TRANSITIONING FROM PP EXTRACT TO A VENDOR NEUTRAL DATA EXTRACTION APPROACH R U T H J E N K I N S, P H D A U G U S T 2 2,

Transcription

1 TRANSITIONING FROM PP EXTRACT TO A VENDOR NEUTRAL DATA EXTRACTION APPROACH R U T H J E N K I N S, P H D A U G U S T 2 2,

2 AGENDA Why a new extract is needed Explain new extract process Data Extracted and Not Extracted Data Documentation recommendations

3 WHY A NEW APPROACH? PPRNet needs data not currently extracted o Codes SNOMED, ICD-10, G codes, LOINC, RXNORM Allow PPRNet to align CQMs with CMS & other incentive programs o Patient Identifiers To Include in PPRNet patient level report Allow PPRNet to become a Qualified Clinical Data Registry (QCDR) McKesson support for prxtract ends in October

4 NEW DATA EXTRACT AND UPLOAD PROCESS Initial Setup o Download new utility* and save in ppart folder o Create new PPRNetData folder in ppart o Export Full Patient Demographics for All Patients Extract data: Export Medical Summary on PP menu Click new utility to transfer data file Instructions and recorded tutorial will be on our web page *Developed in conjunction with MUSC OCIO (IT)

5 INITIALLY - EXPORT FULL PATIENT DEMOGRAPHICS

6 EXPORT MEDICAL SUMMARY

7 EXPORT MEDICAL SUMMARY

8 DATA FILE UPLOAD UTILITY

9 DATA EXTRACTED (1) Patient name (2) Sex (3) Date of birth (4) Race (5) Ethnicity (6) Preferred language (7) Smoking status (VS) (8) Problems (9) Medications (10) Medication allergies (11) Laboratory test identifiers (12) Laboratory values/results (13) Vital signs: height, weight, BP, BMI (14) Care plan: goals, instructions, team (15) Procedures (16) Immunizations (HM)

10 ADDITIONAL DATA EXTRACTED (17) Visit Date and Location (18) Chief Complaint(s) (19) Pending Tests, Future Tests, Future Appointments (20) Patient Education Materials and Patient Instructions (21) Encounter Diagnosis

11 DATA NOT EXTRACTED (except Immunizations) Clinical Elements (except Adv Directives & Funct Status) Title lines User Defined Vital Signs

12 QUALITY MEASURES DOCUMENTATION CHANGES Diabetes Foot and Dilated Eye Exams Cancer Screening AAA, Chlamydia, Osteoporosis, Depression screen Tobacco cessation intervention Alcohol screen & counseling

13 CODE DOCUMENTATION Diagnosis codes (ICD-9-CM, ICD-10-CM, SNOMED-CT) Entered in Practice Partner in: o Major Problems o Other Problems o Diagnoses o Risks Procedure codes (CPT, CPT II, HCPCS-G codes) o Procedures

14 DIABETES FOOT AND DILATED EYE EXAMS Measure Not extracted Documentation Recommendation Diabetes Mellitus: Annual Foot Exam Clinical Elements Procedures Foot exam perform [2028F, CPT] Diabetes Mellitus: Annual Dilated Eye Exam Clinical Elements Procedures Dil Retina Exam [2022F, CPT]

15 CODES INCLUDED IN QUALITY MEASURES ** Will be provided in instructions and tutorial **

16 CANCER SCREENING Measure Not Extracted Documentation Recommendation Cervical Cancer Screening (Pap Smear in 3 years) Breast Cancer Screening (Mammogram in 2 years) Colorectal Cancer Screening (Annual FOB or Sigmoidoscopy in 5 years or Colonoscopy in 10 years) Title Lines Title Lines Title Lines -Screen for malig neopl of cervix [V76,2, I9] Lab table Procedures or Dx Dx Procedures -Screening Mammogram FOB: Lab table -FIT Sigmoidoscopy or Colonoscopy: Procedures or Dx -Screening Colonoscopy -Colon Screening [V76.51, I9] -Sigmoidoscopy

17 SCREENING AAA, CHLAMYDIA, OSTEOPOROSIS, DEPRESSION Measure Not Extracted Documentation Recommendation Abdominal aortic aneurysm screening (for men, once since 65 th birthday) Annual Chlamydia Screening for Women Dx Procedures -US Exam, Abdom Lab table Procedures -Chlamydia Culture Osteoporosis screening (for women, Bone Densitometry since 65 th birthday) Depression screening (for adults in 2 years) Title Lines Title Lines Dx Procedures -DXA Bone Density Study Dx Procedures or Risks table -Health Risk Asses [99420, CPT] -Ann Depress Screen, 15 min [G0444, HCPCS]

18 TOBACCO, ALCOHOL SCREENING & COUNSELING Measure Not Extracted Documentation Recommendation Tobacco Use: Screening plus cessation intervention if identified as user in 2 years Alcohol misuse screening in 2 years Annual Alcohol counseling/ Brief Intervention for pts with alcohol diagnosis or at-risk drinking Clinical Elements Vital Signs Title Lines Tobacco screening: Vital signs Cessation Counseling: Dx or Procedures -Tob Use Cess 3-10min [99406, CPT] -Tob Use Cess >10min [99407, CPT] Dx or Procedures or Risks -Alcohol consumption screening [V79.1, I9] -Alcohol questionnaire completed (finding) [ , SNOMED] -Drinks Alcohol [219006, SNOMED] -Problem drinker (finding) [ , SNOMED] Dx or Procedures or Risks -Alcohol abuse counseling & surveillance [Z71.4, I10] -Alcohol/subs interv 15-30min [99408, CPT] -Alcohol/subs interv >30min [99409, CPT]

19 FINAL COMMENTS ON NEW EXTRACTION PROCESS September 8, 2014 pilot testing September 15, 2014 begin transitioning practices GO LIVE!! October 2014 extract Instructions and recorded tutorial will be on our web page EHR documentation changes will allow data to be included in Clinical Summary documents Not a proprietary process anymore PPRNet becomes vendor neutral: Expansion opportunity