CROWNWeb Data Validation
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1 CMS CROWNWeb Application CROWNWeb Data Validation With Healthcare Management Solutions, LLC November 21, 2013
2 Today s Host Janis Grady, RHIT, CPHQ Contract Officer s Representative (COR) CROWNWeb Outreach, Communication, and Training (OCT) Contract Centers for Medicare & Medicaid Services Oniel Delva, BA, CTT Communications and Training Manager CROWNWeb Outreach, Communication, and Training (OCT) Contract 2 O
3 Today s Presenters Healthcare Management Solutions, LLC Alaina Shmeleva, MBA Project Manager Alaina Shmeleva is a project manager for End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Data Validation and Reliability contract. In her role, Alaina is responsible for the effort to assess the validity and reliability of the CROWNWeb data reported by dialysis facilities. She works closely with the CROWN Data Discrepancy Support contractor to provide support in resolving discrepancies involving CMS-2728, CMS-2746, and CMS-2744 forms entered into CROWNWeb. Additionally, Alaina will lead the pilot validation process on Healthcare- Associated Infection (HAI) events reported by ESRD facilities into the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system. 3 O
4 Latest News and Reminders
5 CROWNWeb Patch Releases CROWNWeb Patch release updates mainly impact the system s behind the scenes processing. CMS released CROWNWeb version on November 14, 2013 to allow CROWNWeb to directly exchange data with CMS Renal Management Information System (REMIS) database. REMIS SIMS Central Database CROWNWeb Users CMS currently has two behind the scenes updates scheduled to take place in December CROWNWeb version CROWNWeb version O
6 December New User Training CROWNWeb new user training is held via WebEx each month. December 2013 new user training is available. 6 O
7 CROWNWeb Data Validation Methods
8 Data Validation CMS utilizes multiple outlets to help ensure the accuracy and validity of data reported via CROWNWeb. CROWNWeb has built-in data verification features to inform users of a missing or out-of-range value. Error Messages Warning Messages Various aspects of CROWNWeb s data entry are cross-checked by CMS-approved contractors or external CMS databases. 8 O
9 CMS Databases CROWNWeb receives discrepancy information each night from CMS Renal Management Information System (REMIS) database, and assigns Notifications and Accretions to facilities based on that information. CROWNWeb uses the Action List screen to resolve discrepancies between CROWNWeb and REMIS database. 9 O
10 Why Notifications and Accretions? Data discrepancies are viewable on the Action List screen as a Notification or an Accretion. Notification A discrepancy in patient data between a CMS database and CROWNWeb. CROWNWeb has Identity and Event/Treatment Notifications. Accretion An ESRD patient identified in another CMS database that appears to be associated with your facility in the CMS database. The patient is not currently admitted to your facility in CROWNWeb. All users are required to work to resolve Notifications and Accretions within 30 days from when they are issued. 10 O
11 Resolving Discrepancies Users can take the following actions to resolve Notifications and Accretions: 11 Notification ACCEPT The user agrees with the patient data provided by the external source. REJECT After research, the user does not agree with the Notification. INVESTIGATE Informs other users that the Notification is under review. ESCALATE The facility cannot resolve the Notification and reassigns it to the Network. Accretions ACCEPT The user agrees with the external source and will admit the patient in CROWNWeb. REJECT The user doesn t agree with the Accretion. He/she has researched and the patient is not ESRD. INVESTIGATE Informs other users that the Accretion is under review. ESCALATE The facility submits the Accretion to the Network to be reassigned to the correct facility. O
12 Approved Contractors CMS employs various contractors to review entries in the following areas: CMS-2728 and CMS-2746 forms Quality Measures Facility attestations Notifications and Accretions And more 12 O
13 ESRD QIP Data Validity & Reliability
14 About HMS HMS is an 8(a) certified, small disadvantaged, woman-owned business. HMS personnel have broad experience in providing clinical, administrative, operations, education, and information technology (IT) solutions to a variety of health care related clients. HMS currently provides service on multiple federal contracts across the United States including, but not limited to: Surveying healthcare facilities Coaching state-based surveyors Assisting in developing methods to improve validation 14 H
15 Goals and Objectives Three main focus areas: 1. Access Clinical Performance Measures (CPM) data validity and reliability. We will sample and test clinical and administrative data 2. Work with CROWNWeb Data Discrepancy Services in resolving discrepancies involving CMS forms submitted into CROWNWeb by facilities 3. Perform pilot validation process on ESRD Healthcare-associated Infection (HAI) events reported by facilities into the CDC s NHSN system 15 H
16 CPM Data Validation Purpose sample and test validity and reliability of CPM data entered into CROWNWeb system: We will randomly select 300 facilities Participating facilities will be contacted and asked to submit source documentation from each patient s medical record Our medical reviewers will abstract the data and compare to the patient medical records The patient record will be the gold standard Reporting period used for validation: April June 2013 Anticipated record request date: December H
17 CMS Forms Change Request Reviews Purpose provide support to CDDS in resolving discrepancies involving CMS-2728, CMS-2744, and CMS-2746 forms: We will be reviewing correction requests submitted by users on an on-going basis Facilities will be contacted to submit patient medical records for review Our medical reviewers will review the record and provide data correction recommendation to CMS and CDDS Requested records will be case dependent 17 H
18 ESRD HAI Event Pilot Purpose develop validation process for CDC s NHSN data: Similar to the CMS Hospital IQR program We are looking for 9 volunteer facilities to participate in the study Volunteers will be able to get an insight on future CMS validation efforts and give feedback on the process Max of 12 patients sampled per facility (based on the facility size) Facilities will be asked to self-report effort/cost associated with the validation [email protected] if interested in participating 18 H
19 Project Timeline Task Estimated Period CPM Record Requests December 2013 HMS CPM Review Process January 2014 May 2014 CMS Forms Change Requests Review Process On-going NHSN Pilot Facility Recruitment December 2013 NHSN Pilot Study & Validation January 2014 March H
20 Opportunities and Lessons Learned Identify areas for improvement to CROWNWeb System functionality and End User experience. Changes to improve system usability to reduce the number of data entry errors. Examples: Recent changes to single user interface New facility attestation features Ability to submit all forms directly into CROWNWeb without filling out a paper copy Future changes to In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) reporting where facilities will work with CMS approved vendors to conduct the survey. Future changes to Mineral Metabolism reporting. 20 H
21 Opportunities and Lessons Learned Learning opportunities to further educate facilities about CROWNWeb data elements. Training opportunities for the CROWNWeb Outreach, Communication, and Training group. Facilities are encouraged to complete CROWNWeb training curriculum located at Continuous feedback on process effectiveness and potential areas for improvement. Ability to drive the change and provide valuable input into the process architecture. 21 H
22 Project Contact Please submit your questions to: 22 H
23 CMS Comments and Wrap-Up
24 Final Comments 24 C
25 Questions 25 O
26 Our Next Session CMS Community Town Hall: Topic: TBD Date: December 19, 2013 Time: 2pm - 3pm ET 26 O
27 Thank You For Further Information Help Me Form: QualityNet Help Desk: Website: 27 This material was prepared by FMQAI, the CROWNWeb Outreach, Communication, and Training contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. OCT contract # HHSM G. Publication Number: FL-OCT-2013OCTT O
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