2013 DATA COLLECTION GUIDE Summary Data Submission. Optimal Asthma Care. (07/01/2012 to 06/30/2013 Dates of Service)

Transcription

1 2013 DATA COLLECTION GUIDE Summary Data Submissin Optimal Asthma Care (07/01/2012 t 06/30/2013 Dates f Service) Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 1

2 TABLE OF CONTENTS Measure Specificatins...3 Asthma Diagnsis Cdes...7 Table 1: ICD-9 Diagnsis Cdes fr Identifying Asthma...7 Cdes Used t Identify Patients wh Meet Exclusin Criteria...7 Table 2: ICD-9 Diagnsis Cdes fr Identifying Patients Meeting Exclusin Criteria...7 Measure Flw Charts... 9 Data Elements and Field Specificatins Data Submissin Instructins Abut Summary Data Submissin Participatin Requirements Cnfidentiality and Patient Persnal Health Infrmatin (PHI) Overview f the Prcess and Timeline Step 1: Registratin n the MNCM Data Prtal and Preparatins Step 2: Identifying the Patient Ppulatin (Denminatr) Step 3: Data Cllectin Step 4: Data Quality Checks Step 5: Summary Data Submissin (SDS) Step 6: Required Dcumentatin fr Data Validatin Appendices Appendix A: Abut MN Cmmunity Measurement and Measure Develpment Appendix B: Clinic Site Definitin Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 2

3 Optimal Asthma Care 2013 Summary Data Submissin (07/01/2012 t 06/30/2013 Dates f Service) Measure Specificatins Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 3

4 Summary f Changes Date f birth clarificatin Optimal Asthma Care Measure 2013 Summary Data Submissin Measure Specificatins Added language t clarify date f birth range. Please nte the changes in the denminatr sectin belw. Exclusin Cdes Added exclusin ICD-9 cdes t clarify diagnses that shuld be excluded. ICD-9 cdes added t exclusin list include: , , , 492.8, , and Descriptin Methdlgy Ratinale Measurement Perid Cmpsite ( ptimal care) measure f the percentage f pediatric and adult patients wh have asthma and are ptimally managed t reduce risk. Ppulatin identificatin is accmplished via a query f a practice management system r Electrnic Medical Recrd (EMR) t identify the ppulatin f eligible patients (denminatr). Data elements are either extracted frm an EMR system r abstracted thrugh medical recrd review. Clinics that had an EMR in place by 07/01/2011 are required t submit data n their full ppulatin. Rughly 7% f adults and children in Minnesta are currently living with asthma. Asthma is a chrnic disease assciated with familial, infectius, allergenic, sciecnmic, psychscial and envirnmental factrs. It is nt curable, but is treatable. Despite imprvements in diagnsis, management, and an increased understanding f the epidemilgy, immunlgy, and bilgy f the disease, asthma prevalence has prgressively increased ver the past 15 years. In additin, variatin in practice frm recmmended clinical guidelines is evident, with nly 33% f adult asthma patients in Minnesta reprting in 2005 t having an actin plan and 75% reprting instructin n what t d when having an asthma attack. It is up t prviders t assess patients, prescribe medicatins, educate abut self-management, help patients identify and mitigate triggers s patients can prevent their exacerbatins. Measurement perid will be a fixed twelve mnth perid: 07/01/2012 t 6/30/2013. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 4

5 Denminatr Optimal Asthma Care Measure 2013 Summary Data Submissin Measure Specificatins Established patient wh meets each f the fllwing criteria is included in the ppulatin: Patient was age 5 t 50 at the start f the measurement perid (date f birth was n r between 07/01/1962 t 07/01/2007). Patient was seen by an eligible prvider in an eligible specialty face-t-face at least tw times during the last tw years (07/01/2011 t 06/30/2013) with visits cded with an asthma ICD-9 cde (in any psitin, nt nly primary). Use this date f service range when querying the practice management r EMR system t allw a cunt f the visits within this time frame. Patient was seen by an eligible prvider in an eligible specialty face-t-face at least ne time during the last twelve mnths (07/01/2012 t 06/30/2013) fr any reasn. This may r may nt include ne f the face-t-face asthma visits. Diagnsis f Asthma; ICD-9 diagnsis cdes include: ; ; ; Eligible specialties: Family Practice (Includes General Practice), Internal Medicine, Pediatrics, Allergy/Immunlgy, Pulmnlgy. Allwable exclusins Eligible prviders: Medical Dctr (MD), Dctr f Ostepathy (DO), Physician Assistant (PA), Nurse Practitiner (NP). Patient was a permanent nursing hme resident during the measurement perid. Patient was in hspice at any time during the measurement perid. Patient died prir t the end f the measurement perid. Dcumentatin that diagnsis was cded in errr. Patient was cded with any f the fllwing diagnses: COPD (ICD-9 diagnsis cdes 491.2, , , , 493.2, , , , 496, 506.4). Emphysema (ICD-9 diagnsis cdes 492, , 492.8, 506.4, 518.1, 518.2). Cystic fibrsis (ICD-9 diagnsis cdes 277.0, , , , ). Acute respiratry failure (ICD-9 diagnsis cdes ). Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 5

6 Numeratr Optimal Asthma Care Measure 2013 Summary Data Submissin Measure Specificatins The number f asthma patients wh met ALL f the fllwing targets: Asthma well-cntrlled (take the mst recent asthma cntrl tl available): Patient had an Asthma Cntrl Test (ACT) scre f 20 r abve (taken frm mst recent Asthma Cntrl Test n file) fr patients 12 and lder OR Patient had a Childhd Asthma Cntrl Test (C-ACT) scre f 20 r abve (taken frm mst recent C-ACT n file) fr patients 11 and yunger OR Patient had an Asthma Cntrl Questinnaire (ACQ) scre f 0.75 r lwer (taken frm mst recent ACQ n file) fr patients 17 and lder OR Patient had an Asthma Therapy Assessment Questinnaire (ATAQ) scre f 0 (taken frm mst recent ATAQ) fr children, adlescents, and adults Patient nt at elevated risk f exacerbatin: Patient reprted values fr bth f the fllwing questins (asked/dcumented within the measurement perid): Number f emergency department visits nt resulting in a hspitalizatin due t asthma in last 12 mnths AND Number f inpatient hspitalizatins requiring an vernight stay due t asthma in last 12 mnths The ttal number f emergency department visits and hspitalizatins due t asthma must be less than 2. Patient had been educated abut his r her asthma and self-management f the cnditin and als had a written asthma management plan present (created r reviewed and revised within the measurement perid); Patient had a written asthma management plan in the chart with the fllwing dcumented: Plan cntains infrmatin n medicatin dses and purpses f these medicatins. Plan cntains infrmatin n hw t recgnize and what t d during an exacerbatin. Plan cntains infrmatin n the patient s triggers. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 6

7 2013 Summary Data Submissin Measure Specificatins Cding Cnventins Used in MN Cmmunity Measurement Dcumentatin MNCM uses the standard HEDIS cding cnventins frm NCQA s HEDIS, Use f Apprpriate Medicatins fr Peple with Asthma (ASM). Unless therwise nted, cdes are stated t the minimum specificity required. Fr example, if a cde is presented t the third digit, any valid furth r fifth digits may be used. When necessary, a cde may be specified with an x, which represents a required digit; fr example, ICD-9-CM diagnsis cde 270.0x indicates a fifth digit is required, but the fifth digit culd be any number allwed by the cding manual. This cding cnventin is used t describe ranges f cdes, please refer t the tables included fr the cmplete list f cdes. Asthma Diagnsis Cdes Table 1: ICD-9 Diagnsis Cdes fr Identifying Asthma ICD-9 Diagnsis Cde ICD-9 Diagnsis Cde Descriptin Extrinsic asthma, unspecified Extrinsic asthma, with status asthmaticus Extrinsic asthma, with (acute) exacerbatin Intrinsic asthma, unspecified Intrinsic asthma, with status asthmaticus Intrinsic asthma, with (acute) exacerbatin Other frms f asthma; Exercise-induced brnchspasm Other frms f asthma; Cugh variant asthma Asthma, unspecified, unspecified Asthma, unspecified, with status asthmaticus Asthma, unspecified, with (acute) exacerbatin Cdes Used t Identify Patients wh Meet Exclusin Criteria Table 2: ICD-9 Diagnsis Cdes fr Identifying Patients Meeting Exclusin Criteria ICD-9 Diagnsis Cde ICD-9 Diagnsis Cde Descriptin Cystic fibrsis Cystic fibrsis, with mecnium ileus Cystic fibrsis, with pulmnary manifestatins Cystic fibrsis, with gastrintestinal manifestatins (excludes with mecnium ileus) Cystic fibrsis, with ther manifestatins Obstructive chrnic brnchitis Obstructive chrnic brnchitis withut exacerbatin Obstructive chrnic brnchitis, with (acute) exacerbatin Obstructive chrnic brnchitis, with acute brnchitis 492 Emphysema Emphysematus bleb Other emphysema Chrnic bstructive asthma Chrnic bstructive asthma unspecified Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 7

8 2013 Summary Data Submissin Measure Specificatins ICD-9 Diagnsis Cde ICD-9 Diagnsis Cde Descriptin Chrnic bstructive asthma with status asthmaticus Chrnic bstructive asthma with (acute) exacerbatin 496 Chrnic airway bstructin, nt elsewhere classified Chrnic respiratry cnditins due t fumes and vaprs Interstitial emphysema Cmpensatry emphysema Acute respiratry failure Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 8

9 Measure Flw Charts Optimal Asthma Care Measure 2013 Summary Data Submissin Measure Flw Charts Is the patient s DOB between 07/01/1962 and 07/01/2007? Yes N Has the patient been seen by an eligible prvider at least twice in the past tw years (07/01/2011 t 06/30/2013) with visits cded with a asthma ICD-9 cde? N PATIENT NOT INCLUDED IN MEASURE 2013 Optimal Asthma Care Measure Flw Chart Please see the Data Elements Table n Pages fr mre detailed infrmatin abut each cmpnent. Yes Has the patient been seen by an eligible prvider in an eligible specialty face-tface at least ne time during the current measurement perid (07/01/2012 t 06/ 30/2013) fr ANY reasn? Yes Des the patient have a ICD-9 diagnsis cde f asthma? N N Yes PATIENT INCLUDED IN DENOMINATOR Des the patient have ne f the fllwing scres during the measurement perid?: Asthma Cntrl Test (ACT) scre f 20 r abve (taken frm mst recent Asthma Cntrl Test n file) nly applicable fr patients 12 and lder ---OR--- Childhd Asthma Cntrl Test (C-ACT) scre f 20 r abve (taken frm mst recent C-ACT n file) nly applicable fr patients 11 and yunger ---OR--- Asthma Cntrl Questinnaire (ACQ) scre f 0.75 r lwer (taken frm mst recent ACQ n file) nly applicable fr patients 17 and lder ---OR--- Asthma Therapy Assessment Questinnaire (ATAQ) scre f 0 (taken frm mst recent ATAQ) fr children, adlescents, and adults Yes N N Has the patient reprted a ttal number f emergency department visits and hspitalizatins due t asthma in the past 12 mnths less than tw? Yes PATIENT NOT INCLUDED IN NUMERATOR N Des the patient have a written asthma management plan that includes ALL f the fllwing cmpnents: 1. Infrmatin n medicatin dses and purpse; 2. Infrmatin n hw t recgnize and what t d during an exacerbatin; AND 3. Infrmatin n patient s triggers Yes PATIENT INCLUDED IN NUMERATOR Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 9

10 Optimal Asthma Care 2013 Summary Data Submissin (07/01/2012 t 06/30/2013 Dates f Service) Data Elements and Field Specificatins Please nte: Data elements and field specificatins listed in this sectin are included t assist in yur clinic s data cllectin and are nt required t be included in yur clinic s Summary Data Submissin fr the Minnesta Statewide Quality Reprting and Measurement System. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 10

11 2013 Summary Data Submissin Data Elements and Field Specificatins Use the Asthma Ttal Pp tab n the Asthma 2013 SDS Spreadsheet template t cllect the fllwing data elements fr this measure. Clumn Field Name Ntes Excel Frmat Example A Clinic ID Enter the MNCM Clinic ID fr every patient/rw submitted. MNCM assigns the clinic ID at the time f registratin. Clinic IDs are listed in the MNCM Data Prtal. Use the MNCM ID listed in the prtal. D NOT use the Medical Grup ID. Quality Check: Verify all IDs match the MNCM ID in the prtal. Verify that each cell has data (n cell shuld be blank). B Patient ID Enter a unique patient ID that will identify each patient. Quality Check: Verify patients were nt duplicated. If patient is duplicated, determine t which clinic yu will attribute patient. If submitting a sample ppulatin, yu will need t replace the deleted recrd with the next sampled patient. Verify that each cell has data (n cell shuld be blank). C Date f Birth Enter the patient s date f birth. Include patients aged 5-50 at the start f the measurement perid. The date f birth range fr this age grup is 07/01/1962 t 07/01/2007. D Insurance Prduct Name Ages 5-17 date f birth range is 07/01/1995 t 07/01/2007 Ages date f birth range is 07/01/1962 t 06/30/1995 Quality Check: Verify each date f birth is within the accepted range. Verify that each cell has data (n cell shuld be blank). Enter the name f the patient s insurance prduct. This infrmatin is used t identify Primary Payer Type in Clumn E. If the patient des NOT have insurance, enter Uninsured/Self-Pay. Quality Check: Verify each cell has data (n cell shuld be blank). Text 9999 Text 200 Date (mm/dd/yyyy) Text 05/08/1985 BlueCrss BlueShield Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 11

12 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example E Primary Payer Type Enter the cde fr the primary payer type categry (use the insurance data in previus field t identify primary payer type): Number 1 1 = Cmmercial/private 7 = Minnesta Health Care Prgrams 5 = Medicare 8 = Uninsured/self-pay If the prduct name is MSHO (Minnesta Senir Health Optins) OR Medicaid fee-frservice, enter the cde fr MN Health Care Prgrams (7). Quality Check: Verify that each cell has an accepted cde (1, 7, 5 r 8). Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 12

13 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example F Date f asthma cntrl test Target=Date f an asthma cntrl tl given during the measurement perid 07/01/2012 t 06/30/2013 Enter the date f the mst recent asthma cntrl test n r prir t 06/30/2013. Leave BLANK if an asthma cntrl test was never perfrmed D NOT enter any test date that ccurred after 06/30/2013. Test frm an utside referring prvider r specialist is acceptable (nt required) but nly if dcumented in the primary clinic s recrd and is mre recent than the primary clinic s test. The fllwing are apprved, valid asthma cntrl tests. Tests ther than the nes listed belw will nt be accepted. ACT (Asthma Cntrl Test) Date (mm/dd/yyyy) 07/22/2012 CACT (Child-Asthma Cntrl Test) ACQ (Asthma Cntrl Questinnaire) ATAQ (Asthma Therapy & Assessment Questinnaire) Asthma cntrl tests must be given accrding t validated age ranges. Age shuld be calculated as f the date f the asthma cntrl test. ACT valid fr patients 12 and lder (valid birth date range = 07/01/1962 thrugh patients aged 12 at the time f the asthma cntrl test valid dates may include dates f birth thrugh 06/30/2000) C-ACT valid fr patients 11 and yunger (valid birth date range = include patients aged 11 and yunger at the time f asthma cntrl test dates with dates f birth as early as 07/01/2001 thrugh 07/01/2007) ACQ valid fr patients 17 and lder (valid birth date range = 07/01/1962 thrugh patients aged 17 at the time f the visit valid dates include dates f birth thrugh 06/30/1995) ATAQ valid fr patients 5 t 50 (valid birth date range = 07/01/1962 t 07/01/2007) Quality Check: Verify that there are n dates after 06/30/2013 if data is entered int the cell. Verify cell has data if Clumn G and Clumn H are ppulated. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 13

14 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example G Asthma cntrl test name Enter the cde t indicate the name f the mst recent asthma cntrl test that crrespnds t date in Clumn F: Number 1 Target = Name f test 1 = Asthma Cntrl Test (ACT) 2 = Child-Asthma Cntrl Test (C-ACT) 3 = Asthma Cntrl Questinnaire (ACQ) 4 = Asthma Therapy Assessment Questinnaire (ATAQ) Leave BLANK if an asthma cntrl test was never perfrmed OR if the wrng test was administered t the patient at the visit (e.g., a 12-year-ld patient received the C-ACT instead f the ACT). Quality Check: Verify that each cell has an accepted cde (1, 2, 3 r 4). H Asthma cntrl test scre Target = See belw: Enter the scre f the mst recent asthma cntrl test referenced in Clumn G. If the test is blank r nt cmplete, lk fr an earlier cmpleted asthma cntrl test cmpleted within the measurement perid. Edit Clumn F and Clumn G t crrespnd with new test infrmatin. Number 22 ACT scre > 20 Leave BLANK if Clumn G is blank. CACT scre > 20 ACQ scre < 0.75 ATAQ scre = 0 The asthma cntrl test scre shuld be the scre frm the tl that is referred t in Clumn F (Asthma cntrl test date) and Clumn G (Asthma cntrl test name) clumns. All three f these clumns shuld be referring t the same mst recent tl. D NOT submit partial r incmplete scres. Range t determine if asthma is well-cntrlled: ACT scre greater than r equal t 20 CACT scre greater than r equal t 20 ACQ scre less than r equal t 0.75 ATAQ scre equals 0 Quality Check: Verify that each cell has a scre if Clumn F and Clumn G have data. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 14

15 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example I Asthma well cntrlled? Target = Yes Enter a 1 (Yes) if the patient s asthma is well cntrlled based n the fllwing criteria: Clumn F (Asthma cntrl test date) is within the reprting perid (07/01/2012 t 06/30/2013) Number 1 Clumn G (Asthma cntrl test name) has ne f the accepted cdes (1, 2, 3, r 4) Clumn H (Asthma cntrl test scre) is within the apprpriate ranges specified fr the test administered If ne r mre f the abve criteria are NOT met, enter a 0 (N). Quality Check: Verify each clumn has a 1 r 0 entered. Verify answer crrespnds t Clumn F, Clumn G and Clumn H. J Date f patient reprted emergency department visits and hspitalizatins A date is necessary fr rate calculatin. D NOT leave blank unless there is n data. Enter the date within the measurement perid that the patient is asked abut any hspitalizatins and emergency department visits. This date shuld be assciated with Clumn K (Number f patient-reprted emergency department visits) and Clumn L (Number f patient-reprted hspitalizatins) during the past 12 mnths (these are the fllwing tw fields). Date (mm/dd/yyyy) 07/22/2012 D NOT enter any visit that ccurred after 06/30/2013. A date after the measurement perid will create an errr upn submissin. Leave BLANK if the patient was nt asked abut emergency department visits and hspitalizatins. Quality Check: Verify that there are n dates after 06/30/2013 if data is entered int the cell. Verify cell has date if Clumn K and Clumn L are ppulated. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 15

16 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example K Number f patient reprted emergency department visits due t asthma that did NOT result in a hspitalizatin in the past 12 mnths (frm date f visit) Enter the value cllected and recrded n r prir t 006/30/2013. Enter the numeric value fr the number f emergency department visits due t asthma as stated by the patient (e.g., 0, 1, 2, etc.). Leave BLANK if patient was nt asked r there is n data. 0 = Patient reprts 0 r had n ED visits 1 = Patient reprts 1 ED visit 2 = Patient reprts 2 ED visits Etc. D NOT include urgent care visits. Special ntes abut patient reprted ED visits: Number 0 Target = 0 The patient shuld respnd with a number f visits fr the prir 12 mnths regardless f when the visit ccurs if the visit ccurs in September f 2012, the previus 12 mnths wuld be September 2011 August If the visit ccurs in January 2013, the previus 12 mnths wuld be January December D NOT search fr actual emergency department visits in yur recrd system. This value must reflect what the patient reprted when asked. If using an EMR, cnsider building a field t capture this data. If using paper, check the prgress ntes and ther dcumentatin frm the mst recent visit lking backward. D NOT enter a number recrded prir t 07/01/2012. Suggestins fr scripting this questin: Hw many times in the past 12 mnths did yu visit the emergency department fr yur asthma withut being admitted t the hspital? Quality Check: If this cell has data, verify Clumn J has date listed. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 16

17 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example L Number f patient reprted inpatient hspitalizatins due t asthma during the past 12 mnths (frm date f visit) Target = 0 Enter the value cllected and recrded n r prir t 06/30/2013. Enter a numeric value fr the number f inpatient hspitalizatins due t asthma as stated by the patient (e.g. 0, 1, 2, etc.). Leave BLANK if patient was nt asked r there is n data 0 = Patient reprts 0 r had n ED visits 1 = Patient reprts 1 ED visits 2 = Patient reprts 2 ED visits Etc. D NOT include urgent care visits. Number 1 Special ntes abut patient reprted inpatient hspitalizatins: Enter the patient reprted number f inpatient hspitalizatins due t asthma. The patient shuld respnd with a number f inpatient hspitalizatins fr the prir 12 mnths regardless f when the visit ccurs if the visit ccurs in September f 2012, the previus 12 mnths wuld be September 2011 August If the visit ccurs in January 2013, the previus 12 mnths wuld be January December D NOT submit nn-patient reprted inpatient hspitalizatins due t asthma (e.g., the number f hspitalizatins pulled frm the EMR). This number may nt reflect visits the patient had ut-f-system. If using an EMR, cnsider building a field t capture this data. If using paper, check the prgress ntes and ther dcumentatin frm the mst recent visit lking backward. D NOT enter a number recrded prir t 07/01/2012. Suggestins fr scripting this questin: Prvider asks patient, Hw many times in the past 12 mnths were yu hspitalized vernight because f yur asthma? Quality Check: If this cell has data, verify Clumn J has date listed. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 17

18 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example M Ttal number f patient reprted emergency department visits and in-patient hspitalizatins Enter the sum f Clumn K and Clumn L. Leave BLANK if the patient was nt asked abut emergency department visits and hspitalizatins. If the patient was asked abut bth and answered 0 fr bth, enter 0. Quality Check: Verify this is sum f Clumn K and Clumn L. Number 1 Target = Less than 2 Please nte: With regard t Clumns AA t AD, yu may submit t MNCM a blank asthma management plan fr MNCM review t verify that the tl captures all apprpriate fields. N Date f mst recent written asthma management plan Target = Date f written asthma management plan is within the valid date range f 07/01/2012 t 06/30/2013 A date is necessary fr rate calculatin. D NOT leave blank unless there is n data. Enter the date f the mst recent cmpleted written asthma management plan created r reviewed/updated n r prir t 06/30/2013. Leave BLANK if the patient des nt have a written asthma management plan. Prvide nly the date f the mst recent plan. If the prvider reviews a previusly created asthma management plan and ntes that the plan has been reviewed and updated with the patient during the measurement perid, enter this date as the mst recent asthma management plan. D NOT enter any dates fr management plans that were written after 06/30/2013; enter plans befre this date nly. A date after the measurement perid will create an errr upn submissin. Date (mm/dd/yyyy) 08/17/2012 Written asthma management plans frm any utside referring prvider r specialist is acceptable (nt required) but nly if dcumented in the primary clinic s recrd and is mre recent than the primary clinic s reading. Quality Check: Verify that there are n dates after 06/30/2013 if data is entered int the cell. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 18

19 2013 Summary Data Submissin Data Elements and Field Specificatins Clumn Field Name Ntes Excel Frmat Example O Written actin plan includes infrmatin abut the patient s triggers Target = Yes (1) Enter 1 (Yes) r 0 (N) if the written asthma management plan cntains infrmatin n triggers that can be cnfirmed upn validatin. Nte: The trigger infrmatin must be specific t the patients triggers and nt a general statement abut triggers r cmmn triggers. Quality Check: Verify cell has ne f the accepted cdes. Number 1 P Written actin plan includes infrmatin abut medicatins Enter 1 (Yes) r 0 (N) if the written asthma management plan cntains infrmatin n medicatin dses and purpses f the medicatin that can be cnfirmed upn validatin. Quality Check: Verify cell has ne f the accepted cdes. Number 1 Target = Yes (1) Q Written actin plan includes infrmatin abut what t d during an exacerbatin Enter 1 (Yes) r 0 (N) if the written asthma management plan cntains infrmatin abut what t d during an exacerbatin that can be cnfirmed upn validatin. Quality Check: Verify cell has ne f the accepted cdes. Number 1 Target = Yes (1) Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 19

20 Optimal Asthma Care 2013 Summary Data Submissin (07/01/2012 t 06/30/2013 Dates f Service) Data Submissin Instructins Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 20

21 Abut Summary Data Submissin Optimal Asthma Care Measure 2013 Summary Data Submissin Data Submissin Instructins The gal f data submissin is t cllect aggregate r summary data frm physician clinics n specific health care cnditins and publicly reprt cmparable rates f health care quality at the physician clinic site level. All medical grups fllw the same instructins fr ppulatin identificatin and data cllectin. MNCM certifies methdlgies prir t data cllectin. Then, each medical grup submits summary data cunts t the Minnesta Department f Health (MDH) fr the Minnesta Statewide Quality Reprting and Measurement System via MNCM s secure nline data prtal. As an independent auditr, MNCM may validate the data fr accuracy. The data will be publicly reprted by MDH. Purpse and Functin f this Guide This guide is intended t be a cmprehensive instructin fr the Summary Data Submissin (SDS) prcess. Please cntact MNCM with any questins r feedback by supprt@mncm.rg. Imprtant Infrmatin fr 2013 Reprting Reprting requirements fr the Minnesta Statewide Quality Reprting and Measurement System: By cmpleting the registratin prcess in the MNCM Data Prtal and by cmpleting the Summary Data Submissin (SDS) prcess utlined in this guide, a physician clinic will fulfill the state requirements fr reprting n this measure. Ttal ppulatin submissin fr physician clinics using an electrnic medical recrd: Physician clinics with electrnic medical recrds (EMRs) in place fr the prir full measurement perid (07/01/2011 t 06/30/2012) are required t submit data n their full patient ppulatin. Physician clinics withut EMRs in place fr the prir full measurement perid are encuraged t submit data using their full patient ppulatin fr each measure, but may use a randm sampling methdlgy (please see page fr mre infrmatin). Participatin Requirements Physician clinics are required t participate in the clinical quality data submissin prcess and t d the fllwing: Fllw the timeline utlined in this guide Agree t MNCM s Site Terms f Use Agreement (sign electrnically n the MNCM Data Prtal) Submit summary data cunts fr each physician clinic lcatin rather than at a medical grup level Submit data in required frmat (summary data cunts) Participate in the data validatin prcesses as required by the Minnesta Department f Health Cnfidentiality and Patient Persnal Health Infrmatin (PHI) Because medical grups will maintain the detailed patient infrmatin and will nly submit summary data cunts fr the clinical quality measures, n persnal health infrmatin (PHI) is transferred during the summary data submissin (SDS) prcess. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 21

22 2013 Summary Data Submissin Data Submissin Instructins Overview f the Prcess and Timeline Prcess Step Registratin Medical grup registers clinics and prviders n the MNCM Data Prtal and electrnically signs the Site Terms f Use Agreement and Business Assciate Agreement. NOTE: If yu have already registered fr 2013, yu d nt need t register again r cmplete separate agreements fr submissin f the Optimal Asthma Care measure. If yu have nt registered, yu must d s befre yu can submit data. Resurces: Dwnlad registratin instructins frm the MNCM Data Prtal r Ppulatin Identificatin (Denminatr) Medical grup submits a dcument utlining the methd fr identifying the patient ppulatin (denminatr) t the MNCM Data Prtal. MNCM reviews and apprves the denminatr. IMPORTANT: MNCM must certify the denminatr prir t sampling and data cllectin t ensure that the crrect patient ppulatin is being pulled. Data Cllectin and Submissin Medical grup cllects clinical data and calculates summary cunts that are entered in the MNCM Data Prtal. Data cllectin begins after the billing cycle is cmplete fr the measurement perid. Resurces: Dwnlad frm MNCM Data Prtal under RESOURCES tab: SDS Data Cllectin Guide fr Optimal Asthma Care Data Cllectin Frm fr Optimal Asthma Care (ptinal) Asthma 2013 SDS Spreadsheet template fr Optimal Asthma Care Summary Data Submissin Respnd t Data Validatin Requests MNCM may cntact physician clinics t cnduct data validatin activities. Data Results After the successful submissin f the clinical data, the results will be publicly reprted. Helpful Dates t Remember Registratin ccurs annually during the fall (cmmunicatin is sent t all primary prtal data cntacts when prtal is pen fr registratin). Cntact MNCM at supprt@mncm.rg if yur clinic did nt register Denminatr certificatin submissin can begin after registratin. Recmmended deadline: prir t Nvember 30, MNCM respnds within 2-3 business days. MNCM Data Prtal clses fr SDS Data Submissin in December After the summary data is successfully entered in the MNCM Data Prtal, MNCM may cntact the clinic with a data validatin request. Late Thank yu fr yur participatin in the Minnesta Statewide Quality Reprting and Measurement System. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 22

23 2013 Summary Data Submissin Data Submissin Instructins Step 1: Registratin n the MNCM Data Prtal and Preparatins Registratin must be cmpleted nce annually. Please refer t separate registratin instructins fr step-by-step instructins fr this prcess. A dwnladable instructinal guide is available n the MNCM Data Prtal. Please see Appendix B fr mre infrmatin fr mre detailed infrmatin regarding the clinic site definitin and types f clinics. Other data submissin preparatins: Save the MNCM Web sites in yur Favrites internet flder fr future reference. MNCM Data Prtal: MNCM Web Site: MN HealthScres: Create a flder in yur netwrk drive dedicated t all data submissin dcuments. Save all spreadsheets, frms and data submissin materials in the dedicated flder. Name versins f dcuments clearly s yu are using the mst recent files. Lg in t the MNCM Data Prtal at In the Resurces tab f the data prtal, yu are able t access the fllwing items: Summary Data Submissin Resurces. Dwnlad the fllwing Summary Data Submissin Resurces. Dwnlad the fllwing Optimal Asthma Care 2013 Summary Data Submissin Guide Optimal Asthma Care 2013 Denminatr Certificatin Frm Optimal Asthma Care 2013 Data Cllectin Frm Asthma 2013 SDS Spreadsheet Excel Template Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 23

24 2013 Summary Data Submissin Data Submissin Instructins Step 2: Identifying the Patient Ppulatin (Denminatr) Denminatr Definitin: The denminatr is the bttm number in a fractin. In epidemilgy, the denminatr represents a ppulatin grup at risk f a specific disease. In this step, the ttal number f patients wh are eligible fr the measure are identified using a standard set f criteria. Please review the Denminatr sectin nted in the Measure Specificatins in this guide fr the detailed criteria used t identify eligible patients fr the denminatr. Certificatin f the Patient Ppulatin (Denminatr Certificatin) T help medical grups achieve accuracy and/r avid inadvertently pulling the wrng patient ppulatin fr the measure, MNCM will cmplete an upfrnt review f each medical grup s surce cde r methdlgy that is used t prduce the patient ppulatin (denminatr) t help identify ptential errrs. The denminatr certificatin prcess is intended t help identify ptential issues prir t data submissin. Hwever, the respnsibility t submit an accurate denminatr rests with the medical grup. Please cntact supprt@mncm.rg with any specific questins. PLEASE NOTE: Denminatr certificatin may als include a cmprehensive review by MNCM f the prcess steps used t identify the denminatr, including the final list f patients. Please save all riginal queries, dcuments, spreadsheets and prcess steps that are used t identify the patient ppulatin. MNCM may ask t review this infrmatin. Denminatr Template Frm This template is prvided t ensure all medical grups are using the same set f criteria t identify patients fr the denminatr. Medical grups are asked t cmplete this frm and submit it t the MNCM Data Prtal. Surce cde r screen shts are als helpful in MNCM s review f the denminatr. 1. Lgin t the MNCM Data Prtal ( 2. G t the RESOURCES tab and select Asthma Resurces frm the drp-dwn menu. Dwnlad the Denminatr Template frm. 3. Cmplete the frm and save the frm n yur netwrk directry. 4. Lgin t the MNCM Data Prtal and click n Denminatr Certificatin under the Optimal Asthma Care Data Submissin Reprt (07/01/ /30/2013 DOS) sectin. Fllw the instructins t uplad the frm t the data prtal. 5. MNCM will review the methd and respnd within 2-3 business days. MNCM will either (1) cntact the medical grup if mre clarificatin is needed, in which case the medical grup will need t make the necessary revisins and re-uplad the frm; r, (2) certify the methd in the MNCM Data Prtal. An autmatic will ntify the medical grup that the methd is certified. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 24

25 2013 Summary Data Submissin Data Submissin Instructins Details fr the Denminatr Methdlgy The denminatr template frm prvides a template fr yu t address all the elements that MN Cmmunity Measurement needs t certify yur denminatr. In yur denminatr frm, MNCM shuld be able t identify: Birth date ranges used ICD-9-CM cdes included Visit date range and visit cunt details that ensures established patient criteria were fllwed Descriptin f hw patients will be attributed (assigned) t ne prvider and ne clinic Bard certified specialties ffered by the clinic that ensures the apprpriate specialties fr each measure were included Whether exclusins will be taken and hw exclusins will be handled Clinics using and electrnic medical recrd may list which allwable exclusins will be filtered thrugh the query prcess Clinics that will manually abstract data may describe that exclusins will be identified and dcumented during recrd review Whether ttal ppulatin r a sample f the patient ppulatin will be submitted; if a sample, the prcess fr generating a sample (including an versample) Inactive patients: Patients designated as inactive in a practice management system, billing system r electrnic medical recrd must be included in the patient ppulatin if they meet the criteria Surce cde r screen shts may be included D NOT include patient lists r PHI (persnal health infrmatin) as part f yur denminatr dcument. Please use the dcument template fr Optimal Asthma Care (Wrd dcument) and paste yur query surce cde at the end f the dcument. D NOT start cllecting data until yur clinic s denminatr has been certified. Once yu have submitted yur dcuments fr denminatr certificatin, we will review them and ntify yu via when yur prcess has been certified. It is ur aim t cmplete all certificatins within 2 business days. If yu have nt received a ntificatin within 5 business days, cntact supprt@mncm.rg. Patient attributin: A patient is attributed t ne clinic and ne prvider that are cnsidered t be respnsible fr managing the patient s care. Please use the fllwing attributin methds in rder: 1. First, attribute the patient t the clinic and prvider that are assigned t the patient and are respnsible fr the patient s care. If the patient des nt have an assigned clinic r prvider, then 2. Attribute the patient t the clinic and prvider that saw the patient mst ften in the measurement perid. If mre than ne prvider saw the patient equally, then 3. Attribute the patient t the clinic and prvider that saw the patient mst recently in the measurement perid. If a prvider has left the clinic, yu may attribute the patient t the prvider wh has left r t a new prvider nw managing the patient s care. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 25

26 2013 Summary Data Submissin Data Submissin Instructins System Query: Helpful data elements that can be included in the system query Clinic r facility: This infrmatin must be substituted with the Clinic ID as nted in the MNCM Data Prtal in the data file that is submitted t MNCM. Patient name and ID number Patient Date f Birth (DOB) Insurance infrmatin: This infrmatin can be used t determine primary payer type (Cmmercial/Private, Minnesta Health Care Prgrams, Medicare, Uninsured/Selfpay). Date f last visit in the measurement perid: This is nt necessary but may be helpful when abstracting data. Keep a Crsswalk : It is very imprtant t keep a crsswalk between the unique identifier and the patient s name and DOB, s that recrds can be lcated by clinic staff if validatin activities are cnducted by MNCM. If a medical grup pened r acquired a new clinic in the last year, the new clinic must register and submit data with the medical grup. If the new clinic uses a different practice management system, billing system r EMR, they wuld identify patients and cllect the data separately frm the ther clinics in the medical grup, but wuld include their data in the same file that the medical grup uses t calculate SDS cunts t submit t MNCM (the identifier is the Clinic ID). Fr clinics and medical grups that implemented a new practice management system r EMR in the last tw years: Please cnsider hw t generate the patient ppulatin using bth systems. Tw queries r patient lists may be necessary. The lists shuld then be cmbined and a cmmn identifier(s) selected t de-duplicate the list. Please cntact supprt@mncm.rg with any questins. Finalizing the patient ppulatin list: 1. Srt the list by the clinic site (where the patient is attributed). 2. De-duplicate the list and include nly ne recrd fr each patient. If a patient is listed mre than ne time within a clinic r within the entire medical grup, determine which prvider r clinic the patient will be attributed t and delete the ther patient recrd/rw. Tip: The Excel PivtTable functin can shw cunts f patients. Use the patient medical recrd number, accunt number r ther unique ID as the cmmn identifier. 3. Evaluate the number f patients in the ppulatin: Is the ttal number f patients in the ppulatin similar t last year? If the ttals are significantly different, des the difference make sense? Maybe a clinic pened/clsed, r maybe a clinic s verall patient ppulatin increased/decreased this year, etc. Des a crrectin in the methdlgy r query need t be made? Allwable Exclusins Allwable exclusins are kept t a minimum and are supprted by evidence. The evidence must shw frequency f ccurrence in which the results wuld be distrted withut the exclusin r is clinically apprpriate. Please see the Allwable Exclusins nted in the Measure Specificatins r Table 2 n pages 7-8 fr a mre detailed list f allwable exclusins. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 26

27 2013 Summary Data Submissin Data Submissin Instructins If a patient meets the established patient criteria fr the ppulatin and nne f the allwable exclusins apply, the patient must be included. Tracking excluded patients fund during data cllectin: Track excluded patients fund during data cllectin fr validatin purpses: Exclusins Tab: A separate tab n the Asthma 2013 SDS Spreadsheet template that cntains the clinic s detailed patient clinical data is used fr tracking excluded patients. Please nte: There is a tab fr excluded ADULT patients and excluded PEDIATRIC patients. If a sample f patients will be submitted and a patient that meets ne f the exclusin reasns abve is fund, dcument this reasn and n the riginal patient list r data submissin template, and enter this patient in the Exclusins tab n the Asthma 2013 SDS Spreadsheet template If the ttal ppulatin will be submitted using an EMR extractin f data, it is kay t maintain a different Excel file f excluded patients that are remved frm the ppulatin. Using the Exclusins tab n the Asthma 2013 SDS Spreadsheet template is nt necessary, althugh the exclusin reasn fr each patient must be clear. D NOT enter patients wh did nt meet the initial established patient criteria (e.g., nt ages 5-50, did nt meet the visit criteria, etc.). Visits: Helpful infrmatin fr identifying the patient ppulatin Fr the purpses f determining if a patient is established t a practice, medical grups will cunt the number f face-t-face visits using the criteria described in the Measure Specificatins in this guide. Medical grups may have different ways f defining r classifying visit types within a practice, but the intent is t cunt visits where there is face-t-face evaluatin f the patient by an MD, DO, PA r NP. Face-t-face visits include the fllwing visit types: ffice visit, physical exam, annual visits, and pre-p visits. If the clinic ffers after-hurs primary care, these patients must be included. D NOT include hspital visits. Clinic lab-nly visits are nt included in the visit cunt. Evaluatin & Management CPT Cdes (ptinal) The fllwing list f cdes may be helpful in determining what types f visits t include fr identifying the patient ppulatin (denminatr). E & M cdes d NOT need t be used when querying a practice management system t determine visit cunts; hwever, they have been included here t help further define what is meant by a face-t-face visit with a prvider. Please refer t a CPT cding manual fr mre details. Descriptin E & M Cdes Preventive Cdes Office Cnsultatin Individual Cunseling Grup Cunseling Other Preventive Medicine Services Unlisted E & M Cdes CPT Cdes , , , Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 27

28 2013 Summary Data Submissin Data Submissin Instructins Visit Scenaris (t help define visit criteria) Belw are examples shwing applicatin f the visit criteria (assuming all ther denminatr cmpnents are met): Visit scenari Patient was seen face-t-face by a prvider in Jan and April 2012 fr asthma. Patient was als seen in Dec fr an insect bite. Patient was seen face-t-face by a prvider in Nvember 2011 and December Patient was als seen in Dec All visits were fr asthma. Patient was seen face-t-face by a prvider in Aug and Dec fr asthma. Patient als cmpleted an Asthma Cntrl Test ver the phne in Oct and was seen in Nv reassess medicatins. Patient was seen face-t-face by a prvider in Aug and Dec fr asthma. Patient was seen face-t-face by a prvider in Aug and Aug fr asthma. Include patient in ppulatin? Yes. This patient meets the visit criteria (patient saw a prvider tw times in the past tw measurement perids fr Asthma and nce during the measurement perid). Yes. This patient meets the visit criteria (patient saw a prvider tw times in the past tw measurement perids fr Asthma and nce during the measurement perid). Yes. This patient meets the visit criteria (patient saw a prvider tw times in the past tw measurement perids fr Asthma and nce during the measurement perid). Nte: The telephne Asthma Cntrl Test des nt qualify as a face-t-face visit. N. This patient des meet the visit criteria (patient did nt see a prvider during the measurement perid). Yes. (Patient saw a prvider tw times in the past tw measurement perids fr Asthma and nce during the measurement perid.) Ttal Ppulatin Submissin Physician clinics with electrnic medical recrds in place fr the prir full measurement perid (07/01/2011 t 06/30/2012) are required t submit data n their full patient ppulatin. Physician clinics withut electrnic medical recrds in place fr the prir full measurement perid are encuraged t submit data using their full patient ppulatin fr each measure, but may use a randm sampling methdlgy. Using the ttal ppulatin t calculate the rates creates a higher likelihd that the rate accurately reflects the physician clinic s perfrmance. Sample Submissin Using a sample is als an ptin (e.g., fr clinics that use paper recrds r fr clinics that d nt have a fully implemented EMR). Belw are the requirements fr using a sample t calculate the summary data cunts: Each clinic must use TWO samples ne fr pediatric patients aged 5-17 (date f birth range includes 07/01/1995 t 07/01/2007) and ne fr adult patients ages (date f birth range includes 07/01/1962 t 06/30/1995). If a clinic has fewer than 60 pediatric asthma patients and/r fewer than 60 adult asthma patients, submit all pediatric asthma patients and/r all adult asthma patients: Fr example, if there are 59 pediatric asthma patients and 24 adult asthma patients, submit all 59 pediatric asthma patients and all 24 adult asthma patients. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 28

29 Optimal Asthma Care Measure 2013 Summary Data Submissin Data Submissin Instructins If a clinic has 60 r mre pediatric asthma patients and/r 60 r mre adult asthma patients, first cnsider using all pediatric asthma patients and/r all adult asthma patients, therwise yu may use a sample. The minimum required sample is 60 pediatric asthma patients and 60 adult asthma patients per clinic site: Fr example, if there are 79 pediatric asthma patients and 79 adult asthma patients, first cnsider using all 79 pediatric asthma patients and all 79 adult asthma patients; therwise use a sample f at least 60 pediatric asthma patients and 60 adult asthma patients. HOW TO DO SAMPLING FOR THE OPTIMAL ASTHMA CARE MEASURE T generate yur data fr the asthma measure, yu will need t generate lists f randm samples by age grup and clinic. Each clinic needs ne randmly sampled list f pediatric asthma patients and ne randmly selected list f adult asthma patients. STEP 1: CREATE SEPARATE RANDOMLY SELECTED LISTS FOR EACH AGE GROUP A. First generate a list f ALL asthma patients aged 5-50 at a single clinic and enter the patient data n the Ttal Pp tab n the Asthma 2013 SDS Spreadsheet template. B. Break the list int tw age grups: Ages 5-17 in ne list (date f birth range includes 07/01/1995 t 07/01/2007). Cpy and paste this data in t the Ttal Pp PEDS tab n the Asthma 2013 SDS Spreadsheet template. Ages in anther list (date f birth range includes 07/01/1962 t06/30/1995). Cpy and paste this data in t the Ttal Pp ADULTS tab n the Asthma 2013 SDS Spreadsheet template. C. Use ne f the sampling methds fr each age grup (sampling methds are listed belw) t identify the patients in yur denminatr. This becmes the list f patients that yu will need t lk up the data fr. D. Repeat step C fr the ther age grup. E. Repeat steps A-D abve fr all f yur clinics. NOTE: Yu will need t calculate patient cunts BY AGE GROUP and BY CLINIC. Randm Sample Selectin Methds METHOD 1: Excel Randm Number Generatr Sample Selectin: Fr patient lists generated in Excel, use the RAND functin t assign a randm number t each recrd (please als see Micrsft Excel Help, tpic RAND fr mre infrmatin): 1. Enter all patient data n t the age apprpriate Asthma Ttal Pp tab. 2. Separate the list f patients int tw age grups and cpy and paste the patient data fr each grup t the apprpriate tab (Ttal Pp PEDS r the Ttal Pp ADULTS tab) cmplete the fllwing steps fr bth yur pediatric patients AND yur adult patients 3. Insert a blank clumn n the leftmst side f the spreadsheet and label new clumn RAND 4. Place cursr in the first blank cell (A2) and type =RAND() Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 29

30 2013 Summary Data Submissin Data Submissin Instructins 5. Press enter (a randm number like will appear) 6. Place the cursr back int this cell, while resting ver the crner t have the pinter change t a black crss, duble click r drag the frmula dwn t the last rw/patient 7. Highlight the whle clumn and click Edit, Cpy, Paste Special = Values t freeze the randm number (therwise it will change with every click n the spreadsheet) 8. Srt entire patient ppulatin by this new randm number 9. Wrk dwn the list rw by rw, starting with rw 1 until the number f recrds in the sample is met fr submissin (at least 60 patients per clinic, per measure) 10. Cpy and paste the selected patient data t the apprpriate tab (Sample Pp PEDS r Sample Pp ADULTS) n the Asthma 2013 SDS Spreadsheet template 11. If a patient meets ne f the allwable exclusins, nte this n the exclusins spreadsheet and keep wrking dwn the list. Use versample recrds fllwing the last recrd/rw f the riginal sample. Fr example, if 60 recrds will be used and exclusins were fund in the first 60 recrds/rws, use patients frm rws 61, 62, and s frth t replace the excluded recrds. METHOD 2: Paper List Sample Selectin: Fr paper-generated lists, cmplete the fllwing steps: 1. Separate the list f patients int tw age grups d steps 2 and 3 belw fr bth yur pediatric patients AND yur adult patients 2. Start with a list that has patients srted by sme unique patient related variable. a. Identifying number like a medical recrd number [MRN] r chart number is ideal. b. Srting alphabetically is the least desirable in terms f randmness; hwever, this may be used when there is n ther alternative. 3. Select every Nth patient fr the number f patients that will be reprted. a. N shuld equal the clinic site s ttal ppulatin divided by the number f patients that will be used (if needed, rund dwn t the nearest whle number). Highlight r mark every Nth patient n the list. This is the sample. b. Example: If a clinic site has 600 pediatric asthma patients and 600 pediatric patients will be randmly selected, divide 600/60 = 10. Select and review every 10th pediatric patient n the list. 4. Enter the patient data int the apprpriate tab (Sample Pp PEDS r Sample Pp ADULTS) n the Asthma 2013 SDS Spreadsheet template. 5. If a patient meets ne f the accepted exclusins, nte this n the data cllectin frm and exclusins spreadsheet and select the very next patient n the list (just belw the excluded patient). Missing recrds: If a recrd in the sample is nt available r missing, d NOT exclude this recrd. Either lcate the recrd and cmplete the data cllectin, r include the recrd, but leave the data fields blank. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 30

31 Step 3: Data Cllectin Optimal Asthma Care Measure 2013 Summary Data Submissin Data Submissin Instructins Medical grups and physician clinics can cllect clinical data frm medical recrds by either 1) extracting the data frm an electrnic medical recrd thrugh a data query, r 2) abstracting the data frm the medical recrd (paper recrd r EMR). Data cllectin ccurs after: 1. The clinic s billing and medical recrd updates are cmplete fr the measurement perid; 2. The denminatr methd is certified by MNCM; and 3. The patient ppulatin is identified, and if applicable, a sample is selected accrding t the measure specificatins and sampling instructins. Tls fr Data Cllectin and Data Entry Data Cllectin Frm A data cllectin frm was created fr medical grups that manually cllect data frm an EMR r paper recrd. The necessary data elements are n the frm. These frms can als be used t nte where certain data elements were fund in the medical recrd. Data cllected n these frms must als be entered int the Asthma 2013 SDS Spreadsheet template. Please dwnlad these frms frm the MNCM Data Prtal under the RESOURCES tab, select Summary Data Submissin frm the drp-dwn menu. Excel Template The Asthma 2013 SDS Spreadsheet template was created t ensure all necessary data elements are cllected. This file cntains all f the necessary fields as well as the crrect clumn frmatting accrding t the measure specificatins. There are separate tabs fr the detailed patient clinical data, exclusins and the final summary cunts. Please dwnlad the Asthma 2013 SDS Spreadsheet template frm the MNCM Data Prtal under the Resurces tab, select Summary Data Submissin frm the drp-dwn menu. Field Frmatting in the Excel File: Prir t entering data in the Asthma 2013 SDS Spreadsheet template is imprtant that the field frmats fllw the measure specificatins in this guide. Pay special attentin t field frmatting (e.g., dates lk like dates, etc.). D NOT use General frmatting in Excel. The Excel template prvided n the MNCM Data Prtal will prvide the crrect frmatting. Using Multiple Data Abstractrs and Inter-Rater Reliability (IRR) Ideally, ne data abstractr r data cllectin prcess is preferred because it ensures that the data is cllected in ne cnsistent way. If, hwever, mre than ne persn will be abstracting data, we recmmend cnducting several sample audits with all abstractrs fr training purpses t imprve IRR. Internal training culd include a review f the guide and data cllectin frm, and instructins fr lcating infrmatin in the clinic s medical recrd. Als, refer t data cllectin errrs made in previus submissins, make plans t imprve the data cllectin prcess, and perfrm quality checks n the data. This ensures that the measurement specificatins are interpreted cnsistently and that the data is cllected in a unifrm way. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 31

32 2013 Summary Data Submissin Data Submissin Instructins Lcating Data Elements in the Patient Recrd The primary surce f data is the clinic s dcumentatin in the medical recrd (e.g., flw sheets, prgress ntes, lab reprts, etc.). Data cllectrs may als chse t review the utside crrespndence in the clinic s medical recrd that dcuments mre recent data within the measurement perid, but this is ptinal. If data is used frm utside crrespndence, please dcument this fr the validatin audit. Belw are tips fr lcating data in the patient recrd. Please fllw the measure specificatins fr data cllectin. Asthma Cntrl Experience using a validated test Date test was given frm the prgress nte, including the name f the test and test result Test recrded result/value as recrded in the electrnic medical recrd Cpy f test as scanned int the electrnic medical recrd Cpy f test in a paper medical chart Dated value in a nte frm a referring prvider r specialist (e.g., cnsult) Asthma Risk Experience using patient reprted emergency department visits and inpatient hspitalizatins due t asthma Prgress nte r flw sheet that is part f the clinic s medical recrd Number f visits as recrded in the electrnic medical recrd as single fields f data Dated values in a nte frm a referring prvider r specialist (e.g., cnsult) Pssible Validatin Audit and Outside Crrespndence in the Patient Recrd: If the mst recent data frm the primary clinic s medical recrd is used, validatin will NOT d a mre extensive review f utside crrespndence. Data Cllectin Tips: When manually cllecting data using an EMR, highlight the rw, clumn r cell that cntains the data needed. This reduces the chance f lking at the wrng rw, clumn r cell. Watch fr TYPOS when entering data (number transpsitins, etc.). Asthma educatin and written asthma management plan Cpy in the written management plan scanned int the electrnic medical recrd Cpy f written asthma management plan in a paper medical chart Prgress ntes with all dictated elements NOTE: A written management plan n file frm a specialist will cunt as lng as it is included in the electrnic r paper chart and the prgress ntes indicate it was reviewed fr the essential elements f medicatins, triggers, and what t d during an exacerbatin. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 32

33 2013 Summary Data Submissin Data Submissin Instructins Tracking Where Data is Lcated in the Patient Recrd It is imprtant t keep track f where data is lcated in the patient recrd. Fr example, if data is used frm an utside specialist r prvider nte (that is within the primary clinic s recrd), dcument the surce n the data cllectin frm r the Asthma 2013 SDS Spreadsheet template. If yu are cllecting data directly in the Asthma 2013 SDS Spreadsheet template, create a NOTES clumn and enter the surce details in this clumn. After yu have cmpleted data cllectin, SAVE A COPY f the Excel file and remve the NOTES clumn in the file that will be used t calculate the summary data cunts. Patient Registries: A patient registry is an imprtant tl t help clinics track patient prgress and t use fr quality imprvement purpses. Hwever, MNCM cautins the use f a patient registry fr identifying patients in the ppulatin r fr the cllectin f clinical data. Many registries give a snapsht f patients at a given time and wuld therefre nt include all patients fr the MNCM measure accrding t established patient criteria r may nt reflect the mst recent clinical data (e.g., mst recent asthma cntrl test results). Registries that are prgrammed t update the patient ppulatin and clinical results n a cntinual basis (24/7) culd pssibly be used; hwever, please discuss this with MNCM. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 33

34 Step 4: Data Quality Checks Optimal Asthma Care Measure 2013 Summary Data Submissin Data Submissin Instructins MNCM recmmends cmpleting several internal quality checks f the data befre calculating summary data cunts. Perfrming quality checks n the Asthma 2013 SDS Spreadsheet template ensures that the data is accurate and able t be validated by a MNCM auditr if needed. Excel s AutFilter Use the Filter functin in Excel t lk fr incrrect r missing data: Click inside any data cell and activate the AutFilter by ding the fllwing: In Excel 2003, click the Data menu, pint t Filter, and then click AutFilter. In Excel 2007 and 2010, click the Data tab and in the Srt & Filter area click Filter. The AutFilter arrws nw appear t the right f each clumn heading. Click n the drp-dwn bxes f any clumn and scan fr key entry errrs, ut-f-range r missing data and determine if the data needs t be crrected (e.g., If a date fr a LDL is entered as free text, Abut three mnths ag, the field wuld nt be accepted). T display all data again, click n the same drp-dwn bx and select (All). Remve the Filter ptin by ding the fllwing: In Excel 2003, click Data, Filter, and AutFilter again In Excel 2007 and 2010, click the Filter ptin again in the Srt & Filter area Example Quality Check: Verify that every asthma cntrl test date is within the measurement perid. First, turn n the Filter and in the Date f asthma cntrl test clumn drp-dwn menu scrll and review all dates t ensure they are between 07/01/2012 t 06/30/2013. Internal Audit f Clinical Data: Befre calculating the summary data cunts, yu may wish t review a randm sample f recrds (8-10) t see if the data matches what was cllected frm the patient recrd. If errrs are fund, make the crrectins in the Excel file; hwever, als cnsider if the errrs were islated cases r indicative f a larger data cllectin prblem. Example f a larger data cllectin prblem: There are n patients with asthma plan dates and yu knw that at least sme patients had plans created in the year. Imprtant Quality Checks (Excel File) It is imprtant t cmplete the fllwing quality checks f the file befre calculating summary data cunts. Cmpleting these checks can help avid delays in the file submissin and ensure that yu have the mst accurate data. Make any changes/additins in the Excel file befre calculating summary data cunts. Htline: supprt@mncm.rg Data Prtal: MN Cmmunity Measurement, All rights reserved. Page 34