MN Community Measurement and Measure Development ............ 59 Appendix B: Aspirin and Anti-Platelet Medications.......................................................... 60 Table 5: Products Containing Aspirin .......................................................................... 60 Table 6: Oral Anti-Platelet Medications...................................................................... 60 Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 2 Optimal Diabetes Care 2013 Direct Data Submission (01/01/2012 to 12/31/2012 Dates of Service) Measure Specifications Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 3 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications Summary of Changes Date of birth clarification Added language to clarify date of birth range. Please note the changes in the denominator section. Addition of Ischemic Vascular Disease ICD-9 Diagnosis Codes Added ICD-9 Diagnosis codes 440.0, 444.01 and 444.09 to the list of ICD-9 diagnosis codes used to identify patients who have a co-morbidity of Ischemic Vascular Disease. Description Composite (“optimal” care) measure of the percentage of adult patients who have type 1 or type 2 diabetes with optimally managed modifiable risk factors. Methodology Population identification is accomplished via a query of a practice management system or electronic medical record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Clinics that had an EMR in place by 01/01/2011 are required to submit data on their full population. Rationale According to the Minnesota Department of Health, diabetes is a high impact clinical condition in Minnesota. More than one in three adults and one in six youth in Minnesota have diabetes or are at high risk of developing it. Each year more than 20,000 Minnesotans are newly diagnosed with diabetes. Diabetes is the sixth leading cause of death in Minnesota and is a significant risk factor in developing cardiovascular disease and stroke, non-traumatic lower extremity amputations, blindness, and end-stage renal disease. Diabetes costs Minnesota almost $2.7 billion annually, including medical care, lost productivity and premature mortality. According to the American Diabetes Association, an estimated 23.6 million American children and adults have diabetes. Most people with diabetes have other risk factors, such as high blood pressure and cholesterol that increase the risk for heart disease and stroke. In fact, more than 65% of people with diabetes die from these complications. Measurement Period Measurement period will be a fixed twelve-month period: 01/01/2012 to 12/31/2012. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 4 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications Denominator Established patient who meets each of the following criteria is included in the population: Patient was age 18 to 75 at the start of the measurement period (date of birth was on or between 01/01/1937 to 01/01/1994). Patient was seen by an eligible provider in an eligible specialty face-to-face at least two times during the last two years (01/01/2011 to 12/31/2012) with visits coded with a diabetes mellitus ICD-9 diagnosis code (in any position, not only primary). Use this date of service range when querying the practice management or EMR system to allow a count of the visits within this time frame. Patient was seen by an eligible provider in an eligible specialty face-to-face at least one time during the last twelve months (01/01/2012 to 12/31/2012) for any reason. This may or may not include one of the face-to-face diabetes visits. Diagnosis of Diabetes mellitus; ICD-9 diagnosis codes include: 250—250.93. Eligible specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatric Medicine, Endocrinology. Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP). Allowable Exclusions Numerator Patient was a permanent nursing home resident during the measurement period. Patient was in hospice at any time during the measurement period. Patient died prior to the end of the measurement period. Documentation that diagnosis was coded in error. Patient was pregnant during measurement period (ICD-9 diagnosis codes: 648.0648.04). The number of diabetes patients who met ALL of the following targets: The most recent HbA1c in the measurement period has a value <8.0. The most recent LDL test in the measurement period has a value <100. The most recent Blood Pressure in the measurement period has a systolic value of <140 and a diastolic value of <90 (BOTH values must be less than). There is documentation in the chart that the patient is currently a non-tobacco user. If the patient has a co-morbidity of Ischemic Vascular Disease, there is documentation in the measurement period that the patient is on daily aspirin OR there is documentation of an accepted contraindication (any date). Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 5 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications Coding Conventions Used in MN Community Measurement Documentation MNCM uses the standard HEDIS coding conventions from HEDIS 2013, Comprehensive Diabetes Care. Unless otherwise noted, codes are stated to the minimum specificity required. For example, if a code is presented to the third digit, any valid fourth or fifth digits may be used. When necessary, a code may be specified with an “x,” which represents a required digit; for example, ICD-9-CM diagnosis code 250.0x indicates a fifth digit is required, but the fifth digit could be any number allowed by the coding manual. This coding convention is used to describe ranges of codes, please refer to the tables included for the complete list of codes. Diabetes Mellitus Codes Table 1: ICD-9 Diagnosis Codes for Identifying Diabetes Mellitus ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 250.00 DMII WO CMP NT ST UNCNTR 250.01 DMI WO CMP NT ST UNCNTRL 250.02 DMII WO CMP UNCNTRLD 250.03 DMI WO CMP UNCNTRLD 250.10 DMII KETO NT ST UNCNTRLD 250.11 DMI KETO NT ST UNCNTRLD 250.12 DMII KETOACD UNCONTROLD 250.13 DMI KETOACD UNCONTROLD 250.20 DMII HPRSM NT ST UNCNTRL 250.21 DMI HPRSM NT ST UNCNTRLD 250.22 DMII HPROSMLR UNCONTROLD 250.23 DMI HPROSMLR UNCONTROLD 250.30 DMII O CM NT ST UNCNTRLD 250.31 DMI O CM NT ST UNCNTRLD 250.32 DMII OTH COMA UNCONTROLD 250.33 DMI OTH COMA UNCONTROLD 250.40 DMII RENL NT ST UNCNTRLD 250.41 DMI RENL NT ST UNCNTRLD 250.42 DMII RENAL UNCNTRLD 250.43 DMI RENAL UNCNTRLD 250.50 DMII OPHTH NT ST UNCNTRL 250.51 DMI OPHTH NT ST UNCNTRLD 250.52 DMII OPHTH UNCNTRLD 250.53 DMI OPHTH UNCNTRLD 250.60 DMII NEURO NT ST UNCNTRL 250.61 DMI NEURO NT ST UNCNTRLD 250.62 DMII NEURO UNCNTRLD 250.63 DMI NEURO UNCNTRLD 250.70 DMII CIRC NT ST UNCNTRLD 250.71 DMI CIRC NT ST UNCNTRLD Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. 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Page 6 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications ICD-9 Diagnosis Code 250.72 250.73 250.80 250.81 250.82 250.83 250.90 250.91 250.92 250.93 ICD-9 Diagnosis Code Description DMII CIRC UNCNTRLD DMI CIRC UNCNTRLD DMII OTH NT ST UNCNTRLD DMI OTH NT ST UNCNTRLD DMII OTH UNCNTRLD DMI OTH UNCNTRLD DMII UNSPF NT ST UNCNTRL DMI UNSPF NT ST UNCNTRLD DMII UNSPF UNCNTRLD DMI UNSPF UNCNTRLD Ischemic Vascular Disease Codes used to identify co-morbidity Table 2: ICD-9 Diagnosis Codes for Identifying Ischemic Vascular Disease ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 410.00 AMI ANTEROLATERAL,UNSPEC 410.01 AMI ANTEROLATERAL, INITIAL 410.02 AMI ANTEROLATERAL,SUBSEQ 410.10 AMI ANTERIOR WALL,UNSPEC 410.11 AMI ANTERIOR WALL, INITIAL 410.12 AMI ANTERIOR WALL,SUBSEQ 410.20 AMI INFEROLATERAL,UNSPEC 410.21 AMI INFEROLATERAL, INITIAL 410.22 AMI INFEROLATERAL,SUBSEQ 410.30 AMI INFEROPOST, UNSPEC 410.31 AMI INFEROPOST, INITIAL 410.32 AMI INFEROPOST, SUBSEQ 410.40 AMI INFERIOR WALL,UNSPEC 410.41 AMI INFERIOR WALL, INITIAL 410.42 AMI INFERIOR WALL,SUBSEQ 410.50 AMI LATERAL NEC, UNSPEC 410.51 AMI LATERAL NEC, INITIAL 410.52 AMI LATERAL NEC, SUBSEQ 410.60 TRUE POST INFARCT,UNSPEC 410.61 TRUE POST INFARCT, INITIAL 410.62 TRUE POST INFARCT,SUBSEQ 410.70 SUBENDO INFARCT, UNSPEC 410.71 SUBENDO INFARCT, INITIAL 410.72 SUBENDO INFARCT, SUBSEQ 410.80 AMI NEC, UNSPECIFIED 410.81 AMI NEC, INITIAL Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. 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Page 7 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications ICD-9 Diagnosis Code 410.82 410.90 410.91 410.92 411.0 411.1 411.81 411.89 412 413.0 413.1 413.9 414.00 414.01 414.02 414.03 414.04 414.05 414.06 414.07 414.2 414.3 414.8 414.9 429.2 433.00 433.01 433.10 433.11 433.20 433.21 433.30 433.31 433.80 433.81 433.90 433.91 434.00 434.01 434.10 434.11 434.90 ICD-9 Diagnosis Code Description AMI NEC, SUBSEQUENT AMI NOS, UNSPECIFIED AMI NOS, INITIAL AMI NOS, SUBSEQUENT POST MI SYNDROME INTERMED CORONARY SYND ACUTE COR OCCLSN W/O MI AC ISCHEMIC HRT DIS NEC OLD MYOCARDIAL INFARCT ANGINA DECUBITUS PRINZMETAL ANGINA ANGINA PECTORIS NEC/NOS COR ATH UNSP VSL NTV/GFT CRNRY ATHRSCL NATVE VSSL CRN ATH ATLG VN BPS GRFT CRN ATH NONATLG BLG GRFT COR ATH ARTRY BYPAS GRFT COR ATH BYPASS GRAFT NOS COR ATH NATV ART TP HRT COR ATH BPS GRAFT TP HRT CHR TOT OCCLUS COR ARTRY COR ATH DUE TO LIPID RICH PLAQUE CHR ISCHEMIC HRT DIS NEC CHR ISCHEMIC HRT DIS NOS ASCVD OCL BSLR ART WO INFRCT OCL BSLR ART W INFRCT OCL CRTD ART WO INFRCT OCL CRTD ART W INFRCT OCL VRTB ART WO INFRCT OCL VRTB ART W INFRCT OCL MLT BI ART WO INFRCT OCL MLT BI ART W INFRCT OCL SPCF ART WO INFRCT OCL SPCF ART W INFRCT OCL ART NOS WO INFRCT OCL ART NOS W INFRCT CRBL THRMBS WO INFRCT CRBL THRMBS W INFRCT CRBL EMBLSM WO INFRCT CRBL EMBLSM W INFRCT CRBL ART OC NOS WO INFRC Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. 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Page 8 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications ICD-9 Diagnosis Code 434.91 440.0 440.1 440.20 440.21 440.22 440.23 440.24 440.29 440.4 444.0 444.01 444.09 444.1 444.21 444.22 444.81 444.89 444.9 445.01 445.02 445.81 445.89 ICD-9 Diagnosis Code Description CRBL ART OCL NOS W INFRC ATHERSCLEROSIS OF AORTA RENAL ARTERY ATHEROSCLER ATHSCL EXTRM NTV ART NOS ATH EXT NTV AT W CLAUDCT ATH EXT NTV AT W RST PN ATH EXT NTV ART ULCRTION ATH EXT NTV ART GNGRENE ATHRSC EXTRM NTV ART OTH CHR TOT OCCL ART EXTREM ABD AORTIC EMBOLISM SADDLE EMBOLUS OF ABDOMINAL AORTA OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA THORACIC AORTIC EMBOLISM UPPER EXTREMITY EMBOLISM LOWER EXTREMITY EMBOLISM ILIAC ARTERY EMBOLISM ARTERIAL EMBOLISM NEC ARTERIAL EMBOLISM NOS ATHEROEMBOLISM,UPPER EXT ATHEROEMBOLISM,LOWER EXT ATHEROEMBOLISM, KIDNEY ATHEROEMBOLISM, SITE NEC Major Depression and Dysthymia Diagnosis Codes Table 3: ICD-9 Diagnosis Codes for Identifying Major Depression or Dysthymia ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 296.2 Major depressive disorder single episode 296.20 Major depressive affective disorder single episode unspecified degree 296.21 Major depressive affective disorder single episode mild degree 296.22 Major depressive affective disorder single episode moderate degree 296.23 Major depressive affective disorder single episode severe degree without psychotic behavior 296.24 Major depressive affective disorder single episode severe degree specified as with psychotic behavior 296.25 Major depressive affective disorder single episode in partial or unspecified remission 296.26 Major depressive affective disorder single episode in full remission 296.3 Major depressive disorder recurrent episode 296.30 Major depressive affective disorder recurrent episode unspecified degree 296.31 Major depressive affective disorder recurrent episode mild degree Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. 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Page 9 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications ICD-9 Diagnosis Code 296.32 296.33 296.34 296.35 296.36 300.4 311 ICD-9 Diagnosis Code Description Major depressive affective disorder recurrent episode moderate degree Major depressive affective disorder recurrent episode severe degree without psychotic behavior Major depressive affective disorder recurrent episode severe degree specified as with psychotic behavior Major depressive affective disorder recurrent episode in partial or unspecified remission Major depressive affective disorder recurrent episode in full remission Dysthymic disorder Depression NOS not elsewhere classified Codes used to identify patients who meet exclusion criteria Table 4: ICD-9 Diagnosis Codes for Identifying Pregnancy for Patients with Diabetes Mellitus ICD-9 Diagnosis Code ICD-9 Diagnosis Code Description 648.00 DM of mother, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 648.01 DM of mother, complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 648.02 DM of mother, complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 648.03 DM of mother, complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 648.04 DM of mother, complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 10 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications Is the patient’s date of birth on or between 01/01/1937 and 01/01/1994? No Patient not included No Patient not included 2013 Optimal Diabetes Care Measure Patient Flow for patients who DO NOT HAVE a comorbidity of IVD Yes Does the patient have a diagnosis code listed in Table 1 on pages 6-7? Yes Has the patient been seen by an eligible provider at least two times in the past two years (01/01/2011 to 12/31/2012) with visits coded with a diabetes ICD-9 code? No (see Table 2 on pages 79 for IVD codes) Patient not included PLEASE NOTE: All questions are to be answered using data from dates of service 01/01/2012 to 12/31/2012 Yes Has the patient been seen by an eligible provider in an eligible specialty face-toface at least one time during the measurement period for ANY reason? No Patient not included Yes PATIENT IS IN THE DENOMINATOR Was the patient’s most recent HbA1c less than 8.0? No PATIENT NOT INCLUDED IN NUMERATOR Yes Was the patient’s most recent LDL less than 100? No PATIENT NOT INCLUDED IN NUMERATOR Yes Was the patient’s most recent systolic blood pressure less than 140 and diastolic less than 90? No PATIENT NOT INCLUDED IN NUMERATOR No PATIENT NOT INCLUDED IN NUMERATOR Yes Is there documentation in the patient’s chart that they are currently a non-tobacco user? Yes PATIENT INCLUDED IN NUMERATOR Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 11 Optimal Diabetes Care 2013 Direct Data Submision Measure Specifications Is the patient’s date of birth on or between 01/01/1937 and 01/01/1994? No Patient not included Yes Does the patient have a diagnosis code listed in Table 1 on pages 6-7 AND a diagnosis code listed in Table 2 on pages 7-9? No Patient not included Yes Has the patient been seen by an eligible provider at least two times in the past two years (01/01/2011 to 12/31/2012) with visits coded with a diabetes ICD-9 code? No Patient not included No Patient not included Yes Has the patient been seen by an eligible provider in an eligible specialty face-toface at least one time during the measurement period for ANY reason? Yes PATIENT IS IN THE DENOMINATOR Was the patient’s most recent HbA1c less than 8.0? 2013 Optimal Diabetes Care Measure Patient Flow Chart for patients who HAVE a comorbidity of IVD (see Table 2 on pages 7-9 for IVD codes) PLEASE NOTE: All questions are to be answered using data from dates of service 01/01/2012 to 12/31/2012 PATIENT NOT INCLUDED IN NUMERATOR No Yes Was the patient’s most recent LDL less than 100? PATIENT NOT INCLUDED IN NUMERATOR No Yes Was the patient’s most recent systolic blood pressure less than 140 and diastolic less than 90? PATIENT NOT INCLUDED IN NUMERATOR No Yes Is there documentation in the patient’s chart that they are currently a non-tobacco user? PATIENT NOT INCLUDED IN NUMERATOR No Yes Is there documentation in the patient’s chart that the patient is on daily aspirin or has a contraindication of aspirin? PATIENT NOT INCLUDED IN NUMERATOR No Yes PATIENT INCLUDED IN NUMERATOR Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 12 No Optimal Diabetes Care 2013 Direct Data Submission (01/01/2012 to 12/31/2012 Dates of Service) Data Elements and Field Specifications Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 13 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Summary of Changes Removal of Health Care Homes Data Elements Health Care Homes data elements no longer need to be submitted in the data file. Please note; however, that Health Care Homes clinics will need to use the primary care provider’s NPI (Column O) when submitting data. Column Field Name Notes Excel Format Example A Enter the MNCM Clinic ID for every patient/row submitted. MNCM assigns the clinic ID at the time of registration. Use the MNCM ID listed in the portal. Text 9999 Text 1 Date (mm/dd/yyyy) 05/08/1985 Clinic ID Do NOT use the Medical Group ID. Blank values will create an ERROR upon submission. B Patient ID Enter a unique patient ID that will identify each patient. Options: Enter “1” through the total number of patient records that will be submitted for the medical group. Keep a “crosswalk” between the patient ID and the patient name and DOB to help clinic staff locate the record for the validation audit, or Enter clinic-assigned ID (e.g., MRN, account number). Do NOT enter social security numbers. Blank values will create an ERROR upon submission. C Patient Date of Birth Enter the patient’s date of birth. Patient must be ages 18–75 at the start of the measurement period (01/01/2012 to 12/31/2012) The date of birth range for this age group is 01/01/1937 to 01/01/1994. Correct dates of birth is important to assist in payment incentive programs Blank values or values outside the range 01/01/1937 to 01/01/1994 will create an ERROR upon submission. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 14 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example D Enter the patient’s gender: Female = F; Male = M; Unknown = U Text F Text 55111 Patient Gender Blank values will create an ERROR upon submission. E Patient Zip Code, Primary Residence Enter the patient’s five-digit zip code of primary residence at the most recent encounter on or prior to 12/31/2012. If EMR query extracts a nine-digit number, submit the nine-digit number (the portal will remove the last four digits automatically). Blank values or values less than five digits will create an ERROR upon submission. F Race/Ethnicity1 G Race/Ethnicity2 H Race/Ethnicity3 I Race/Ethnicity4 J Race/Ethnicity5 K Country of Origin Code L Country of Origin “Other” Description M Preferred Language Code N Preferred Language “Other” Description Please refer to a separate document entitled REL Data Field Specifications and Codes 2013 for these field specifications. This document can be found under the Resources tab in the data portal under the “Race/Ethnicity/Language Data (REL)” section from the drop-down menu. For more information about collecting this data from patients in your clinic practice, please refer to the Handbook on the Collection of Race Ethnicity and Language Data available at www.mncm.org. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 15 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example O Enter the ten-digit NPI of the provider who manages the patient’s care most frequently (or most recently if more than one provider saw the patient equally). Text 1234567891 Number 1 Provider NPI Health Care Homes Clinics: Please enter the NPI of the patient’s primary care provider. If the provider does not have an NPI, enter the provider ID as registered in the MNCM Data Portal. Blank values will create an ERROR upon submission. P Provider Specialty Code Enter the specialty code of the physician (see codes below). If the provider is not a physician, enter the code that best describes the clinic’s specialty. 1 = Family Medicine 5 = Geriatric Medicine 2 = Internal Medicine 7 = Endocrinology If a provider from a specialty other than those listed above has diabetic patients and wishes to submit data, please contact [email protected]. Blank values will create an ERROR upon submission. Q Insurance Coverage Code R Insurance Coverage “Other” Description S Insurance Plan Member ID Please refer to a separate document entitled Insurance Coverage Data Field Specifications and Codes 2013 for these field specifications. This document can be found under the Resources tab in the data portal under the “Insurance Coverage Info” section from the drop-down menu. PLEASE NOTE: This should be the patients’ most recent insurance on or prior to 12/31/2012 Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 16 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example T Enter a code to indicate if the patient has a diagnosis of ischemic vascular disease (IVD) that can be confirmed upon validation audit. See Table 2 on pages 7-9 in Measure Specifications for list of IVD ICD-9 diagnosis codes. Number 0 Patient Has IVD? (as a co-morbidity) 1 = Yes 0 = No This field is subject to audit because it determines whether the aspirin component is applicable to a patient or not. The MNCM auditor will look for a diagnosis of IVD in the measurement period and the year prior. Use all of the following sources to identify the diagnosis: Patient’s problem list Documentation in patient’s record (progress notes, etc.), AND ICD-9 codes (EMR or practice management system) Blank values will create an ERROR upon submission. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 17 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example U Enter a code to indicate if the patient has a diagnosis of depression that can be confirmed upon validation audit (e.g., ICD-9 codes 296.2x, 296.3x, 304.0, and 311). See list of ICD-9 diagnosis codes in Table 3 on pages 9-10 for a list of Major Depression or Dysthymia ICD-9 diagnosis codes. Number 0 Number 1 Patient Has Depression? (as a co-morbidity) 1 = Yes 0 = No Leave BLANK if Unknown/Not submitting data Use all of the following sources to identify the diagnosis: Patient’s problem list Documentation in patient’s record (progress notes, etc.), AND ICD-9 codes (EMR or practice management system) (NOTE: The 311 code is not used for the purpose of identifying patients for MNCM’s Depression Measures denominator; however, please include the 311 code for identifying a depression co-morbidity for this measure.) V Type 1 or Type 2 Diabetes? Enter the patient’s diabetes diagnosis “type” (Type 1 or Type 2 diabetes) 1 = Type 1 2 = Type 2 3= Not specified or documented Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 18 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example W Enter the date of the most recent HbA1c test on or prior to 12/31/2012. Date (mm/dd/yyyy) 07/22/2012 Number 6.3 Date (mm/dd/yyyy) 07/22/2012 Number 68 HbA1c Date Target = At least one test in the measurement period (01/01/2012 to 12/31/2012) X Y Leave BLANK if an HbA1c was never performed. Do NOT enter test date that occurred in 2013. Dates in 2013 will create an ERROR upon submission. Test from an outside referring provider or specialist is acceptable (not required) but only if documented in the primary clinic’s record and is more recent than the primary clinic’s test. Point-of-care HbA1c labs: If the HbA1c is “too high to calculate,” enter the HbA1c date field and leave the HbA1c value field blank. HbA1c Value Enter the value of the most recent HbA1c test on or prior to 12/31/2012. Target = Less than 8.0 Leave BLANK if an HbA1c was never performed. LDL Date Enter the date of the most recent LDL test on or prior to 12/31/2012. ODC target = At least one test in the measurement period (01/01/2012 to 12/31/2012) FYI, Optimal Vascular Care measurement period is different; for this component see OVC specifications Z Leave BLANK if an LDL was never performed. Do NOT enter test date that occurred in 2013. Dates in 2013 will create an ERROR upon submission. Test from an outside referring provider or specialist is acceptable (not required) but only if documented in the primary clinic’s record and is more recent than the primary clinic’s test. Elevated Triglyceride: If LDL is “too high to calculate,” enter the LDL date field and leave the LDL value field blank. LDL Value Enter the value of the most recent LDL test on or prior to 12/31/2012. Target = Less than 100 Leave BLANK if an LDL was never performed. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 19 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example AA Enter the date of the most recent Blood Pressure (BP) test on or prior to 12/31/2012. Other considerations: Date (mm/dd/yyyy) 07/22/2012 Number 124 BP Date Target = At least one blood pressure in the measurement period (01/01/2012 to 12/31/2012) AB BP Systolic Target = Less than 140 Leave BLANK if a BP was never performed. For multiple BPs on the same date, it is acceptable (not required) to use the lowest systolic value and lowest diastolic value from any of the readings on that date. The systolic and diastolic results do not need to be from the same reading. Do NOT enter BP date that occurred in 2013. Dates in 2013 will create an ERROR upon submission. BP from any outside referring provider or specialist is acceptable (not required) but only if documented in the primary clinic’s record and is more recent than the primary clinic’s reading. Nurse-only BP checks in the clinic may be used. Do NOT enter a BP that is associated with a surgical procedure, inpatient or ER visit, diagnostic testing or a diagnosis that is associated with acute pain. Do NOT enter BP reported by or taken by the patient. Enter the “systolic” value according to the rules above for selecting the correct BP date. The systolic BP is the upper number. For example, the systolic value for a BP 124/72 is “124.” Leave BLANK if a blood pressure test was never performed. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 20 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example AC Enter the “diastolic” value according to the rules above for selecting the correct BP date. The diastolic BP is the lower number. For example, the diastolic value for a BP 124/72 is “72.” Number 72 Date (mm/dd/yyyy) 07/22/2012 BP Diastolic Target = Less than 90 Leave BLANK if a blood pressure test was never performed. NOTE: If there is no diastolic value, the patient is considered not controlled and therefore misses the diastolic target. AD Aspirin (ASA) Date Target = Patient with a diagnosis of Ischemic Vascular Disease (IVD) has documented daily ASA or anti-platelet use anytime during the measurement period (01/01/2012 to 12/31/2012), or valid contraindication date (see below). If there is no diagnosis of IVD, the patient automatically passes the aspirin component. Each patient should have only one date entry in either the aspirin date field or the contraindication date field, NOT both date fields. Enter the date of documented ASA or anti-platelet during the measurement period (01/01/2012 to 12/31/2012). Any documented date of ASA or an antiplatelet is acceptable during 2012; the date does not need to be the most recent date in 2012. The following are accepted ASA or anti-platelet medications (please see Table 5 and Table 6 in Appendix B for a list of Aspirin and Anti-Platelet containing products): Aspirin (ASA) Plavix (clopidogrel) Ticlid (ticlopidine) Aggrenox (aspirin/dipyridamole) Low dose enteric-coated 81 mg ASA (Ecotrin or Bayer) NOTE: Enter the date in which ASA (or other accepted anti-platelet) was documented as a current medication (e.g., med reconciliation date). Leave BLANK if there is no documentation of daily ASA or anti-platelet. Do NOT enter a 2013 date. Dates in 2013 will create an ERROR upon submission. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 21 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name AD cont. AE Notes Aspirin (ASA) Date cont. Aspirin (ASA) Contraindication Date If the patient is NOT taking ASA and has a contraindication to ASA, leave ASA date field blank and enter the contraindication date in the next field. Do NOT count an ASA/narcotic combo medication for the “daily aspirin use” component of the measure whether it is used for temporary or chronic pain. If patient has a documented contraindication to ASA, enter the date of the contraindication. Any valid contraindication date (2012 date or prior) will be given credit. MNCM auditor must be able to validate this date. Accepted contraindications: Anticoagulant use (for example: Lovenox (Enoxaparin), Pradaxa (Dabigatran) or Coumadin (Warfarin))* *PLEASE NOTE: This is not a comprehensive list of medications. Any history of gastrointestinal (GI)** or intracranial bleed (ICB) Allergy to ASA **Gastroesophogeal reflux disease (GERD) is not automatically considered a contraindication but may be included if specifically documented as a contraindication by the physician. The following may be exclusions if specifically documented by the physician: Use of non-steroidal anti-inflammatory agents Documented risk for drug interaction Uncontrolled hypertension defined as >180 systolic, >110 diastolic Other provider documented reason for not being on ASA therapy Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 22 Excel Format Example Date (mm/dd/yyyy) 06/01/2008 Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes AE (cont.) NOTE: Aspirin (ASA) Contraindication Date (cont.) Excel Format Leave the ASA Contraindication Date field BLANK if ASA Date field is completed (patient is taking ASA), this field is only needed for patients not taking daily ASA with a documented contraindication to ASA. For patients taking Coumadin or Lovenox AND ASA, enter the ASA date and NOT the contraindication date. Leave BLANK if there is no documentation of taking ASA, anti-platelets or a contraindication. Do NOT enter a 2013 date. Dates in 2013 will create an ERROR upon submission. Contraindication date does not need to be in the measurement period. If only the month and year is known (e.g., GI Bleed- June 2009), enter a valid date to indicate the time, (e.g., 6/01/2009). Look back at least three years (dates of service in 2012, 2011 or 2010) for contraindication date. Looking back four years or more is optional. The MNCM auditor must be able to validate this date. If the patient is on an anticoagulant, enter the most recent date. If the ASA has been discontinued prior to a surgical procedure, do NOT count this as a contraindication; rather document this patient as taking ASA during the measurement period. NOTE: Do NOT assume that a preop standing order like, “Do not take ASA seven days prior to the procedure,” means that a patient is taking ASA every day; there must be other documentation in the record that the patient is taking daily ASA. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 23 Example Optimal Diabetes Care 2013 Direct Data Submission Data Elements and Field Specifications Column Field Name Notes Excel Format Example AF Enter the most recent date the patient’s tobacco status was documented. This date can be in 2012 or prior as long as it is the most recent documented status. The MNCM auditor must be able to validate the date and status, and validate that the date and status are the most recent. Date (mm/dd/yyyy) 07/22/2012 Number 1 AG Tobacco Status Documentation Date Tobacco Status Target = Tobacco Free Status Leave BLANK and enter 2 (No Documentation) for the Tobacco Status (Column AG) if the patient was not asked or there is no associated date with the patient’s tobacco status Do NOT enter any 2013 tobacco status date. Dates in 2013 will create an ERROR upon submission. Enter the tobacco status. Tobacco includes any amount of cigarettes, cigars, pipes, or “chew.” 1 = Tobacco Free (patient does not use tobacco) 2 = No Documentation 3 = Current Tobacco User Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 24 Optimal Diabetes Care 2013 Direct Data Submission (01/01/2012 to 12/31/2012 Dates of Service) Direct Data Submission Instructions Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 25 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Summary of Changes Best Practice Questions When entering the denominator you will now be asked to indicate if you follow best practices for Race, Ethnicity, Language and Country of Origin data collection. Please refer to Step 1 under Data File Creation and Data Submission on pages 52 for more detailed instruction. Data Comparison Tool After you upload the data, you will be asked to review the preliminary rates in comparison to the last data submission cycle’s rates for this measure. Please refer to Step 4 under Data File Creation and Data Submission on page 54 for more detailed instruction. About Direct Data Submission The goal of Direct Data Submission (DDS) is to collect data from medical groups on specific health care conditions and publicly report comparable rates of health care quality at the clinic site level. All medical groups follow the same instructions for population identification and data collection. MNCM certifies methodologies prior to data collection. Then, each medical group submits data to MNCM via a secure, online data portal. As an independent auditor, MNCM validates the data for accuracy, calculates rates from the validated data, and publicly reports the data on the MNCM Web site www.mnhealthscores.org. Required Reporting DDS fulfills participation requirements for the Minnesota Department of Health’s Minnesota Statewide Quality Reporting and Measurement System as well as other health plan pay-for-performance programs and Minnesota Bridges to Excellence. In addition, DDS results can be used by medical groups for quality improvement purposes. Health Care Homes If your medical group has providers or clinics that are certified by the Minnesota Department of Health as a health care home then you will need to enter the patient’s primary care provider NPI in the data file. Please note the additional health care home data fields have been removed from the specifications and are NOT part of data submission for health care homes. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 26 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions DDS Participation Requirements To participate in the DDS process, medical groups must agree to Follow the MNCM timelines Agree to MNCM’s Site Terms of Use Agreement (sign electronically on the MNCM Data Portal) Submit data for ALL clinic sites Submit data in required format (.csv) Participate in the data validation process as required by MNCM Have results publicly reported on www.mnhealthscores.org and the annual Health Care Quality Report Thank you for participating in Direct Data Submission! MN Community Measurement appreciates your participation in DDS. Medical groups’ efforts to submit data via DDS allows MN Community Measurement to report comparable health care quality rates in Minnesota and communities that border Minnesota. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 27 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Confidentiality and HIPAA for DDS Our legal firm, Lindquist & Vennum P.L.L.P., has assured us that direct data submission fits within the scope of lawful compliance with HIPAA and MN statute as long as we have a signed Business Associate Agreement (BAA) with the medical group. This document can be electronically signed on the MNCM Data Portal, or MNCM would be open to signing a medical group’s standard BAA document version. The BAA is signed annually and remains in effect for all direct data submissions for the year. Health Insurance Portability and Accountability Act (HIPAA) Law: This activity is considered within the scope of “health care operations” associated with the medical group quality improvement efforts. The federal HIPAA law specifically allows release of individually identifiable health information - without the consent or authorization of the individual - for treatment, payment and health care operations of, or for, the provider. Minnesota Statute: The primary governing Minnesota statute is MN Stat. Section 144.335. Subd. 3a. entitled "Patient consent to release of records; liability" states: (a) A provider, or a person who receives health records from a provider, may not release a patient's health records to a person without a signed and dated consent from the patient or the patient's legally authorized representative authorizing the release, unless the release is specifically authorized by law. However, the statute does not restrict release (without patient authorization) to only those circumstances authorized by state law. Legal opinion assures us that it is reasonable to conclude that the HIPAA privacy regulation does specifically address authorization for release of such information. The appropriate method for a covered entity to allow such release and to verify the release is for a certain, narrow purpose, is either via a data confidentiality agreement or, if the auditor or other entity to whom the information is released will be maintaining any individually identifiable health information, a business associate agreement. American Recovery and Reinvestment Act of 2009: MNCM ensures HIPAA compliance with the ARRA provisions. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 28 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Overview of the Process and Timeline Process Step Registration Medical group registers clinics and providers on the MNCM Data Portal and electronically signs the Site Terms of Use Agreement and Business Associate Agreement. Helpful Dates to Remember Registration begins December 12, 2012 Deadline: February 8, 2013 Resource: Download Clinic and Provider Registrations Instructions from the Resource Tab on the MNCM Data Portal https://data.mncm.org/login or www.mncm.org. Denominator Certification Medical group submits a denominator document outlining the method for identifying the patient population to the MNCM Data Portal. MNCM reviews and approves the denominator. MNCM must approve your denominator before you begin pulling your data. Please plan accordingly. Submit denominator document in December 2012 or early January 2013 MNCM responds within 2-3 business days after receiving the denominator document Resources: Download Optimal Diabetes Care 2013 Denominator Template from Resource Tab on the MNCM Data Portal Data Collection and Submission Medical group collects data and maintains a “crosswalk” of the patient list for future patient identification. Data collection begins after the billing cycle is completed for the measurement period. Medical group prepares file (.csv format) to submit to MNCM via the MNCM Data Portal. MNCM Data Portal opens: January 14, 2013 MNCM Data Portal closes: February 15, 2013 Resources: Download Data Collection Guide Optimal Diabetes Care 2013 and Data Collection Spreadsheet Template from Resource Tab on the MNCM Data Portal Data Validation Resources: Crosswalk patient list, Data collection forms/spreadsheet with notes, Staff participation A MNCM auditor will contact the medical group to schedule the validation audit after the data file is successfully uploaded onto the MNCM Data Portal. Data Results May 2013 MNCM auditor conducts audits to validate that the submitted data matches the source data in the patient medical record. After the successful submission and validation of the clinical data, MNCM will post the results on www.mnhealthscores.org. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 29 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Resources to Help You Get Started To identify your population, collect data, and get started in the data submission process, MN Community Measurement offers a selection of resources and tools. To access the resources and tools for Optimal Diabetes Care measure, log in to the data portal using the following website: https://data.mncm.org and click on the RESOURCES tab. Select Diabetes Resources from the drop-down menu. The Diabetes Resources screen contains Optimal Diabetes Care Data Collection Guide, Diabetes Resources and Frequently Asked Questions. The documents you will need to download include: Optimal Diabetes Care 2013 Data Collection Guide Optimal Diabetes Care 2013 Excel Template Optimal Diabetes Care 2013 Exclusions Template Optimal Diabetes Care 2013 Denominator Template (available in May 2012) Optional: Optimal Diabetes Care Data Collection Form – this form is a patient-level form that is most useful for medical groups and clinics using paper records. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 30 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 1: Registration and Data Submission Preparations Your medical group/clinic should have previously registered with MN Community Measurement. Registration must be completed once annually. Please refer to separate registration instructions for this process. A downloadable instructional guide will be available on the MNCM Data Portal. Other data submission preparations: Save the MNCM Web sites in your “Favorites” internet folder for future reference. o MNCM Data Portal: https://data.mncm.org/login o MNCM Web Site: www.mncm.org o MN HealthScores: www.mnhealthscores.org Create a folder in your network drive dedicated to all data submission documents. o Save all spreadsheets, forms and data submission materials in the dedicated folder. Name versions of documents clearly so you are using the most recent files. Log in to the MNCM Data Portal at https://data.mncm.org/login. In the Resources tab of the data portal, you are able to access the following items: o Direct Data Submission Resources. Download the following Optimal Diabetes Care 2013 Direct Data Submission Guide Optimal Diabetes Care 2013 Denominator Certification Form Optimal Diabetes Care 2013 Data Collection Form Optimal Diabetes Care 2013 Exclusion Template Optimal Diabetes Care 2013 Spreadsheet Template Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 31 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 2: Identifying the Patient Population (Denominator) Denominator Definition: The denominator is the bottom number in a fraction. In epidemiology, the denominator represents a population group at risk of a specific disease. In this step, the total number of patients who are eligible for the measure are identified using a standard set of criteria. Please review the “Denominator” section noted in the Measure Specifications in this guide for the detailed criteria used to identify eligible patients for the denominator. Certification of the Patient Population (Denominator Certification) To help medical groups achieve accuracy and/or avoid inadvertently pulling the wrong patient population for the measure, MNCM will complete an upfront review of each medical group’s source code or methodology that is used to produce the patient population (denominator) to help identify potential errors. The denominator certification process is intended to help identify potential issues prior to data submission. However, the responsibility to submit an accurate denominator rests with the medical group. Please contact [email protected] with any specific questions. PLEASE NOTE: Denominator certification may also include a comprehensive review by MNCM of the process steps used to identify the denominator, including the final list of patients. Please save all original queries, documents, spreadsheets and process steps that are used to identify the patient population. MNCM may ask to review this information. Denominator Template Form This template is provided to ensure all medical groups are using the same set of criteria to identify patients for the denominator. Medical groups are asked to complete this form and submit it to the MNCM Data Portal. Please note, the denominator form asks for source code or “screen shots” which are helpful in MNCM’s review of the denominator. 1. Login to the MNCM Data Portal 2. Go to the Resources tab > Diabetes Resources and download the Optimal Diabetes Care 2013 Denominator Template Form. 3. Complete the form and save the form on your network directory. 4. Login to the MNCM Data Portal and click on Denominator Certification under the Optimal Diabetes Care – 2013 Report (2012 DOS) section. Follow the instructions to upload the form to the data portal. 5. MNCM will review the method and respond within 2-3 business days. MNCM will either (1) contact the medical group if more clarification is needed, in which case the medical group will need to make the necessary revisions and re-upload the form, or (2) approve and certify the method in the MNCM Data Portal; an automatic e-mail will notify the medical group that the method is certified. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 32 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Details for the Denominator Methodology The following elements are included on the denominator template form. Medical groups will need to indicate on the form how they will identify each element for MNCM: Date of birth range ICD-9-CM codes included in query o When querying the system for ICD-9 diagnosis codes, use the appropriate sets of code ranges. Do NOT use one single code range (i.e., do NOT use “410-445.8”) to query the system as this will include more patients in the population that do not apply to this measure. Visit date range and visit count details that ensures established patient criteria were followed Board certified specialties offered by the medical group that ensures the appropriate specialties for each measure were included Whether exclusions will be taken and how exclusions will be handled o EMR groups can list which accepted exclusions will be filtered through the query process o Medical groups that will manually abstract data can describe that exclusions will be identified and documented during record review Whether total population or a sample of the patient population will be submitted. If a sample is submitted, the process for generating a sample will need to be described. “Inactive” patients: Patients designated as “inactive” in a practice management system, billing system or electronic medical record must be included in the patient population if they meet the criteria. Patient attribution: A patient is attributed to one clinic and one provider that are considered responsible for managing the patient’s care. Please use the following attribution methods in order: 1. First, attribute the patient to the clinic and provider that are assigned to the patient and are responsible for the patient’s care. If the patient does not have an assigned clinic or provider, then 2. Attribute the patient to the clinic and provider that saw the patient most often in the measurement period. If more than one provider saw the patient equally, then 3. Attribute the patient to the clinic and provider that saw the patient most recently in the measurement period. If a provider has left the clinic, you may attribute the patient to the provider who has left or to a new provider now managing the patient’s care. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 33 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions System Query: Helpful data elements that can be included in the system query Clinic or facility (This information must be substituted in the data file with the corresponding MNCMassigned Clinic ID as listed in the portal.) Patient ID number (If you will substitute this number with a unique number, keep a “crosswalk” of this information for the validation audit. Do NOT submit Social Security Numbers.) Patient Date of Birth (DOB) Provider name and NPI Provider type/specialty code (This information must be substituted in the data file with the MNCM-assigned specialty code.) Keep a “Crosswalk”: It is very important to keep a “crosswalk” between the unique identifier and the patient’s name and DOB, so that records can be located by clinic staff at the time of validation by MNCM. Insurance payer (This information must be substituted in the data file with the MNCM-assigned insurance code. This should be the patients’ most recent insurance on or prior to 12/31/2012.) Insurance member ID (This information must be formatted as TEXT in the Excel file so that IDs with number and letters or leading zeros maintain their format. Do NOT submit Social Security Numbers.) Date of last visit in the measurement period (This is not necessary but may be helpful when abstracting data.) Gender Zip Code Race/Ethnicity (Please refer to the REL Data Field Specifications and Codes 2012 document referenced in the field specification section for the corresponding codes.) If a medical group opened or acquired a new clinic in the last year, the new clinic must register and submit data with the medical group. If the new clinic uses a different practice management system, billing system or EMR, they would identify patients and collect the data separately from the other Excel Pivot Table clinics in the medical group, but would include their data in the same file that the medical group submits to MNCM (the identifier is the Clinic ID). Tip: The Excel Pivot Table function can show For medical groups that implemented a new practice management system or counts of patients. Use EMR in the last two years: Please consider how to generate the patient the patient medical population using both systems. Two queries or patient lists may be necessary. record number, account number or other unique The lists should then be combined and a common identifier(s) selected to deID as the common duplicate the list. Please contact [email protected] with any questions. identifier. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 34 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Finalizing the patient population list: 1. Sort the list by the clinic site (where the patient is attributed). 2. De-duplicate the list and include only one record for each patient. If a patient is listed more than one time within a clinic or within the entire medical group, determine which provider or clinic the patient will be attributed to and delete the other patient record/row. 3. Evaluate the number of patients in the population: Is the total number of patients in the population similar to last year? If the totals are significantly different, does the difference make sense? Maybe a clinic opened/closed, or maybe a clinic’s overall patient population increased/decreased this year, etc. Does a correction in the methodology or query need to be made? Allowable Exclusions Allowable exclusions are kept to a minimum and are supported by evidence. The evidence must show frequency of occurrence in which the results would be distorted without the exclusion or is clinically appropriate. Please see the “Allowable Exclusions” noted in the Measure Specifications and in Table 4 on page 10 in this guide for a complete list of allowable exclusions. If a patient meets the established patient criteria for the population and none of the allowable exclusions apply, the patient must be included. Track the excluded patients found during data collection for validation purposes: Exclusions Template: A template will be available on the MNCM Portal to use for tracking excluded patients. This document will need to be uploaded to the MNCM Data Portal when the clinical data file is submitted. MNCM will review this list and validate a selection of records during the validation audit. Please read more about the Exclusions Template in the Data File Creation and Data Submission step in this guide. If a sample of patients will be submitted and a patient who meets one of the exclusion reasons above is found, document this reason and on the original patient list or data collection form, and enter this patient in the Exclusions Template. If the total population will be submitted using an EMR extraction of data, it is okay upload a different Excel file of excluded patients that are removed from the population. Using the Exclusions Template is not necessary, although the exclusion reason for each patient must be clear. Do NOT enter a patient on the template if the patient did not meet the initial denominator criteria (e.g., not ages 18-75, did not meet the visit criteria). Only include patients that meet one of the allowable exclusions. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 35 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Visits: Helpful information for identifying the patient population For the purposes of determining if a patient is established to a practice, medical groups will count the number of face-to-face visits using the criteria described in the Measure Specifications in this guide. Medical groups may have different ways of defining or classifying visit types within a practice, but the intent is to count visits where there is face-to-face evaluation of the patient by an MD, DO, PA or NP. Face-to-face visits include the following visit types: office visit, physical exam, annual visits, and pre-op visits. If the clinic offers after-hours primary care, these patients must be included. Do NOT include hospital visits. Clinic lab-only visits or nurse BP checks are not included in the visit count; however, these visits could be data collection sources for recent labs or BPs. Evaluation and Management (E & M) CPT Codes (optional) The following list of codes may be helpful in determining what types of visits to include for identifying the patient population (denominator). E & M codes do not need to be used when querying a practice management system to determine visit counts; however, they have been included here to help further define what is meant by a “face-to-face” visit with a provider. Please refer to a CPT coding manual for more details. Description E & M Codes Preventive Codes Office Consultation Individual Counseling Group Counseling Other Preventive Medicine Services Unlisted E & M Codes CPT Codes 99201 – 99205, 99211 – 99215 99384- 99397 99241-99245 99401-99404 99411-99412 99420, 99429 99499 Visit Scenarios (to help define visit criteria) Below are examples showing application of visit criteria (assuming all other denominator components are met): Visit scenario Patient saw a provider face-to-face in January 2011 and April 2011 for diabetes; patient was also seen in December 2012 for a sore throat. Patient saw a provider face-to-face in August 2011 and December 2012 for diabetes. Patient saw a provider face-to-face in August 2012 and November 2012 for diabetes. Patient only saw a provider face-to-face in January 2011 and April 2011 for diabetes. Patient saw a provider face-to-face in January 2011 for IVD and in January 2012 for a hand injury. Include patient in population? Yes. This patient meets the visit criteria (Patient saw a provider two times in the past two measurement periods for diabetes and once during the measurement period). Yes. This patient meets the visit criteria (Patient saw a provider two times in the past two measurement periods for diabetes with one visit happening during the measurement period). Yes. This patient meets the visit criteria. (Patient saw a provider two times in the past two measurement periods for IVD with both visits happening during the measurement period). No. This patient does not meet the visit criteria. (Patient did not see a provider during the measurement period). No. This patient does not meet the visit criteria (Patient did not see by a provider at least two times in the past two measurement periods for diabetes). Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 36 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Total Population Submission Physician clinics with electronic medical records in place for the prior full measurement period (Dates of service 01/01/2011 to 12/31/2011) are required to submit data on their full patient population. Physician clinics without electronic medical records in place for the prior full measurement period are encouraged to submit data using their full patient population for each measure, but may use a random sampling methodology. Using the total population to calculate the rates creates a higher likelihood that the rate accurately reflects the physician clinic’s performance. MNCM encourages medical groups to submit total population instead of sample if possible. There are benefits to doing so: More precise rates. Optimal care rates based on total population submission more precisely reflect the clinic’s performance. In MNCM’s annual Health Care Quality Report, the upper and lower confidence interval (CI) around the rate is displayed (this shows both a lower rate and an upper rate that would be possible if another random sample of patients was observed for the measure). By submitting total population, the CI is more likely to be narrower. Clinics with a rate and CI that are fully above the statewide average are highlighted by MNCM as High Performers. If a clinic submits a sample, it is likely that the CI would be wider, and if the CI crosses the statewide average, the clinic would not achieve the designation of High Performer. This may be especially important to clinics participating in MN Bridges to Excellence and other health plan pay-for-performance programs that rate clinics based on whether total population or a sample was submitted. Allows health plans to identify health plan product (Commercial, Medicare, Medicaid) for all patients: If medical groups submit a sample, it is only possible to identify health plan product on the sampled patients; not all patients from which the sample is drawn. This can affect the risk adjustment methodology that uses health plan product. Allows MN Bridges to Excellence and other pay-for-performance programs to use total population denominators (which tend to have higher counts) for payments. For medical groups that submit a sample, BTE must instead use health plan data for payments. Opportunity to submit total population data for multiple programs: CMS’s Physician Quality Reporting System (PQRS), E-Prescribing (eRx), and Direct Data Submission (DDS). MNCM serves as a registry for medical groups to submit data to CMS for the PQRS and eRx programs. If you participate in PQRS or eRx, the same data files submitted for PQRS and eRx can be used to prepare your file for DDS. This is advantageous to medical groups because one set of data files can be used for multiple reporting programs. For more information about these programs, please contact [email protected]. If your group is using total population submission, please skip the sample submission process below and move directly to Step 3: Data Collection. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 37 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Sample Submission Submitting a sample is also an option (e.g., for clinics that use paper records or for clinics that do not have a fully implemented EMR). Below are the requirements for submitting a sample: Each clinic must submit a sample. If a clinic has less than 60 patients in the population for the measure, submit ALL patients (e.g., if a total of 59 patients are in the population for the measure, submit all 59 patients). If a clinic has 60 or more patients, first consider submitting all patients, otherwise you may submit a sample. The minimum required sample is 60 patients per clinic site (e.g., if there are 79 eligible patients in the population, first consider submitting all 79 patients, otherwise submit a sample of at least 60). Missing records: If a record in the sample list is not available or “missing,” do NOT exclude this record. Missing records must still be included in the sample. Random Sample Selection Methods METHOD 1: Excel Random Number Generator: For patient lists generated in Excel, use the “RAND” function to assign a random number to each record (please also see Microsoft Excel Help, topic RAND for more information): 1. Insert a blank column on the leftmost side of the spreadsheet 2. Label new column “RAND” 3. Place cursor in the first blank cell (A2) and type =RAND() 4. Press enter (a number like 0.793958 will appear) 5. Place the cursor back into this cell; resting over the corner to have the pointer change to a black cross, double click or drag the formula down to the last row/patient 6. Highlight the whole column and click Edit, Copy, Paste Special = Values to freeze the random number (otherwise it will change with every click on the spreadsheet) 7. Sort entire patient population by this new random number 8. Work down the list row by row, starting with the first row until the number of records in the sample is met for submission (at least 60 patients per clinic, per measure) 9. If a patient meets one of the accepted exclusions, note this on the exclusions spreadsheet and keep working down the list. Use oversample records following the last record/row of the original sample. For example, if 60 records will be submitted and exclusions were found in the first 60 records/rows, use patients from rows 61, 62, and so forth to replace the excluded records. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 38 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions METHOD 2: Paper List Sample Selection: For paper-generated lists, complete the following steps: 1. Start with a list that has patients sorted by some unique patient related variable. a. Identifying number like a medical record number (MRN) or chart number is ideal. b. Sorting alphabetically is the least desirable in terms of randomness; however, this may be used when there is no other alternative. 2. Select every Nth patient for the number of patients that will be reported. a. N should equal the clinic site’s total population divided by the number of patients that will be submitted (if needed, round down to the nearest whole number). Highlight or mark every Nth patient on the list. This is the sample. b. Example: If a clinic site has 600 diabetes patients and 60 patients will be submitted, divide 600/60 = 10. Select every 10th patient on the list. 3. If a patient meets one of the accepted exclusions, note this on the data collection form and exclusions spreadsheet and select the next patient on the list (just below the excluded patient). Missing records: If a record in the sample is not available or “missing,” do NOT exclude this record. Either locate the record and complete the data collection, or include the record and leave the data fields blank if the record cannot be located. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 39 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 3: Data Collection Medical groups can collect clinical data from medical records by either 1) extracting the data from an electronic medical record through a data query, or 2) abstracting the data from the medical record (paper record or EMR). Data collection occurs after: 1. The clinic’s billing and medical record updates are complete for the measurement period, 2. The denominator method is certified by MNCM, AND 3. The patient population is pulled, and if applicable, a sample is selected according to the measure specifications and sampling instructions. Tools for Data Collection and Data Entry Data Collection Form A data collection form was created for medical groups that manually collect data from an EMR or paper record. The necessary data elements are on the form. These forms can also be used to note where certain data elements were found in the medical record. Data collected on these forms must also be entered into the Excel file mentioned below. Please download these forms from the MNCM Data Portal, Resources tab, select Diabetes Resources from the drop-down menu. Excel Template The Excel template was created to ensure all necessary data elements are collected for DDS. This file contains all of the necessary fields and the correct column formatting according to the measure specifications. Please download the Excel template from the MNCM Data Portal, Resources tab, select Diabetes Resources from the drop-down menu. Field Formatting in the Excel File: Prior to entering data in the Excel file, it is important that the field formats follow the measure specifications in this guide. Pay special attention to field formatting (e.g., dates look like dates, etc.). THE EXCEL TEMPLATE PROVIDED HAS THE CORRECT FORMATTING. Do NOT use “General” formatting in Excel. The Excel template provided on the MNCM Data Portal will provide the correct formatting. Pay particular attention to the formatting of the insurance member IDs. This field must be formatted as “Text” for IDs that contain numbers and letters or leading zeros. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 40 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Using Multiple Data Collectors | Inter-Rater Reliability (IRR) Ideally, one data collector or data collection process is preferred because it ensures that the data is collected in one consistent way. If, however, more than one person will abstract data, we recommend conducting several sample audits with all abstractors for training purposes to improve IRR. Internal training could include a review of the guide and data collection form, and instructions for locating information in the clinic’s medical record. Also, refer to data collection errors made in previous submissions, make plans to improve the data collection process, and perform quality checks on the data. This ensures that the measurement specifications are interpreted consistently and that the data is collected in a uniform way. Locating Data Elements in the Patient Record The primary source of data is the clinic’s documentation in the medical record (e.g., flow sheets, progress notes, lab reports, etc.). Data collectors may also choose to review the outside correspondence in the clinic’s medical record that documents more recent data within the measurement period, Possible Validation but this is optional. If data is used from outside correspondence, please Audit and Outside document this for the validation audit. Below are tips for locating data in the patient record. Please follow the measure specifications for data Correspondence in collection. the Patient Record: If the most recent data from the primary clinic’s Lab Values (HbA1c and LDL-cholesterol) medical record is used, the Lab report/lab data that is part of the primary clinic’s medical MNCM auditor will NOT do a more extensive review of record outside correspondence Dated value in a note from a referring provider or specialist (e.g., during the validation audit. consult) NOTE: Measurement periods for LDL are different for ODC (LDL in Data Collection Tips: the last 12 months) and OVC (LDL in the last 15 months) measures When manually collecting Blood Pressure data using an EMR, highlight the row, column Progress note or vital sign flow sheet that is part of the clinic’s or cell that contains the medical record data needed. This Dated values in a note from a referring provider or specialist (e.g., reduces the chance of consult) looking at the wrong row, NOTE: A BP from an outside referring provider or specialist is column or cell. Watch for TYPOS when acceptable if it is documented in the primary clinic’s record; this entering data (number reading may be used only if it is more recent than the primary transpositions, etc.). clinic’s reading Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 41 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Tobacco Status Annual exam, progress note, health questionnaire, flow sheet, etc. that is part of the primary clinic’s medical record Dated documentation in the primary clinic’s medical record from outside correspondence (note from a referring provider or specialist such as a consult, hospital records or emergency room visits) NOTE: Tobacco status from an outside referring provider or specialist is acceptable if it is documented in the primary clinic’s record; this status may be used only if it is the most recent documented status Aspirin or ASA Contraindication Medication list, progress note, or condition-specific flow sheet that is part of the primary clinic’s medical record Dated documentation in the primary clinic’s medical record from outside correspondence (note from a referring provider or specialist such as a consult, hospital records or emergency room visits) Ensure that ASA/ASA contraindication dates are entered in the correct field. Examples: ASA/Contra Found in Record: Enter date in ASA field? Enter date in ASA Contra Field? ASA documented 06/01/2012 YES - Enter 06/01/2012 NO - Leave blank Plavix (or other accepted anti-platelet) YES – Enter 06/01/2012 NO - Leave blank documented 06/01/2012 Coumadin/Warfarin documented NO – Leave blank YES – Enter 06/01/2012 06/01/2012 ASA 01/03/2012, Coumadin 04/03/2012 YES – Enter 01/03/2012 NO - Leave blank GI bleed in June 2009 documented on NO - Leave blank YES – Enter either 06/01/2009 or 01/03/2012 01/03/2012 ASA med start date 06/01/2011 (no other Enter 06/01/2012 or leave blank NO - Leave blank ASA documentation) since ASA date is not in measurement year ASA med start date 06/01/2011 and ASA YES - Enter 06/01/2012 NO - Leave blank med review date 06/01/2012 Tracking Where Data is Located in the Patient Record It is important to keep track of where data is located in the patient record. For example, if data is used from an outside specialist or provider note (that is within the primary clinic’s record), document the source on the data collection form or Excel spreadsheet. If you are collecting data directly in the Excel spreadsheet, create a “NOTES” column and enter the data source details in this column. After you have completed data collection, SAVE A COPY of the Excel file and remove the “NOTES” column in the file that will be used for submitting to MNCM. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 42 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Patient Registries: A patient registry is an important tool to help clinics track patient progress and to use for quality improvement purposes. However, MNCM cautions the use of a patient registry for identifying patients in the population or for the collection of clinical data. Many registries give a “snapshot” of patients at a given time and would therefore not include all patients according to established patient criteria or may not reflect the most recent clinical data (e.g., most recent blood pressure or labs). Registries that are programmed to update the patient population and clinical results on a continual basis (24/7) could possibly be used, however, please discuss this with MNCM. During the validation audit, the MNCM auditor will review the patient record for validation and not the patient registry. If a clinic uses data from a patient registry, the auditor may find a more recent date/value in the medical record and this would be counted as a validation error. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 43 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 4: Data Quality Checks MNCM recommends completing several internal quality checks of the data before submitting the data. Performing quality checks ensures that the data is accurate and able to be validated by a MNCM auditor. If corrections are needed, make these in the Excel file. Excel’s AutoFilter Use the Filter function in Excel to look for incorrect or missing data: Click inside any data cell and activate the AutoFilter by doing the following: o In Excel 2003, click the Data menu, point to Filter, and then click AutoFilter. o In Excel 2007 and Excel 2010, click the Data tab and in the Sort & Filter area click Filter. The AutoFilter arrows now appear to the right of each column heading. Click on the drop-down boxes of any column and scan for key entry errors, “out-of-range” or missing data and determine if the data needs to be corrected (e.g., an A1c value entered as 68 instead of 6.8) o To display all data again, click on the same drop-down box and select (All). Remove the Filter option by doing the following: o In Excel 2003, click Data, Filter, and AutoFilter again o In Excel 2007 and Excel 2010, click the Filter option again in the Sort & Filter area Example Quality Check: Verify that every LDL date has an associated LDL value entered by clicking the LDL Value drop-down menu to see a list of values and other selections; scroll through to find the (Blank) selection; click (Blank) to see which record(s) had a missing value; verify the data in the medical record and make changes in the Excel file if necessary. Internal Audit of Clinical Data: Before submitting the data file, you may wish to review a random sample of records (8-10) to see if the data matches what was collected from the patient record. If errors are found, make the corrections in the Excel file, however also consider if the errors were isolated cases or indicative of a larger data collection problem. (Examples of a larger data collection problem: There are no patients with Aspirin (ASA) Contraindications Dates and you are certain that there are patients who have Aspirin (ASA) contraindications.) Important Quality Checks (Excel File) It is important to complete the following quality checks of the file before submitting data to MNCM. Completing these checks can help avoid delays in the file submission and ensure that you have the most accurate data. Make any changes/additions in the Excel file before submitting data to MNCM. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 44 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Column Field Name Quality Check A Clinic ID Verify all clinic IDs match the “MNCM ID” that the portal lists. Do NOT use the Medical Group ID. Verify that each cell has data. Blank values will create an ERROR upon submission. B Patient ID Verify that each cell has data. Blank values will create an ERROR upon submission. Verify patients were not duplicated: C Patient Date of Birth Use the Excel pivot table to do counts by patient ID (or patient insurance member ID if the patient ID is de-identified). If a duplicate is found, determine which provider/clinic the patient is attributed to and delete the other record. Keep in mind that if you are submitting a sample, you will need to replace the deleted record with the next sampled patient. Verify that each cell has data. Set the filter, view this field, and verify that the date of birth is within the accepted range. Blank values or values outside the range 01/01/1937 to 01/01/1994 will create an ERROR upon submission. D Patient Gender Verify that each cell has data. Blank values will create an ERROR upon submission. Verify each cell has one of the accepted codes. E Patient Zip Code, Primary Residence Verify that each cell has data. Blank values or values less than five digits will create an ERROR upon submission. Verify the zip code is five digits long. F-J Race/Ethnicity Codes Blank cells (where no data is available) are acceptable. Verify accepted codes are used. K Country of Origin Code Blank cells (where no data is available) are acceptable. Verify accepted codes are used. L Country of Origin “Other” Description Verify this field is populated if the previous cell was entered 999 (other) M Preferred Language Code Blank cells (where no data is available) are acceptable. Preferred Language “Other” Description Verify this field is populated if the previous cell was entered 99 (other) N Verify accepted codes are used. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 45 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Column Field Name Quality Check O Provider NPI Verify that each cell has data. Blank values will create an ERROR upon submission. P Provider Specialty Code Verify that each cell has data. Blank values will create an ERROR upon submission. Verify each cell is one of the accepted codes. Q Insurance Coverage Code Verify that each cell has data. Blank values will create an ERROR upon submission. Verify each cell is one of the accepted codes. Set the filter and view only the 99 codes: Verify insurance names are also entered in the next field (“Other” Description). Verify any of the entries in the “Other” Description field do not already have an available code. If there is an available code, change the code to the corresponding insurance payer. (e.g., If the description of Aetna Medicare Advantage was entered, the insurance code should be changed to 18 for Aetna.) R Insurance Coverage “Other” Description Verify this field is populated if the previous cell was entered 99 (other) S Insurance Plan Member ID Verify this cell has the appropriate member ID if the patient has insurance. Do NOT enter social security numbers (Medicare IDs). Blank cells are acceptable. T-U Patient Has IVD or Depression (comorbidity)? Verify each cell is one of the accepted codes. V Type 1 or Type 2 Diabetes? Verify each cell has one of the accepted codes. W HbA1c Date Set the filter, view this field, and verify the date is what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. X HbA1c Value Set the filter, view this field, and verify the values look correct. Blank cells (where no data is available) are acceptable. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 46 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Column Field Name Quality Check Y LDL Date Set the filter, view this field, and verify the date is what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. Z LDL Value Set the filter, view this field, and verify the values look correct. Blank cells (where no data is available) are acceptable. AA BP Date Set the filter, view this field, and verify the date is what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. AB BP Systolic Set the filter, view this field, and verify the values look correct. Blank cells (where no data is available) are acceptable. AC BP Diastolic Set the filter, view this field, and verify the values look correct. Blank cells (where no data is available) are acceptable. AD Aspirin (ASA) Date Set the filter, view this field, and verify the date is what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. Date should reflect ASA use in the measurement period (med review date vs. med start date that might be prior to the measurement period). AE Aspirin (ASA) Contraindication Date Set the filter, view this field, and verify dates are what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. AF Tobacco Status Documentation Date Set the filter, view this field, and verify that the date is what is expected. 2013 dates will create an ERROR upon submission. Blank cells (where no data is available) are acceptable. AG Tobacco Status Verify that each cell has data. Blank values will create an ERROR upon submission. Verify each cell is one of the accepted codes. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 47 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Column Field Name Quality Check Other: 1. Exclusions 2. Values (A1c, LDL, BP) 3. Hyphens or “0”s 4. Blank rows in spreadsheet 1. Verify excluded records are removed and recorded on Exclusions Template. 2. Verify each entered value has an associated date. 3. If the data field is supposed to be blank, do NOT enter hyphens or “0” (leave blank). 4. Check that the Excel file does not have blank rows at the bottom of the spreadsheet. Blank rows at the bottom of the spreadsheet can slow the data submission process. To check for blank rows: Press Ctrl/End at the same time to go to the bottom-most cell in the spreadsheet. If there are blank rows, remove them by highlighting the BLANK rows, right-clicking in the left margin, and select Delete (this deletes the rows and not only the text within the cells). Optional Quality Check: Complete an Audit of Clinical Data Another option is to select a random sample of several records (about 30) and audit those records to see if the data matches what was collected from the patient record. If errors are found, make the corrections in the Excel file, however also consider if the errors were isolated cases or indicative of a larger data collection problem. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 48 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 5: Data File Creation and Data Submission Final Steps to Complete in the Excel File: Before proceeding with the file submission, be sure to: Complete all data collection and data entry. Complete data quality checks. Combine all clinic files onto one spreadsheet. All clinics must be uploaded in one, single spreadsheet. The clinic identifier is the Clinic ID. Verify that each column is formatted according to measure specifications (TEXT, NUMBER, or DATE formatting). Columns can be any width. Check that the field labels in the header row (first row) matches the labels on the Excel template exactly. Ensure that all original columns remain in the spreadsheet even if there is no data. Do NOT delete any columns. If at any point in the process it is discovered that corrections to the data are needed, make the necessary changes in the Excel file and save a new CSV file with using a different name. Important Message Regarding the CSV File: After creating the CSV file, do NOT open the CSV file in Excel. Opening the CSV file in Excel destroys the formatting and alters the data. To view the data again, open the original Excel file. If you need to make changes to your file, make the changes in your original excel file, not in the .csv file, and save the changes to a new .csv file. If the CSV file is mistakenly opened in Excel, simply re-save a new CSV file from the original Excel file. Rename the old CSV file or delete it entirely. What is a CSV file? Why is a CSV file needed for data submission? CSV stands for “comma separated values.” A CSV file is a common and simple format that is used to import /transport data between systems or software applications that are not directly related (e.g., from a spreadsheet to a database). Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 49 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Create CSV File for Data Submission The next step is to create a CSV file that will be used for upload to the MNCM Data Portal. Below are steps for creating a CSV file (Excel 2003, 2007 or 2010 users). If multiple tabs were created in the Excel spreadsheet, select the correct tab and proceed with the following steps (if spreadsheet has only one tab, start with step 6). For Excel 2003 Users For Excel 2007 Users For Excel 2010 Users 1. Open the original Excel file (.xls) and do the following: 2. Click Edit or right-click the tab of the spreadsheet you wish to save (near the bottom of the screen) 2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen) 2. Right-click the tab of the spreadsheet you wish to save (near the bottom of the screen) 3. Select Move or Copy Sheet 3. Select Move or Copy Sheet 3. Select Move or Copy Sheet 4. To book (new book) – this is a drop-down selection 4. To book (new book) – this is a drop-down selection 5. Select Create a Copy and click “OK.” 5. Select Create a Copy and click “OK.” 6. In this new book, click the Office Button (upper left-hand corner of screen); Select Save As 6. In this new book, click the File tab (upper left-hand corner of screen); Select Save As 4. To book (new book) – this is a drop-down selection 5. Create Copy (check this box) 6. In this new book, click File, Save As 7. Select the folder and file name of your choice. 8. At the very bottom, you will see Save as type; choose from the drop-down menu, CSV (comma delimited). 9. Click Save. When you save the CSV file, the following warning will appear: “…may contain features that are not compatible with CSV. Do you want to keep the workbook in this format?” Click Yes. 10. Now you can close the file; a message will appear: “Do you want to save this file...?” Click either yes or no. Your CSV file is now ready for upload to the MNCM Data Portal. Do NOT open the CSV file in Excel. If the file is mistakenly opened, simply resave a new CSV file. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 50 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Exclusions File (Excel) Upload to the MNCM Data Portal For medical groups that manually collect data, any patient meeting an allowable exclusion must be tracked on the Exclusions Template. This template can be downloaded from the MNCM Data Portal. Enter each excluded patient (patient ID, clinic ID, DOB) found during manual data collection in the spreadsheet. Enter “1” in the cell of the accepted exclusion. Enter any notes for future reference. NOTE: 1) Do NOT add columns for other reasons that are not one of the accepted exclusions. 2) Do NOT enter patients that did not meet the initial inclusion criteria (e.g., not ages 18 to 75, etc.). Keep the Exclusions File in Excel format; do NOT convert the file to CSV format. The Exclusions File must be kept in Excel format that is different from the Data File that needs to be in CSV format. Before uploading the Exclusions File to the MNCM Data Portal, please do the following: 1. Sort the data by clinic site 2. Save the file for future reference When you are ready to submit data, click on the EXCLUSIONS step on the HOME tab of the data portal under the Optimal Diabetes Care 2013 measure heading. If no exclusions were taken, click on the “No Exclusions” button. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 51 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Data File (.csv) Upload to the MNCM Data Portal The last step is to upload the CSV file to the MNCM Data Portal. Login to the MNCM Data Portal and go to the Home Page. Click on Data Submission under the correct measurement period section and complete the following steps. Step 1 Enter Denominator Enter the following information for each clinic row. Once the information is entered, click on Save and Continue. Method Used for Data Collection: Select one of the methods from the drop-down box o EMR: All data pulled via query o EMR: Some data looked up manually o EMR: All data looked up manually o Manual: Paper records only o Manual: EMR and paper record REL Data Collection: Please indicate if you collect race, Hispanic ethnicity, preferred language and country of birth using best practice methods. Best practice methods include: o Hispanic Ethnicity and Race: Allowing patient to self-report race AND not using a multiracial category AND system allows the collection and reporting of more than one race o Preferred Language and Country of Birth: Allowing patient to self-report these demographic data Number of Eligible Patients (Exclusions Removed): Enter the number of patients who are eligible or met the inclusion criteria for the measure o Do NOT include patients who met an accepted exclusion (e.g., deceased, etc.). Including excluded patients in this count will decrease the final rate, so remember to subtract these patients from the total population. o If submitting a sample, this number must be higher than the number entered in the next field (Number of Patients Submitting). Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 52 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Number of Patients Submitting: Enter the number of patients in the clinic that are being submitted. o For total population submission, enter the same number as what was entered in the Number of Eligible Patients category. o For a sample submission, enter the number of patients being submitted for the sample. Not Reporting: Check this box if a clinic is not reporting for this cycle of data collection. o Please be advised that MNCM’s policy is that ALL clinic sites within a medical group submit their data through the DDS process. Likewise, this is a condition of participation for Minnesota Bridges to Excellence (BTE) and other pay-for-performance programs. o Provide a reason the clinic is not reporting. For example: The clinic has no patients meeting eligibility criteria. Step 2 Review & Save Verify the numbers entered by reviewing all of the clinic site’s information for accuracy (no typos or duplicate patients). Click Save and Continue, or click Back to Step 1 to re-enter the counts. Step 3 Upload Data Click Browse to search for the CSV file and click Upload CSV and Continue. The portal will now scan the CSV file to identify possible errors. The portal will then provide an “Upload Status” that will indicate if there are errors or warnings in the data file. You may have to click on Refresh. If there are errors, the data file will need to be corrected and resubmitted to portal. Please refer to the Data Elements and Field Specifications (pages 13-24) to review the required data for each column. 1. Errors: These are “hard stops” in the portal (example Date of birth that is out-of-range). Corrections must be made to any errors and a new file uploaded to the MNCM data portal. 2. Warnings: These are possible incorrect data (example: portal finds an LDL like 1000 that should be 100). Review the warnings and decide if corrections are needed. If corrections to the data file are necessary: To start from Step 3: If corrections need to be made to the data file, make corrections in the original Excel file and save; then save a new CSV file to upload. Do NOT make corrections in CSV file as this will destroy the format and alter the data. Click Re-Upload Data File to begin again with Step 3 Upload Data. To start from Step 1: Click Clear & Start Over to start the process completely over from Step 1 Enter Denominator. NOTE: All number entries and a new file upload will be necessary. Once the Data (csv) File has been uploaded to the portal, click Continue to Step 4. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 53 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 4 Review & Submit Review and check each box of the Pre-Submission Quality Checklist and contact MNCM if you have any questions regarding the Pre-Submission Quality Checklist. If you need to resubmit the data file, please click either Re-Upload Data (csv) File or Clear and Start Over at the bottom of the page. If you have checked all the boxes, please click Continue. The page will be refreshed. You will be asked to review the current measurement period’s preliminary rates for each clinic compared to the last data submission for this measure and consider any changes between the current period and the prior period. Provide an explanation in the text box for any changes or indicate that the data comparison is what you expected. If you need to resubmit the data file, please click either Re-Upload Data (csv) File or Clear and Start Over at the bottom of the page. Once you have entered an explanation, click Save Notes. The page will once again be updated to save the notes. You can download the data by clicking Download Data near the top of the data comparison section to see which patients were optimal (1) and which did not meet the optimal target (0) by viewing the additional columns added by the portal to the right of the document. Please review this information and determine if the file is ready to submit to MNCM. When the data file is ready to submit to MNCM: Click Submit Data to MNCM and proceed to Step 5 Done. Step 5 Done The data file has been successfully submitted. MNCM will send an e-mail that the data has been received. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 54 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 6: MNCM Validation of Submitted Data The validation process is conducted to verify that the submitted data matches the source data in the medical record. After the clinical data file is successfully uploaded to the MNCM Data Portal, MNCM will contact the medical group about the validation process. The validation audit may be conducted remotely via HIPAA secure WebEx technology for groups with an Electronic Medical Record (EMR). Onsite audits will occur for medical groups with paper chart systems. a. A medical record audit will occur after data submission. b. Medical audits may occur more frequently for groups with a history of unsuccessful direct data submissions The medical record validation audit may be conducted remotely via HIPAA secure WebEx technology for groups with an Electronic Medical Record (EMR). Onsite audits will occur for medical groups with paper chart systems. MNCM Validation Process MNCM utilizes the NCQA (National Committee for Quality Assurance) “8 and 30” process for validation audits. The following method is used for each measure: MNCM randomly selects 33 records for each clinic site for validation. At most, 30 records for each clinic site will be reviewed. The additional three records requested are oversamples to ensure there will be 30 records available on the day of the review. MNCM auditor reviews the first eight records of the clinic site’s selected sample to verify that the submitted data matches the source data in the medical record. If all of the first eight records reviewed are in perfect compliance (100%), the clinic site is determined to be in high compliance, and the MNCM auditor may determine that no further record review for that site is necessary. If the first clinic site is in high compliance and the data collection process for all clinic sites within the medical group is identical, further review may be abbreviated at the discretion of the MNCM auditor. If clinic sites are not in high compliance after review of the first eight records, the MNCM auditor will continue to review the remaining 22 records. If after review of all 30 records the clinic site is not in high compliance on all factors (less than 90%), the MNCM auditor will review the results with the clinic representative and communicate the results with MNCM. MNCM will then contact the medical group to develop a mutually agreed upon re-submission plan. (Re-submission plans will only be allowed for errors in the numerator portion.) Clinic sites that are not in high compliance or have not been in high compliance in a previous MNCM audit may be held to a more rigorous denominator certification and validation audit. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 55 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Validation Results: Once all clinics within a medical group have passed the MNCM validation process, MNCM will approve the data in the MNCM Data Portal that generates and automatic e-mail to the medical group’s data contact that the data is verified and approved. Please maintain the data submission files and other documents for two years. Clinic Preparations for the Validation Audit All medical groups are subject to a validation audit. MNCM auditor will contact the medical group to schedule the audit. MNCM will provide list of sample records that will be audited. The medical group or clinic site representative must be available to participate in the entire audit process. o For validation audits using an EMR, a medical group or clinic representative will retrieve and display the selected records and various screens necessary to complete the validation. During the audit, the patient’s date of birth is used to verify the correct record. All other patient information may be blocked out. Clinics must have the following available at the time of the validation audit: o ALL requested patient records o The “crosswalk” between the unique patient identifier and the patient’s name and DOB, so that the record can be located by clinic staff at the time of validation audit o Data collection forms and other notes describing where various data elements were located in the patient record o List of patients that were excluded Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 56 Optimal Diabetes Care 2013 Direct Data Submission Direct Data Submission Instructions Step 7: DDS Results Following the successful submission and validation of the clinical data, medical groups can expect to see results posted in May on the MN HealthScores Web site at www.mnhealthscores.org. Results will also be included in the annual Health Care Quality Report later in the year. DDS results can also be found on the “Results” tab on the MNCM Data Portal. Pay-For-Performance Programs Medical groups will also receive individual communications from the health plans and MN Bridges to Excellence regarding their pay-for-performance programs that utilize DDS results. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 57 Optimal Diabetes Care 2013 Direct Data Submission (01/01/2012 to 12/31/2012 Dates of Service) Appendices Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 58 Optimal Diabetes Care 2013 Direct Data Submission Appendices Appendix A About MN Community Measurement and Measure Development Mission and Vision of MN Community Measurement The mission of MN Community Measurement is to accelerate the improvement of health by publicly reporting health care information. MN Community Measurement’s vision is to: Be the trusted source for performance measurement and public reporting of quality data across the spectrum of health care that Drive change towards more safe, effective, patient centered, timely, efficient, and equitable care Be a resource used by providers to improve care and patients to make better decisions Catalyze our community to work together on health care measurement to reduce administrative costs and maximize value. About Measure Development Measures are selected according to MN Community Measurement’s Strategic Measurement Development Process. An impact and recommendation document presents the topic for discussion at the Measurement and Reporting Committee (MARC). Topics for measure development must meet the following criteria for consideration of development: Will the measure/s make a difference? o Degree of Impact o Degree of Improvability o Degree of Inclusiveness o Degree of Performance Variation o Outcome measures desired Will the measure improve care by affecting the patient/ physician relationship? o Pass the feasibility test (resources/ barriers/ culture) o Fit with National, Regional and Local Priorities o Relevant to consumers o Support and enhance the patient/ provider relationship Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 59 Optimal Diabetes Care 2013 Direct Data Submission Appendices Appendix B Aspirin and Anti-Platelet Medications PLEASE NOTE: This is not a comprehensive list of aspirin and anti-platelet medications Table 5: Products Containing Aspirin 1/2HALFPRIN TAB 162MG EC ADLT ASA LOW TAB 81MG EC ANACIN TAB 400-30MG ASA LO-DOSE TAB 81MG EC ASA LOW DOSE TAB 81MG EC ASPIR-81 TAB 81MG EC ASPIRIN ASPIRIN CHW 81MG ASPIRIN TAB 325MG ASPIRIN TAB 325MG EC ASPIRIN TAB 81MG E/C ASPIRIN TAB 81MG EC ASPIRIN BUFF TAB 325MG Products Containing Aspirin ASPIRIN BUFFERED Aspirin Buff (Ca Carb-Mg CarbMg Ox) ASPIRIN CHLD CHW 81MG ASPIRIN EC TAB 325MG ASPIR-LOW TAB 81MG EC BAYER ASA TAB 325MG BUFFERED ASA TAB 325MG CHILD ASA CHW 81MG CVS ASPIRIN TAB 325MG CVS ASPIRIN TAB 325MG EC CVS ASPIRIN TAB 81MG EC EC ASPIRIN TAB 325MG ECOTRIN LOW TAB 81MG EC ECPIRIN EXCEDRIN TAB 325MG EC TAB EX STR GENACOTE TAB 325MG EC HCA ASPIRIN TAB 325MG HCA ASPIRIN TAB 325MG EC HCA ASPIRIN TAB 81MG LO-DOSE ASA TAB 81MG EC SM ASA CHLD CHW 81MG SM ASPIRIN CHW 81MG SM ASPIRIN TAB 325MG SM ASPIRIN TAB 325MG EC SM ASPIRIN TAB 81MG EC ZORPRIN Table 6: Oral Anti-Platelet Medications Oral Anti-Platelet Medications Aspirin and Dipyridamole; Aggrenox® Clopidogrel; Plavix® Prasugrel; Effient® Cilostazol; Pletal® Dipyridamole; Persantine® Ticlopidine; Ticlid® This list was compiled by a pharmacy expert at one of the MN health plans. This is not a comprehensive list. Do NOT count an ASA/narcotic combo med for the “daily aspirin use” component of the measure whether it is used for temporary or chronic pain. Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login © MN Community Measurement, 2013. All rights reserved. Page 60
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