Minnesota Statewide Quality Reporting

Transcription

1 Minnesota Department of Health: Protecting, maintaining and improving the health of all Minnesotans Minnesota Statewide Quality Reporting and Measurement System (SQRMS): Clinic and Provider Registration, and Clinical Quality Data Submission Requirements January 8 & 10, 2013 Denise McCabe Quality Reform Implementation Supervisor

2 Quality measures: Statutory requirements Minnesota Statutes, 62U.02, Subd. 1 and 3 The commissioner of health shall develop a standardized set of measures by which to assess the quality of health care services offered by health care providers The commissioner shall establish standards for measuring health outcomes, establish a system for risk adjusting quality measures, and issue annual public reports on provider quality 2

3 Partnership between MDH and MN Community Measurement MDH has a 5 year contract with MN Community Measurement (MNCM) as lead member of consortium including the Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Stratis Health and University of Minnesota. 3

4 MN Community Measurement & MDH roles and responsibilities MDH Selects measurement areas and measures for development Obtains input from the public at various steps of rulemaking Annually promulgates rules that define the uniform set of measures Publicly reports measures Develops vision for further evolution of SQRMS MNCM Performs research in support of identifying new areas of measurement Works with groups of stakeholders on the review of existing and development of new measures, including their specifications Develops annually for the State s consideration recommendations of the uniform set of quality measures Develops recommendations for risk adjustment Holds public meeting at which to present recommendations and obtain feedback Facilitates data collection and management of information collected from physician clinics, ambulatory surgical centers, and hospitals Submits data collected to MDH 4

5 Registration requirements Minnesota Administrative Rules, Chapter 4654, and appendices Physician clinics must register annually with MNCM The primary purpose of annual clinic and provider registration is to facilitate the collection of clinical quality measures for SQRMS Clinic and provider registration determines quality measure submission requirements 5

6 Registration requirements MDH also uses clinic and provider registration for its Provider Peer Grouping (PPG) initiative (Minnesota Statutes, 62U.04) Providing full and accurate information during registration including the providers that practice at each clinic is important Information submitted by physician clinics during annual clinic and provider registration including FTE information is used in PPG to properly credit each physician clinic with the services they provided to their patients The methodology and tools for calculating full time equivalents (FTE) have been enhanced to simplify registration and improve precision Registered provider information is NOT tied to the data submitted for clinical quality reporting 6

7 Reporting requirements Each physician clinic must Submit data required to calculate the applicable quality measures, including the data necessary to perform risk adjustment for each applicable quality measures for all health care services provided by the physician clinic Submit the data using the standardized electronic format and procedures Report on a full population basis if it had an electronic medical record system in place for the entire prior measurement period 7

8 Annual update of quality reporting rules Jan Feb Mar Apr ❶ ❷ May Jun ❸ ❹ Jul ❺ Aug ❻ Sep Oct Nov ❼ Dec 1. MDH invites interested stakeholders to submit recommendations on the addition, removal, or modification of standardized quality measures to MDH by June 1 2. MNCM submits preliminary recommendations to MDH mid April; MDH opens public comment period 3. MNCM submits final recommendations to MDH by June 1; MDH opens public comment period 4. MNCM measure recommendations are presented at a public forum toward the end of June 5. MNCM submits final measure specifications to MDH by July MDH publishes a new proposed rule by mid August with a 30 day public comment period 7. Final rule adopted by the end of the year 8

9 Resources Subscribe to MDH s Health Reform ListServ to receive weekly updates tml SQRMS website ex.html For questions about SQRMS, contact: Denise McCabe, Denise.McCabe@state.mn.us,

10 Minnesota Clinic & Provider Registration and Clinical Quality Reporting 2013 Preparations 10

11 MN Community Measurement Publicly reports health care quality measures with the goal of improving the health of patients 2004: HEDIS measures by medical group Health plan data 2006: DDS measures by clinic site Data submitted by clinics 2010: Statewide Quality Reporting and Measurement System 11

12 2013 Timelines Time Task Portal Opens Portal Closes Winter 2013 Summer 2013 Register MN Clinics & Providers December 2012 February 8, 2013 Data Submission: Optimal Diabetes Care Optimal Vascular Care Depression Care Measures January 14, 2013 January 14, 2013 February 4, 2013 February 15, 2013 February 15, 2013 February 28, 2013 Complete Health Information Technology Survey February 15, 2013 March 15, 2013 Patient Experience of Care Survey February 24, 2013 April 2, 2013 Data Submission: Optimal Asthma Care Colorectal Cancer Screening Maternity Care: Primary C section Rate 2014 Data Submission: Total Knee Replacement (2012 Dates of Procedure) Implement tools now (Jan 2013) 2015 Data Submission: Spine Surgery Measures (2013 Dates of Procedure) Implement tools now (Jan 2013) July July 15, 2013 July 15, 2013 August 16, 2013 August 16, 2013 August 16, 2013 April 2014 May 2014 April 2015 May

13 Getting Started on MNCM Website: Getting Started on MNCM Data Portal: 13

14 Registration Download instructions from mncm.org or MNCM Data Portal from the Resource tab Access the MNCM Data Portal: First time users must request login/password Necessary registration information: Medical group information Clinic and specialty information Provider information and file upload Clinic specialties determine which measures a clinic is required to submit data for Must complete registration before February 8, 2013 Registration must be completed before data can be submitted to MNCM 14

15 Clinic Registration and Reporting Registration: Register any and all clinic locations in the state of Minnesota where primary or specialty care ambulatory services are provided for a fee by one or more physicians Clinical Quality Reporting: You may submit data as a single entity ( roll up ) if all of the following apply, clinics must: Have common ownership AND Have a majority (more than half) of common clinic staff working across multiple locations must rotate between all clinics, AND The total clinical staff across all locations is no greater than 20 full time equivalent (FTE) A clinic site must still be registered even if the data from that site will be submitted using the roll up 15

16 Provider Registration Register all providers who bill through a medical group s clinic Upload file of providers and required information Providers include: Physicians (MD, DO, physicians with medical degrees from other countries and those who are locum tenens, residents and fellows) Advance practice registered nurses (e.g., Certified Nurse Practitioners, Certified Nurse Specialist, Certified Nurse Midwife) Physicians assistants Required information: National Provider Identify or Provider ID number Provider Type and Board Certified Specialty Medical license number Full time equivalent (FTE) status for each clinic where the provider practices Please see Clinic and Provider Registration Instructions Appendix C for examples on how to calculate FTE There is also a tool in the portal that will assist in calculating FTEs for providers based on how many hours per week and months they worked at your clinics 16

17 Measures for Required Reporting Winter 2013: Optimal Diabetes Care Optimal Vascular Care Depression Remission at Six Months Spring 2013: Health Information Technology (HIT) Survey Patient Experience of Care Survey (Data submitted by Survey Vendors) Summer 2013: Colorectal Cancer Screening Optimal Asthma Care Maternity Care: Primary C Section Rate Throughout 2013 Implement Functional Status Tools for: 17

18 Optimal Diabetes Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Endocrinology Exempt clinics : Less than 10% adults in clinic population Dates of service: January 1, 2012 December 31, 2012 Denominator: ICD 9 CM codes that define diabetes mellitus Patients ages 18 to 75 Visit criteria (2 face to face visits with provider in last 2 years for diabetes AND 1 visit to the clinic in the last 12 months for any reason) Composite or all or none measure Numerator: Number of patients who meet all of the following targets: Blood sugar control (Target: HbA1c less than 8.0) Blood pressure control (Target: Less than 140/90) LDL or bad cholesterol control (Target: Less than 100) Aspirin documentation Patients with co morbidity of ischemic vascular disease: daily aspirin use or documented contraindication Patients without co morbidity of ischemic vascular disease: passes component automatically Tobacco free status 18

19 Optimal Vascular Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Cardiology Exempt clinics: Less than 10% adults in clinic population Dates of service: January 1, 2012 December 31, 2012 Denominator: ICD 9 CM codes that define ischemic vascular disease (IVD) Patients ages 18 to 75 Visit criteria (2 face to face visits with provider in last 2 years for IVD AND 1 visit to the clinic in the last 12 months for any reason) Composite or all or none measure Numerator: Number of patients who meet all of the following targets: Blood pressure control (Target: Less than 140/90) LDL or bad cholesterol control (Target: Less than 100) Aspirin documentation (Target: Daily aspirin use or valid contraindication) Tobacco free status 19

20 Depression Remission at 6 Months Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, and Psychiatry/Behavioral Health professionals (if there is a physician on staff at the clinic site) Exempt clinics: Less than 10% adults in clinic population Dates of service: January 1, 2012 January 31, months reported to include grace period +30 days Total population submission, no samples Patient Health Questionnaire (PHQ 9) Numerator /Denominator: # adult pts with depression & PHQ 9 score <5 at 6 months(+/ 30 days) # adult pts (18+) with depression or dysthymia AND index contact PHQ 9 >9 20

21 Optimal Asthma Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology Dates of service: July 1, 2012 June 30, 2013 Denominator: ICD 9 CM codes that define asthma Patient age groups: 5 to 17 & 18 to 50 Visit criteria (2 face to face visits with provider in last 2 years for asthma AND 1 visit to the clinic in the last 12 months for any reason) Composite or all or none measure Numerator: Number of patients who meet all of the following targets: Patient s asthma well controlled (Target: Differs by type of asthma control tool administered to patient) Patient not at elevated risk of exacerbation (Target: Less than two visits to emergency department and hospitalizations) Patient is educated about asthma (Target: Written asthma management plan contains all necessary information per specifications) 21

22 Colorectal Cancer Screening Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Obstetrics/Gynecology Exempt clinics: Less than 10% adults in clinic population Dates of service: July 1, 2012 June 30, 2013 Denominator: Patient ages 50 to 75 Visit criteria (2 face to face office visits in last 2 years AND 1 visit to the clinic in the last 12 months) Numerator: Number of patients who are up to date with 22 appropriate screening exam C l (T Hd i i l 10 ) OR

23 Maternity Care: Primary C Section Rate Specialties: Family Medicine (includes General Practice), Obstetrics/Gynecology, Perinatology Clinics that have eligible providers who perform C section deliveries Dates of service: July 1, 2012 June 30, 2013 Total population submission, no samples Denominator: ICD 9 and CPT codes that identify deliveries Singleton deliveries with one liveborn baby Nulliparous flag (woman s first pregnancy and delivery) Numerator: Number of newborns delivered via C section Prenatal Care Flag: Every patient must have prenatal care flag (Flag of 1 or 2) populated Used to indicate medical groups/clinic s involvement in patient s prenatal care 23

24 Total Knee Replacement Specialties: Orthopedic Surgeons who perform TKR Starting with dates of procedure: January 1, 2012 December 31, 2012 LONG lag time for post op collection (15 months postop); First data submission will be in May 2014 Denominator: Primary and Revision Knee Replacement by CPT Codes (ICD 9 codes are also available if a system cannot search by CPT codes) Full population measure, no sample Rates stratified by Primary or Revision Measures: Average change in patients post op functional status at one year (9 to 15 months post op) 24

25 Spine Surgery Measures Specialties: Orthopedic Surgeons and Neurosurgeons who perform lumbar spinal discectomy/ laminotomy and lumbar spinal fusion procedures. Dates of Procedure: January 1, 2013 December 31, 2013 Need to implement assessment tools as soon as possible LONG lag time for post op collection (15 months post op); First data submission will be in May 2015 Denominator: CPT and ICD 9 codes that identify each population Full population measure, no sample Rates stratified by clinical condition for the procedure Two populations: Lumbar Discectomy/Laminotomy Lumbar Spinal Fusion Measures: Three months post op for discectomy population (6 to 18 weeks post op) One year post op for spinal fusion population (9 to 15 months post op) Various outcome and process measures for each population Functional status tools: Owestry Disability Index, EQ5D Quality of Life, Visual Analog Pain Scale 25

26 Results Minnesota Department of Health report (DDS or SDS) MN Community Measurement (DDS): Health Care Quality Report Health plans and Minnesota Bridges to Excellence will communicate with you regarding their individual P4P programs 26

27 Data Submission Requirements Follow timelines Agree to MNCM Site Terms of Use Agreement (signed electronically on MNCM Data Portal) Submit data for all applicable clinic sites and in required format (.csv) Participate in validation process Have rates publicly reported on and in the annual Health Care Quality Report 27

28 Denominator Certification Assurance that patient population (denominator) is identified according to measure specifications Each measure has its own denominator certificate and is available on the MNCM Data Portal Documentation needed Describe process used to identify patients Denominator template form Source code, query, screen shots Upload certificate to MNCM Data Portal MNCM i f lt d ill 28

29 Total Population versus Sample Total population Most precise rates Submit total population when: Measure requires total population submission (e.g., Depression, Primary C section, Total Knee Replacement) EMR was in place for a full measurement period, including the 12 months prior to the measurement period (i.e., EMR was in place at any stage of implementation as of 1/1/2011 or 7/1/2011 depending on measures) Random sample: Can be submitted if total population submission is not required as noted above Minimum number each clinic must submit: 60 patients per clinic, per measure If there are less than 60 eligible patients at a clinic, submit all patients 29

30 Data Collection Can happen: After denominator method is certified After billing and patient records are complete for dates of service for the measure Data collection methods EMR extraction Manual data abstraction Data collection tools (Found under Resources tab) Data Collection Guides Data collection forms 30

31 Data Submission Methods Process of submitting data via the secure internet MNCM Data Portal Two methods accepted for state requirement: Direct Data Submission (DDS): Clinic uploads file onto the MNCM Data Portal Summary Data Submission (SDS): Clinic calculates and submits summary counts for each data element 31

32 Data Submission Methods (cont.) Primary payer type identification DDS: MNCM/Health plans determine payer type SDS: Clinic determines payer type Payer Types: Commercial/Private, Minnesota Health Care Programs, Medicare, Uninsured/Selfpay Health plan P4P and MN Bridges to Excellence DDS: must be used to qualify for P4P programs SDS: Cannot be used for P4P programs 32

33 Data Validation All medical groups are subject to a validation audit Audit conducted to validate that the submitted data matches the source data in the patient medical record Collaborative process between MNCM and clinic Occurs after data submission and prior to public reporting MNCM utilizes the NCQA 8 and 30 process for validation audits 33

34 Thank you! MNCM site: Download registration instructions Learn about upcoming Q&A sessions MNCM Data Portal: Register clinics and providers Register contact info to receive communications Resources tab Download planning calendar Download data collection guides and tools FAQs by measure/topic Questions about registration and technical support

35 Minnesota Clinic & Provider Registration and Clinical Quality Reporting 2013 Preparations 35

36 MN Community Measurement Publicly reports health care quality measures with the goal of improving the health of patients 2004: HEDIS measures by medical group Health plan data 2006: DDS measures by clinic site Data submitted by clinics 2010: Statewide Quality Reporting and Measurement System 36

37 2013 Timelines Time Task Portal Opens Portal Closes Winter 2013 Summer 2013 Register MN Clinics & Providers December 2012 February 8, 2013 Data Submission: -Optimal Diabetes Care -Optimal Vascular Care -Depression Care Measures January 14, 2013 January 14, 2013 February 4, 2013 February 15, 2013 February 15, 2013 February 28, 2013 Complete Health Information Technology Survey February 15, 2013 March 15, 2013 Patient Experience of Care Survey February 24, 2013 April 2, 2013 Data Submission: -Optimal Asthma Care -Colorectal Cancer Screening -Maternity Care: Primary C-section Rate 2014 Data Submission: -Total Knee Replacement (2012 Dates of Procedure) Implement tools now (Jan 2013) 2015 Data Submission: -Spine Surgery Measures (2013 Dates of Procedure) Implement tools now (Jan 2013) July July 15, 2013 July 15, 2013 August 16, 2013 August 16, 2013 August 16, 2013 April 2014 May 2014 April 2015 May

38 Getting Started on MNCM Website: Getting Started on MNCM Data Portal: 38

39 Registration Download instructions from mncm.org or MNCM Data Portal from the Resource tab Access the MNCM Data Portal: First time users must request login/password Necessary registration information: Medical group information Clinic and specialty information Provider information and file upload Clinic specialties determine which measures a clinic is required to submit data for Must complete registration before February 8, 2013 Registration must be completed before data can be submitted to MNCM 39

40 Clinic Registration and Reporting Registration: Register any and all clinic locations in the state of Minnesota where primary or specialty care ambulatory services are provided for a fee by one or more physicians Clinical Quality Reporting: You may submit data as a single entity ( roll-up ) if all of the following apply, clinics must: Have common ownership AND Have a majority (more than half) of common clinic staff working across multiple locations must rotate between all clinics, AND The total clinical staff across all locations is no greater than 20 full-time equivalent (FTE) A clinic site must still be registered even if the data from that site will be submitted using the roll-up method. During clinic registration, you will indicate the main site that will submit the data. Resource: Appendix A in the Registration Instructions 40

41 Provider Registration Register all providers who bill through a medical group s clinic Upload file of providers and required information Providers include: Physicians (MD, DO, physicians with medical degrees from other countries and those who are locum tenens, residents and fellows) Advance practice registered nurses (e.g., Certified Nurse Practitioners, Certified Nurse Specialist, Certified Nurse Midwife) Physicians assistants Required information: National Provider Identify or Provider ID number Provider Type and Board Certified Specialty Medical license number Full-time equivalent (FTE) status for each clinic where the provider practices Please see Clinic and Provider Registration Instructions Appendix C for examples on how to calculate FTE There is also a tool in the portal that will assist in calculating FTEs for providers based on how many hours per week and months they worked at your clinics 41

42 Measures for Required Reporting Winter 2013: Optimal Diabetes Care Optimal Vascular Care Depression Remission at Six Months Spring 2013: Health Information Technology (HIT) Survey Patient Experience of Care Survey (Data submitted by Survey Vendors) Summer 2013: Colorectal Cancer Screening Optimal Asthma Care Maternity Care: Primary C-Section Rate Throughout 2013 Implement Functional Status Tools for: Total Knee Replacement Measure (2012 Dates of Procedure, Reporting occurs 2014) Spine Surgery Measure (2013 Dates of Procedure, Reporting occurs 2015) 42

43 Optimal Diabetes Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Endocrinology Exempt clinics : Less than 10% adults in clinic population Dates of service: January 1, 2012 December 31, 2012 Denominator: ICD-9-CM codes that define diabetes mellitus Patients ages 18 to 75 Visit criteria (2 face-to-face visits with provider in last 2 years for diabetes AND 1 visit to the clinic in the last 12 months for any reason) Composite or all-or-none measure Numerator: Number of patients who meet all of the following targets: Blood sugar control (Target: HbA1c less than 8.0) Blood pressure control (Target: Less than 140/90) 43 LDL or bad cholesterol control (Target: Less than 100) Aspirin documentation Patients with co-morbidity of ischemic vascular disease: daily aspirin use or documented contraindication Patients without co-morbidity of ischemic vascular disease: passes component automatically Tobacco-free status

44 Optimal Vascular Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Cardiology Exempt clinics: Less than 10% adults in clinic population Dates of service: January 1, 2012 December 31, 2012 Denominator: ICD-9-CM codes that define ischemic vascular disease (IVD) Patients ages 18 to 75 Visit criteria (2 face-to-face visits with provider in last 2 years for IVD AND 1 visit to the clinic in the last 12 months for any reason) Composite or all-or-none measure Numerator: Number of patients who meet all of the following targets: Blood pressure control (Target: Less than 140/90) 44 LDL or bad cholesterol control (Target: Less than 100) Aspirin documentation (Target: Daily aspirin use or valid contraindication) Tobacco-free status

45 Depression Remission at 6 Months Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, and Psychiatry/Behavioral Health professionals (if there is a physician on staff at the clinic site) Exempt clinics: Less than 10% adults in clinic population Dates of service: January 1, 2012 January 31, months reported to include grace period +30 days Total population submission, no samples Patient Health Questionnaire (PHQ-9) Numerator /Denominator: # adult pts with depression & PHQ-9 score <5 at 6 months(+/- 30 days) # adult pts (18+) with depression or dysthymia AND index contact PHQ-9 >9 45

46 Optimal Asthma Care Specialties: Family Medicine (includes General Practice), Internal Medicine, Pediatrics, Allergy/Immunology, Pulmonology Dates of service: July 1, 2012 June 30, 2013 Denominator: ICD-9-CM codes that define asthma Patient age groups: 5 to 17 & 18 to 50 Visit criteria (2 face-to-face visits with provider in last 2 years for asthma AND 1 visit to the clinic in the last 12 months for any reason) Composite or all-or-none measure Numerator: 46 Number of patients who meet all of the following targets: Patient s asthma well controlled (Target: Differs by type of asthma control tool administered to patient) Patient not at elevated risk of exacerbation (Target: Less than two visits to emergency department and hospitalizations) Patient is educated about asthma (Target: Written asthma management plan contains all necessary information per specifications)

47 Colorectal Cancer Screening Specialties: Family Medicine (includes General Practice), Internal Medicine, Geriatrics, Obstetrics/Gynecology Exempt clinics: Less than 10% adults in clinic population Dates of service: July 1, 2012 June 30, 2013 Denominator: Patient ages 50 to 75 Visit criteria (2 face-to-face office visits in last 2 years AND 1 visit to the clinic in the last 12 months) Numerator: Number of patients who are up-to-date with appropriate screening exam Colonoscopy (Target: Had screening in last 10 years), OR Sigmoidoscopy (Target: Had screening in last 5 years), OR Stool Blood Tests (Target: Had screening during measurement year) 47

48 Maternity Care: Primary C-Section Rate Specialties: Family Medicine (includes General Practice), Obstetrics/Gynecology, Perinatology Clinics that have eligible providers who perform C-section deliveries Dates of service: July 1, 2012 June 30, 2013 Total population submission, no samples Denominator: ICD-9 and CPT codes that identify deliveries Singleton deliveries with one liveborn baby Nulliparous flag (woman s first pregnancy and delivery) Numerator: Number of newborns delivered via C-section Prenatal Care Flag: Every patient must have prenatal care flag (Flag of 1 or 2) populated Used to indicate medical groups/clinic s involvement in patient s prenatal care 48

49 Total Knee Replacement Specialties: Orthopedic Surgeons who perform TKR Starting with dates of procedure: January 1, 2012 December 31, 2012 LONG lag time for post-op collection (15 months post-op); First data submission will be in May 2014 Denominator: Primary and Revision Knee Replacement by CPT Codes (ICD-9 codes are also available if a system cannot search by CPT codes) Full population measure, no sample Rates stratified by Primary or Revision Measures: Average change in patients post-op functional status at one year (9 to 15 months post-op) Functional status tools: Oxford Knee Score and EQ5D (Quality of Life) 49

50 Spine Surgery Measures Specialties: Orthopedic Surgeons and Neurosurgeons who perform lumbar spinal discectomy/ laminotomy and lumbar spinal fusion procedures. Dates of Procedure: January 1, 2013 December 31, 2013 Need to implement assessment tools as soon as possible LONG lag time for post-op collection (15 months post-op); First data submission will be in May 2015 Denominator: CPT and ICD-9 codes that identify each population Full population measure, no sample Rates stratified by clinical condition for the procedure Two populations: Lumbar Discectomy/Laminotomy Lumbar Spinal Fusion Measures: Three months post-op for discectomy population (6 to 18 weeks post-op) One year post-op for spinal fusion population (9 to 15 months post-op) Various outcome and process measures for each population Functional status tools: Owestry Disability Index, EQ5D Quality of Life, Visual Analog Pain Scale 50

51 Results Minnesota Department of Health report (DDS or SDS) MN Community Measurement (DDS): Health Care Quality Report Health plans and Minnesota Bridges to Excellence will communicate with you regarding their individual P4P programs 51

52 Data Submission Requirements Follow timelines Agree to MNCM Site Terms of Use Agreement (signed electronically on MNCM Data Portal) Submit data for all applicable clinic sites and in required format (.csv) Participate in validation process Have rates publicly reported on and in the annual Health Care Quality Report 52

53 Denominator Certification Assurance that patient population (denominator) is identified according to measure specifications Each measure has its own denominator certificate and is available on the MNCM Data Portal Documentation needed Describe process used to identify patients Denominator template form Source code, query, screen shots Upload certificate to MNCM Data Portal MNCM reviews for completeness and will contact the group with questions or approve the denominator certificate 53

54 Total Population versus Sample Total population Most precise rates Submit total population when: Measure requires total population submission (e.g., Depression, Primary C-section, Total Knee Replacement) EMR was in place for a full measurement period, including the 12 months prior to the measurement period (i.e., EMR was in place at any stage of implementation as of 1/1/2011 or 7/1/2011 depending on measures) Random sample: Can be submitted if total population submission is not required as noted above Minimum number each clinic must submit: 60 patients per clinic, per measure If there are less than 60 eligible patients at a clinic, submit all patients Excel list: use the RAND function in Excel Paper list: select every Nth patient 54

55 Data Collection Can happen: After denominator method is certified After billing and patient records are complete for dates of service for the measure Data collection methods EMR extraction Manual data abstraction Data collection tools (Found under Resources tab) Data Collection Guides Data collection forms Data spreadsheet templates Exclusions templates 55

56 Data Submission Methods Process of submitting data via the secure internet MNCM Data Portal Two methods accepted for state requirement: Direct Data Submission (DDS): Clinic uploads file onto the MNCM Data Portal Summary Data Submission (SDS): Clinic calculates and submits summary counts for each data element 56

57 Data Submission Methods (cont.) Primary payer type identification DDS: MNCM/Health plans determine payer type SDS: Clinic determines payer type Payer Types: Commercial/Private, Minnesota Health Care Programs, Medicare, Uninsured/Self-pay Health plan P4P and MN Bridges to Excellence DDS: must be used to qualify for P4P programs SDS: Cannot be used for P4P programs 57

58 Data Validation All medical groups are subject to a validation audit Audit conducted to validate that the submitted data matches the source data in the patient medical record Collaborative process between MNCM and clinic Occurs after data submission and prior to public reporting MNCM utilizes the NCQA 8 and 30 process for validation audits 58

59 Thank you! MNCM site: Download registration instructions Learn about upcoming Q&A sessions MNCM Data Portal: Register clinics and providers Register contact info to receive communications Resources tab Download planning calendar Download data collection guides and tools FAQs by measure/topic Questions about registration and technical support