CMS CROWNWeb Application CROWNWeb Data Validation With Healthcare Management Solutions, LLC November 20, 2014 Note: Computer speakers or headphones are necessary to listen to streaming audio.
Streaming Audio Audio for this event is available via INTERNET STREAMING. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. 2 Note: Computer speakers or headphones are necessary to listen to streaming audio. O
Submitting Questions Type questions in the Chat with Presenter section, located in the bottom-left corner of your screen. Note: Some questions may require additional research. Unanswered questions may be 3 submitted to CRAFT@projectcrownweb.org. O
Poll Questions When responding to poll questions: 1. Make your selection/entry. 2. Click Submit located immediately below the poll question. 4 Note: Computer speakers or headphones are necessary to listen to streaming audio. O
Today s Hosts 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 5 Note: Computer speakers or headphones are necessary to listen to streaming audio. O
Today s Presenter Healthcare Management Solutions, LLC Alaina Shmeleva, MBA-MIS, PMP, CSM Project Manager Alaina Shmeleva is a project manager for End Stage Renal Disease (ESRD) 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 also works closely with the CROWN Data Discrepancy Support contractor to provide support in resolving discrepancies and correction requests involving CMS-2728, CMS-2746, and CMS-2744 forms entered into CROWNWeb. Additionally, Alaina led 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. 6 Note: Computer speakers or headphones are necessary to listen to streaming audio. O
CROWNWeb Data Validation Methods
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
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
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 10 O
ESRD Data Validity & Reliability
About HMS HMS Provides a range of healthcare services Innovation and Research, Health IT Services, Quality, Compliance and Oversight. Our personnel have broad experience in providing clinical, administrative, operations, education, and information technology (IT) solutions to a variety of health care related clients: Surveying healthcare facilities Coaching state-based surveyors Assisting in developing methods to improve validation HMS has significant experience across multiple government agencies - CMS, FDA, NIH, VA 12 H
Today s Agenda Topics 2013 CROWNWeb CPM Data Validation Results Upcoming 2014 CROWNWeb Data Validation When HMS will Contact Selected Participants Items HMS will Request Q&A 13 H
2013 Data Validation Purpose: Independently sample and test the reliability and validity of the clinical data submitted electronically in CROWNWeb (Consolidated Renal Operations in a Webenabled Network) against providers source medical records. This validation effort focused on Clinical Performance Measures (CPM) data. 14 H
Methodology Overview Validation Period: April June 2013 Patient medical records were the gold standard Abstracted by trained medical record reviewers Requested records from 289 facilities Submission via USPS Certified Mail (paper or CD) or secure fax Facilities contacted if necessary for: Incomplete records Missing records Illegible records 15 H
Validation Results HMS requested records from 289 facilities, and received records from 281 facilities (97.23%). HMS requested 2,161 records, and received 2,091 (96.76%) records. ERROR RATES Overall Error Rate: 10.5% Overall Error Rate Vascular Access: 8.7% Overall Error Rate Adequacy: 19.8% Overall Error Rate Anemia Management: 17.3% 16 Overall Error Rate Mineral Metabolism: 5% H
Validation Results - Continued 17 H
Validation Results - Continued 18 H
Validation Results - Continued 19 H
Validation Results - Continued 20 Data entry errors due to manual processing Date based elements are open to interpretation Example: Prescription Change Date the date physician wrote the Rx, the date medications were to begin or the date when given for the first time. Medical Records included conflicting information Example: Delivered minutes of BUN HD Session could include the minutes ordered, the start and stop time, the time noted on the laboratory sheet with the Kt/V and the time noted in the progress sheet. Delivered Minutes of BUN Hemodialysis Session Indicates the actual delivered time on hemodialysis in minutes at session when Blood Urea Nitrogen (BUN)s were drawn. CROWNWeb field definitions: http://projectcrownweb.org/help/glossary/ H
Improvement Opportunities Encourage regular training for facilities (attending monthly CROWNWeb Town Hall meetings, and access CROWNWeb updates) Continued education and training on data definitions Improved Documentation in patient records could decrease error rates for Static Venous Pressure, Static Venous Pressure Frequency, Doppler and Doppler Frequency Encourage conversion to Electronic Medical Records (EMR) 21 H
2014 CPM Data Validation
Goals & Objectives 2014 Clinical Data Validation Objectives: Comprehensive CPM data quality analysis Missing data and match rates trend analysis Improvement opportunities identification 23 H
Task Description Conduct analysis on CPM data validity and reliability for April-June 2014 time period HMS 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 2014 Anticipated record request date: January 2015 24 H
What to expect January 2015 A number of facilities will receive formal requests for patients selected for validation HMS will be looking at April June 2014 time period Participating facilities will need to provide the following: All laboratory reports Documentation of residual renal function assessment in calculating Kt/V Treatment/Flow Sheets Physician Orders and nursing progress notes Patient Specific documentation of vascular access monitoring results (HD only) Any surgical reports, vascular access documents and hospital discharge papers Facilities policies and protocols, including Calculation Methods/Processes 25 H
HMS Request Letters Example of HMS data request letters from 2013: 26 H
Your Contribution 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. For example (recently implemented): Electronic Population for CMS forms Ability to carry-over elements for vascular access and vaccinations Identify learning opportunities to further educate ESRD community about CROWNWeb data elements Continuous feedback on process effectiveness; ability to drive the change and contribute to the entire dialysis community 27 H
Contact Information Heather DuVall - 304-816-5262 Hduvall@hcmsllc.com Or Email your questions to: CWProject@hcmsllc.com 28 H
Final Comments and Wrap-Up
Questions 30 O
Our Next Session CMS Community WebEx: Topic: CROWNWeb Attestations Date: December 18, 2014 Time: 2pm - 3pm ET Event Moved Up Due to the Holidays! 31 O
Thank You For Further Information Help Me Form: http://help.projectcrownweb.org/ QualityNet Help Desk: 1-866-288-8912 Website: http://www.projectcrownweb.org 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-500-2011-00157G. Publication Number: FL-OCT-OCT-11182014-01 32 O