Checklist for Diabetes Registry Updates & Interim Electronic Audits 6.17

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1 Great Plains Area Indian Health Service Interim Diabetes Care and Outcomes Audit for RPMS/DMS Checklist for Diabetes Registry Updates & Interim Electronic Audits 6.17 Step 1.0 Diabetes Registry Preparation & Update Completed? 1.1 Review the Diabetes Registry or list of diabetes patients for your facility. 1.2 Prepare to update the Diabetes Registry or list of patients with diabetes for your facility by performing at minimum quarterly reports and investigation: 1.3 Run QMAN Reports on each patient status to find if status updates needed: Active, Inactive, Transient, Unreviewed & Lost to follow-up (See Step 1.3 Appendix) 1.4 Find New Patients with Diabetes (WTDP DMS Shortcut 2017 Manual- pg ) 1.5 Find Patients with No Diabetes on the Problem List whom have 1 or more visits with a Diabetes Dx Code (WTDP DMS Shortcut 2017 Manual- pg. 40) 1.6 Find Patients with No Date of Diabetes Onset (WTDP DMS Shortcut 2017 Manualpg. 41) 1.7 Update the Diabetes Registry or modify the list of patients with diabetes for your facility as indicated (WTDP DMS Shortcut 2017 Manual- pg. 3-6) Step 2.0 Create Electronic Audit Data File Completed? 2.1 Review the detailed GPA 2017 Interim Audit Instructions with particular attention to the section on performing an electronic Audit. (See Step 2.1 Appendix) 2.2 Create an electronic Interim Audit data file. At a minimum a quarterly audit is recommended for program tracking and management purposes. Step 3.0 Upload, Process, and Submit Data via the WebAudit Completed? 3.1 Request a WebAudit account if you don t already have one. For more information see the IHS Division of Diabetes Audit web pages Login 2 to the WebAudit via the IHS website rs= GPA DiabetesRegistryInterimHAUGENGPAAudit2017_InterimCheckElec 6.17.doc Page 1 of 2

2 Step 3.0 Upload, Process, and Submit Data via the WebAudit Completed? 3.3 Enter any necessary information about your facility using the Enter Facility Info tool. 3.4 Upload your electronic Audit data file as an Interim Audit using the Upload Data tool. Be sure to read the requirements and instructions on the main screen before uploading. Step 3.0 Upload, Process, and Submit Data via the WebAudit Completed? 3.5 Check for any major potential data errors using the Data Quality Check tool. Fix as many major errors as possible using the View/Edit Data tool or by making corrections using RPMS. If you make corrections using RPMS, you will need to create and upload a new data file. Repeat this step after each upload. 3.6 Run and review the Interim Audit Report. If there are any obvious data problems, fix them if possible using the View/Edit Data tool and go back to Step Changes made in RPMS for Date of Diagnosis, Diabetes Type and/or the optional Complications field must also be changed within the DMS IHS Registry. Step 4.0 Follow-up Activities from the Interim WebAudit Completed? 4.1 Download the data for all records for your facility into an Excel spreadsheet using the Data Download tool. Use these data for additional analysis or other local population management purposes. 4.2 Review the quarterly trends over time for selected Audit outcomes for patients from your facility. 4.3 Provide audit results to leadership, medical/clinical staff and diabetes team members for ongoing quarterly improvement action planning and data tracking. GPA DiabetesRegistryInterimHAUGENGPAAudit2017_InterimCheckElec 6.17.doc Page 2 of 2

3 PERFORMING A 2017 QUARTERLY ELECTRONIC AUDIT RPMS is capable of electronically extracting audit data from the clinical database into an audit data file. The sections that follow give a brief step-by-step synopsis of the quarterly audit process using RPMS Diabetes Management System (DMS). More detailed information is available in the DMS User s Manual, available at: (from the dropdown list of applications, select Diabetes Management System ). In order to use the DMS module, you need to have the proper access keys. Otherwise, the necessary menu items will not show up on your screen. Contact your local site manager if you need assistance in acquiring the necessary menu and security keys. The diabetes register needs to be up-to-date, or you need to create a search template of the active diabetes patients at your facility. Quick Start Directions for Electronic Audits Using the IHS Resource and Patient Management System (RPMS): 1. Select Diabetes Management System (menu item DMS ). 2. Select Diabetes QA Audit Menu (menu item DA ). 3. Select 2017 Diabetes Program Audit (menu item DM17 ). The program will check on the taxonomies needed to support the 2017 Audit. 4. Select Run 2017 Diabetes Program Audit (menu item DM17 ). 5. Enter the Audit Date (this is the ending date of the Audit period). The date for the 2017 Interim Audit submitted to GPA IHS Diabetes is 12/31/ Select the type of sample (choices include individual patients, a search template of patients, or members of a CMS Register). P// C members of a CMS Register. 7. Decide which patients to include in your Audit, using the following options: a. You can limit the Audit to a particular provider or a particular community (select No for the 2017 Interim Audit submitted to GPA IHS Diabetes). Select N// <Enter> for NO for both. b. You can include only Indian/Alaska Native patients, only Non-Indian/Alaska Native patients, or all patients (select 1 to include only Indian/Alaska Native patients for the 2017 Interim Audit submitted to GPA IHS Diabetes). Select 1// <Enter> for include only Indian/Alaska Native patients. c. You can include or exclude pregnant patients in the Audit (select E to exclude pregnant patients for the 2017 Interim Audit submitted to GPA IHS Diabetes). Select E// <Enter> for Exclude. d. You can include all or a random sample of the patients selected so far (select A to include all patients for the 2017 Interim Audit submitted to GPA IHS Diabetes). Select A// <Enter> for All patients. e. You can include or exclude DEMO patients (select E to exclude DEMO patients from the 2017) Interim Audit submitted to GPA IHS Diabetes. Select E// <Enter> for Exclude.

4 8. Select an output: Choice 2 (Create Audit Export File) creates a delimited text file that can be uploaded to the WebAudit and is also readable in Microsoft Excel. Create Audit Export File. 9. Access the WebAudit. See p Obtain the newly created Audit Export File and upload it to the WebAudit. Select Upload Data. See p Select Audit Type: Interim Audit. See Section 7, p.11. Select facility and EHR system used to create data file if indicated. Click on Browse button to navigate to the quarterly data file, then click Open. When the data file has been selected, click on the Upload File button. You will receive a successful or unsuccessful message on the screen. 12. Review the Interim Audit Report and clean any major data quality errors. See Section 7, p Once all data has been entered and all necessary cleaning/editing is complete the Interim Audit is now completed for the facility/quarter. Reports may now be generated. See Section 8, Please note the Interim Audit is not be locked as is typical of the annual audit process. Thanks for your submission! This information will be distributed to each IHS facility s Governing Body meetings in the Great Plains Area and/or is now available for site specific clinical diabetes care improvement activities. 14. Disseminate facility quarterly findings to local teams and incorporate into improvement process. 15. Next quarter start the process over again and realize multiple entries are now allowed within the Interim WebAudit. *Please note referenced page numbers are from the AUDIT 2017 DM Audit Instructions available at it/audit_2017_instructions.pdf

5 Step 1.0 Diabetes Registry Preparation & Update Completed? 1.3 Run QMAN Report on each Register Status to find patients who are no longer active and patients who may have reactivated: -To find patients in the Inactive Register who had a medical visit after : SUBJECT: LIVING PATIENTS // REGISTER UPCOMING APPTS? // NO WHICH CMS REGISTER: (Enter the name of your diabetes register) SELECT PATIENT STATUS: 1// 2 (Inactive) REGISTER DIAGNOSIS: ALL DIAGNOSES// 6 Attribute of IHS DIABETES REGISTER: VISIT First condition of Visit : CLINIC Enter CLINIC: [BGP Primary Care Clinic Enter ANOTHER CLINIC: ENDOCRINOLOGY Enter ANOTHER CLINIC: CHRONIC DISEASE Enter ANOTEHR CLINIC: <enter> (If you have Nephrology clinic you can add that clinic as well. If you are doing IPC then you can technically add Women s Health clinic, etc.) Want to save this CLINIC group? No// <enter> Next condition of Visit : AFTER Exact date: (This date would be the date after your last search depending on how often you are updating your register, ie monthly, quarterly) Next condition of Visit : <enter> Attribute of IHS DIABETES REGISTER: <enter> Select one of the following: (select 7 DELIMITED file via screen capture if you want to put the list on excel worksheet) -Repeat above steps for PATIENT STATUSES Transient, Unreviewed, Lost to F/U. -To find patients in your Active Register who did not have a medical clinic visit after : SUBJECT: LIVING PATIENTS // REGISTER UPCOMING APPTS? // NO WHICH CMS REGISTER: (Enter the name of your diabetes register) SELECT PATIENT STATUS: 1// 1 (Active) REGISTER DIAGNOSIS: ALL DIAGNOSES// 6 Attribute of IHS DIABETES REGISTER: VISIT First condition of Visit : CLINIC Enter CLINIC: [BGP Primary Care Clinic Enter ANOTHER CLINIC: ENDOCRINOLOGY Enter ANOTHER CLINIC: CHRONIC DISEASE Enter ANOTEHR CLINIC: <enter> (If you have Nephrology clinic you can add that clinic as well. If you are doing IPC then you can technically add Women s Health clinic, etc.) Want to save this CLINIC group? No// <enter> Next condition of Visit : AFTER

6 Exact date: (This date would be the date after your last search depending on how often you are updating your register, ie monthly, quarterly) Next condition of Visit : NULL Attribute of IHS DIABETES REGISTER: <enter> Select one of the following: (select 7 DELIMITED file via screen capture if you want to put the list on excel worksheet) -To find people in your Active Diabetes Register who may not have diabetes. If you are really ambitious, you could do this for the entire registry. SUBJECT: LIVING PATIENTS // REGISTER UPCOMING APPTS? // NO WHICH CMS REGISTER: (Enter the name of your diabetes register) SELECT PATIENT STATUS: 1// 1 (Active) REGISTER DIAGNOSIS: ALL DIAGNOSES// 6 (Pre-DMs may show up on your list if you do not have a separate Pre-DM registry) Attribute of IHS DIABETES REGISTER: Hemoglobin A1c (You will need to enter the spelling used by your facility, ie. A1c, HgbA1c, etc.) Condition of Hemoglobin A1c : greater than Value: 6.5 Next condition of Hemoglobin A1c : Null Attribute of IHS DIABETES REGISTER: <enter> Select one of the following: (select 7 DELIMITED file via screen capture if you want to put the list on excel worksheet)

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