Michigan Care Improvement Registry/MCIR Ongoing Data Quality Improvement Plan

Transcription

1 Michigan Department of Health and Human Services Immunizations Michigan Care Improvement Registry/MCIR Ongoing Data Quality Improvement Plan Version 2015

2 Table of Contents 1. Introduction Assumptions/Constraints/Risks Assumptions Constraints Risks Data Quality Principles Organization Roles and Responsibilities Data Quality Tools Routine MCIR Data Quality Processess Data Quality Processes and Schedules ACRONYMS Referenced Documents Record of Changes Ongoing Data Quality Improvement Plan Version 2015 ii Michigan Care Improvement Registry/MCIR

3 1. Introduction There are many advantages to maintaining immunization data in a statewide Immunization Information System (IIS) such as the Michigan Care Improvement Registry (MCIR). MCIR allows authorized organizations to print immunization histories without pulling medical charts; it allows automated forecast of immunizations due based on the child s age, history, and recommendations put forth by the Advisory Committee on Immunization Practices (ACIP) through the ACIP schedule. The MCIR; makes immunization histories transportable if the patient seeks care elsewhere; and makes it possible for medical practices, counties and the State of Michigan to assess immunization coverage and generate recall notices at all of these levels. The IIS can also be used for surveillance activities. However, all these benefits depend on the quality of the information in the MCIR. The information in MCIR should be a true reflection of all of the immunizations a patient has received. For MCIR to be a robust and useful immunization information system, stakeholders must be able to have confidence in the data it contains. The accuracy of immunization records is a decisive factor in improving the health of patients. Both public health decision-making and healthcare clinic operations rely on the accuracy of the MCIR. Inaccurate immunization records may result in increased morbidity and mortality. It is the responsibility of the MCIR program and the stakeholders to ensure the reliability of data stored in the registry. Data are entered into the MCIR from a variety of external sources; it is especially critical to establish standards for validating incoming data at the data entry point. Accurate, complete, and timely data in MCIR promotes participation among healthcare providers, health plans, schools and others. Higher participation in the registry results in complete immunization records for patients. Benefits of higher data quality include: Increased provider trust Increased use of the data Improvements in clinical decisions Improved patient health Improved public health Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

4 Poor data quality could result in a loss of confidence in MCIR and could create an incomplete picture of a patient's immunizations, and possible erroneous forecast recommendations. Incomplete and inaccurate data could impact provider participation in the MCIR. Program and public policy decisions could be impacted by inaccurate summary data as organizations move towards increased electronic data sharing capabilities. It is critical that all users and stakeholders in the system adopt a consistent approach to data quality. 2. Assumptions/Constraints/Risks 2.1 Assumptions MCIR is designed to: 1. Create or support effective interventions such as clinical decision support, reminder and recall activities. 2. Generate and evaluate public health responses to outbreaks of vaccine-preventable disease. 3. Facilitate vaccine management, vaccine ordering and accountability. 4. Determine a person s vaccination status for decisions made by clinicians, and schools. 5. Aid in surveillance and investigations of vaccination rates, missed vaccination opportunities, invalid dose administration, and disparities in vaccination coverage. 2.2 Constraints The support of the state immunization program, all users and stakeholders of the system is required to support the MCIR design criteria listed above. 2.3 Risks The advancement of electronic health records (EHRs), MCIR and the interoperability between the systems has and will continue to decrease the use of the general MCIR user interface for direct vaccine submission and patient query. Fewer users will view data submissions at the time of entry, which could increase duplicate patient and vaccine record submissions. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

5 3. Data Quality Principles Table 1: Data Quality Principles Principle Condition Examples Consistency The conditions (criteria) for validating data items should be the same regardless of how the data items have been reported to MCIR. Regardless of a data item s source and the method of data reporting (e.g., direct user entry or via HL7 reporting), the data item should go through the same set of data validation checks. Rejected data When information is rejected by MCIR, the following actions should occur: Electronic import logs errors and notifies submitters HL7 users can generate an Electronic Submission Summary Report (ESSR) User Interface (UI) displays an error message, offering user opportunity for error correction The MCIR Electronic Submission Summary Report and Doses Administered Report, along with available inventory reports, assist the end user in finding, correcting and resubmitting data errors. UI users receive edit checks verifying information on the screen, before data submission. Internal consistency Characteristics of the vaccination history should not contradict one another. This includes reported data as well as existing MCIR data. This principle is a basis for all crosscheck validations. This principle covers cross-validations between characteristics of multiple vaccination events that comprise immunization history, as well as cross-validations between characteristics of individual vaccination events. Vaccination history includes demographics, and information on all recorded vaccination events. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

6 Accuracy Principle Condition Examples Appropriate vaccination The data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate. The vaccinations reported by a provider should be appropriate for the population served at the clinic. MCIR staff periodically audit a random sample of incoming data to verify that it matches clinical records. Submitters should periodically audit a random sample of data to verify that it is correctly documented in MCIR. MCIR Doses Administered Report (DAR) Vital Records Validation priority ACIP recommendations principle: Vital Records is the definitive source for: Date of Birth Date of Death Adoption Validation of correct demographic information Management of duplicate EBC records The importance of validating a data item is related to the data item s significance in clinical decision-making, public health assessments, and research. Deviations from ACIP recommendations and U.S. licensure may indicate data It is possible that an incorrect birth date or death date is transmitted from vital records, but those are rare occasions. Currently, approximately 90% of birth dates come from the electronic birth certificate records. End users may flag a person as deceased. A feed from vital records also provides an electronic file of official death records to MCIR. Adoption records are managed at the regional level. Critical high priority data items are: Vaccine Type Vaccination Encounter Date Eligibility Lot number Manufacturer Date of Birth Zip Codes If a date of birth is modified on a MCIR record, it could result in some vaccine encounter dates being Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

7 Principle Condition Examples quality problems MCIR does not accept immunization data prior to patient DOB documented before the date of birth. Timeliness Completeness Supremacy of medical records Michigan Department of Health and Human Services requires immunization data to be entered into MCIR within 72 hours of administration for children less than 20 years of age. The information submitted to MCIR must contain the minimum/mandatory set of data items in order to be accepted by MCIR. Patient medical records are of greater reliability in collecting immunization data than patient billing records (CPT codes). MCIR has not accepted billing data since To be useful for clinical decision support and health policymaking, immunization data should appear in the MCIR soon after the clinical event occurs. Required data fields and the minimum/mandatory data sets for necessary MCIR function and operation Relevant data is optional and of value in improving MCIR function. The goal is to capture all relevant data on patients and their vaccination events. MCIR accepts vaccine (clinical) data Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

8 4. Organizational Roles and Responsibilities Table 2: Organizational Roles and Responsibilities Organization Role Quality Responsibility Immunization Provider To provide accurate patient level and vaccine data to MCIR within 72 hours of administration. Ensure that the data recorded in MCIR should match exactly what happens in a clinical encounter, whether or not it is clinically appropriate Generate required data quality reports on a weekly basis allowing data quality errors to be corrected in MCIR Conduct reminder and or recall mailings and update patient addresses from returned reminder or recall mail notifications Health Plan To increase immunization coverage level of members. Assure participating provider meet Healthcare Effectiveness Data and Information Set (HEDIS) measure and comply with ACIP Document address changes on members and flag possible duplicate records in MCIR Conduct reminder and or recall mailings and update patient addresses from returned reminder or recall mail notifications Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

9 Organization Role Quality Responsibility Health System To provide accurate patient level and vaccine information to MCIR within 72 hours of vaccine administration Ensure that the data recorded in MCIR matches exactly what happens in a clinical encounter; whether or not it is clinically appropriate Generate required data quality reports on a weekly basis and fix errors related to data quality in a reasonable amount of time Assess clinic-level compliance and coverage rates, and ensure clinicallevel compliance with the 72 hour mandate Schools and Childcares To ensure accurate immunization coverage levels by school building and to maintain compliance with local health department (LHD) reporting requirements End users add immunization data to students records, as necessary School/Childcare data and immunizing provider data are separated in MCIR School/Childcare data is not viewable to immunizing providers Local health departments are able to verify school/childcare data, after which it become accessible (viewable) to immunizing providers Report duplicate student vaccination records, and request required data corrections to student records Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

10 Organization Role Quality Responsibility Local Health Departments (LHDs) To provide accurate patient level and vaccine data to MCIR within 72 hours of administration. Assure immunizations are given appropriately and timely in their jurisdiction To oversee the Vaccine for Children s Program at the local level Ensure that the data recorded in MCIR matches exactly what happens in a clinical encounter; whether or not it is clinically appropriate Enter all historical information on a patient to assist with increasing immunization coverage levels in the jurisdiction Routinely monitor the quality of data being submitted and make the necessary corrections in MCIR within a reasonable amount of time Conduct reminder and or recall mailings and update patient addresses from returned reminder or recall mail notifications Recommend data quality strategies to immunization providers in their jurisdiction Health Information Exchanges (HIE) To transport accurate patient level data to MCIR Assure that the required fields in the message header are populated and formatted correctly Accountable Care Organizations To increase the immunization coverage level of members Assure participating providers meet HEDIS measures and comply with ACIP recommendations for immunizations Document change of addresses on members and flag duplicate patients in MCIR Conduct reminder and or recall mailings and update patient addresses from returned reminder or recall mail notifications Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

11 Organization Role Quality Responsibility Electronic Health Record (EHR) Vendor Michigan Department of Health and Human Services (MDHHS) Division of Immunizations Division Director Immunizations MCIR Coordinator To develop electronic medical records (EMR) that meet healthcare organization requirements, and federal requirements for required documentation support for immunization services To provide oversight of the State of Michigan Immunization Program To provide oversight of the Michigan Care Improvement Registry program Develop and support HL7 interface requirements according to MCIR specifications for their customer s specifications Provide oversight of MCIR data quality policies Promote, develop and monitor MCIR data quality policies Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

12 Organization Role Quality Responsibility Immunizations MCIR Regional Coordinators To monitor, recruit and train immunization providers, health plans and health systems. To generate and create Business Objects ( ad hoc ) reports on behalf of MCIR users To develop and update regional forms and training materials, as necessary To monitor data submission and immunization rates for the region To assure all regional users are updated on MCIR system changes and procedural changes To develop strategies to increase private provider enrollment and participation in MCIR To maintain listing of providers and users trained for the region To operate and manage regional help desk activities. To monitor data quality, including the performance of patient and vaccine level deduplicate measures Perform patient and vaccine level record de-duplications Monitor electronic data submission Work with LHDs to establish an internal process to assure persons who have died within their county are appropriately flagged in the IIS Refer EBC and NICU data quality issues to PHBPP for required follow-up Train providers on submitting HL7 messages and generating the MCIR ESSR report Process MCIR Petition for Modification requests Generate routine reports to monitor and identify MCIR data quality issues: 72 hour submission (accreditation) report Active site listing report Profile Reports Inventory Control Reports First time HL7 submitters production First time HL7 submitters onboarding Weekly HL7 message count Sites with no weekly HL7 activity Offer data quality assurance (DQA) best practice strategies to providers Refer DQA issues to appropriate stakeholders [LHDs, Assessment, Feedback, Incentives and exchange (AFIX), Peer Education Program and/or State MCIR Program] Provide tier 1 helpdesk support to regional MCIR end users Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

13 Organization Role Quality Responsibility Immunizations Vaccines for Children (VFC) program To provide access to vaccines (recommended by the Advisory Committee on Immunization Practices) to children whose parents or guardians may not be otherwise able to afford them, helping to ensure that all children have a better chance of receiving recommended vaccinations on schedule. Vaccines available through the VFC Program Monitor data quality assurance for provider adherence to eligibility requirements, vaccine ordering and inventories Referrals to MCIR staff for data quality reviews and training Referrals to LHD s for inventory management issues Immunizations Assessment, Feedback, Incentives and exchange (AFIX) program To raise immunization coverage levels, reduce missed opportunities to vaccinate, and improve standards of practice at the provider level through quality improvement processes Assist with monitoring data quality at the clinic level Refer providers to MCIR regional staff for data quality improvement training Immunizations Perinatal Hepatitis B Prevention Program (PHBPP)* *Established in 1991 To prevent hepatitis B transmission from pregnant women to their infants, household and sexual contacts. To coordinate the sharing of preventative perinatal hepatitis B transmission information between primary care providers, hospitals, laboratories, the state and local health departments Monitoring Hepatitis B vaccine compliance in birthing hospitals, including NICUs Identifying duplicate patient records Correct information identified as missing or requiring correction in the MCIR Electronic Birth Certificate (EBC) record Monitor and perform necessary follow-up on Hospital Worksheet s Unknown Hep B immunization and Unknown Immune Globulin (IG) data Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

14 Organization Role Quality Responsibility Immunizations Immunization Nurse Educators (INEs) MDHHS Office of Public Health Preparedness (OPHP) To provide free immunization education*, performed by INEs from both the Michigan Department of Health and Human Services and LHDs, to Michigan provider offices statewide *The educational modules are developed and maintained by a core group of MDHHS-based nurses. Registered LHD nurses meeting the established qualifications and requirements, and completing the INE orientation are approved to teach these immunization educational programs within their LHD jurisdiction(s). To protect the health of Michigan citizens before, during and after an emergency through the integration of public health and medical preparedness initiatives and by leveraging diverse partnerships To educate and promote data quality improvement strategies to immunization providers. Identify data quality issues and refer provider offices to MCIR Regional Staff for data quality improvement training. Monitoring data quality assurance for vaccine/antiviral ordering and distribution. To maintain a dual role in both preparedness planning and in emergency response activities encompassing all hazards, including natural and manmade disasters, acts of bioterrorism, infectious disease outbreaks and other emergencies that impact the health of the public Immunizations Epidemiologists To conduct ad-hoc queries, for the Immunizations, used to identify pockets of need, and trends in vaccination coverage To develop queries and identify data quality issues in the MCIR database. To provide recommendations to the Division of Immunizations for business rules or best practices to increase the quality of data in MCIR. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

15 Organization Role Quality Responsibility Immunizations Adolescent program Immunizations Technical Team Vital Records Lifecourse Epidemiology & Genomics Newborn Screening (NBS) program Lifecourse Epidemiology & Genomics Early Hearing Detection And Intervention (EHDI) program To monitor adolescent coverage rates for the State of Michigan To develop campaigns to increase adolescent immunization rates To provide technical infrastructure and related support To develop IIS enhancements and newly identified functionality To compile and store records of: Michigan births, deaths, adoptions and marriages filed as early as 1867 Michigan divorces filed as early as 1897 To identify babies with rare but serious disorders who require early treatment*, as identify by Michigan law *All babies are tested in order to find the small numbers who have a rare medical condition. To assist in identifying infants with hearing loss To follow the identified infants to enrollment of early intervention services To work in collaboration with hospitals, clinics, parents, and audiologists Promotion of MCIR to adolescent service providers Promote use of Patient Status, complete immunization records documented in MCIR. Promote MCIR Reminder/Recall activities. To conduct testing of the MCIR web application, as needed To coordinate and monitor Health Plan data loads for HEDIS reporting. Tier 3 state-level MCIR help desk support for the Michigan Public health Institute (MPHI). Quality assurance related to provider onboarding. To provide the MCIR with complete and accurate electronic birth records To provide timely and accurate death record information to MCIR. To flag duplicate patient records in MCIR To flag duplicate patient records in MCIR Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

16 Organization Role Quality Responsibility MDHHS Early Periodic Screening Diagnosis and Treatment (EPSDT) MDHHS Center for Medicaid and Medicare Services (CMS) To offer early and periodic screening, diagnosis, and treatment (EPSDT) services to Medicaid eligible beneficiaries younger than 21 years of age, as required by Federal regulations To support shared services that are utilized by the MCIR program, e.g. the Master Patient Index, MPI, and the Data warehouse To flag duplicate patient records in MCIR. To share known duplicate patient records found in the MPI with MCIR To share Medicaid Patient ID s with MCIR on a monthly basis Michigan Department of Technology, Management and Budget To manage all Information Technology (IT) services within state government To provide database management services and disaster recovery services for the Division of Immunizations Women Infant and Children (WIC) WIC program To provide supplemental foods, health care referrals, and nutrition education* to lowincome pregnant, breastfeeding, and nonbreastfeeding postpartum women, and infants and children up to age five who are found to be at nutritional risk To flag duplicate patient records in MCIR. To share WIC ID s and clients addresses with MCIR on a monthly basis *funded through federal grants to the WIC Special Supplemental Nutrition program Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

17 Organization Role Quality Responsibility Michigan Public Health Institute (MPHI) To provide technical and programmatic assistance to Immunization to successfully develop, deploy, and support statewide use of the MCIR To provide testing and approval for electronic file submission, according to MDHHS-approved policy & procedure. To update the MCIR Vaccine Code List and to identify system bugs and enter them into bug tracking software. To maintain a second-tier helpdesk for technical support of the MCIR web application. To maintain a first-tier helpdesk for technical support of school and childcare usage of the MCIR. To conduct testing of the MCIR web application as needed. Provide tier 2 state-level helpdesk support to MCIR end users (i.e., providers) statewide Provide quality assurance service on new functionality programmed into MCIR. Center for Disease Control and Preventions (CDC) National Center for Immunization and Respiratory Diseases (NCIRD) Immunization Information Systems Support Branch (IISSB) To maximize protection against vaccine-preventable diseases by leading the advancement of IIS, including the capture of accurate data on which to make informed immunization decisions. To facilitate the development, implementation, and acceptance of IIS, whereby immunization providers will have access the data required to make informed clinical decisions To develop national standards to ensure the quality of data in an IIS Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

18 Organization Role Quality Responsibility American Immunization Registry Association (AIRA) University of Michigan Child Health Evaluation and Research (CHEAR) Unit To promote the development and implementation of IIS as an integral tool in the prevention and control of vaccine preventable diseases, through collaborative interaction of the nation s IIS To conducts projects, which involve both primary data collection and secondary data analysis, and utilizes both quantitative and qualitative research methods where appropriate Develop performance measures for IIS data quality compliance and best practices to achieve the recommended standards developed by CDC To provide data quality analysis and recommendations for improved MCIR data, through a contract with the MDHHS Division of Immunizations Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

19 5. Data Quality Tools Table 3: Data Quality Tools MCIR Data Quality Tool Quality Tool Description Handles data from different providers differently depending on data quality issues encountered in the past and what kind of data is expected. Reviews an entire batch of HL7 messages for problems. Applies added vaccination specific rules and knowledge to a single message Monitors and reports back to submitters and MCIR staff the status of imports on a submitter level. Business Objects Business Objects software allows MCIR staff to develop ad hoc reports from the MCIR database. Several data quality reports are generated on a routine basis, including: Accreditation Report, County Cleanup Report, Active Site Listing, Electronic Submissions By Provider By County, and Monthly Shot Crosstab Report. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

20 6. Routine MCIR Data Quality Processess Table 4: Routine MCIR Data Quality Processes Patient De-Duplication Quality Process Tools & Techniques MCIR Regional Staff are responsible for merging duplicate patient records on a daily basis. MCIR staff review each record in the duplicate patient list. They verify that the duplicate records are valid duplicates. If indicators are insufficient to allow for an accurate determination, they contact the current provider for supporting information. If the provider is unable to substantiate information for completion of the merge, a responsible party may be contacted. Vaccine administrations are reviewed to determine if the merging of the patient records may affect the vaccine inventory in MCIR. A determination must be made regarding whether patient records can be consolidated (merged) or should be designated as Not Duplicates. Vaccine De-Duplication Onboarding Death Records The Medicaid Data Warehouse submits a death record file to MCIR on a monthly basis. (birth through 18 years of age) Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

21 Record Modifications Patient Searches Quality Process Tools & Techniques 1. MCIR end users may modify or delete errors in the MCIR record if the data was added to the system by their office. The change does not require the submission of a Petition for Modification to the Regional Office. The ability for end user data correction pertains to immunization data only, not patient demographics, e.g., name, DOB, etc. 2. All other data entry edits not mentioned above must be submitted through sending a Petition for Modification form to the Regional office. Appropriate documentation may be required for requested modifications to MCIR shot data. Sites requesting name changes are NOT required to submit additional documentation (the office staff should have verified the name with the responsible party by following internal office policies). 3. If the requested change is determined to be valid, the Petition for Modification will be processed within 7 days of receipt. 4. Regional staff will determine the modification actions necessary for the following: modifying demographics, merging duplicate patient and/or vaccine records, deleting invalid doses, and adjusting inventory. Users must search twice for a record before creating a new patient record in MCIR. Users may call regional office before adding a patient born after Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

22 Table 5: MCIR Data Quality Business Rules Business Rule Action Comment A patient should not have more than:* 50 vaccinations recorded in MCIR before age 5 35 vaccinations recorded in MCIR before 2 years of age 70 vaccinations recorded in MCIR regardless of age. Vaccination encounter date must not be before patient date of birth. Data items: Vaccination Encounter Date Date of Birth Vaccination encounter date should not be after the patient date of death. Data items: Vaccination Encounter Date Patient Date of Death The MCIR State and Regional staff may query the MCIR using Business Objects on a yearly basis to determine If any MCIR records exceed this Business Rule. This report needs to be developed. Electronic import: Reject the patient and all related vaccination event submissions (new/incoming) User interface: Reject the vaccination event Electronic import: Reject the patient and all related vaccination event submissions (new/incoming) User interface: Reject the vaccination event If this condition does exist from incoming data, the source should be notified and the patient record should be reviewed and modified to reflect accurate immunization information from the patient record. *Requires IIS Design & Development of the business rule [included in Table 6] MCIR reviews each vaccination event in the record being validated; MCIR will reject the information if any encounter date precedes date of birth. Possible interpretations: Vaccination encounter date is incorrect Patient date of birth is incorrect Patient date of birth and vaccination encounter date are incorrect Patient identification is incorrect (e.g., could be a sibling) Implementation Example: Check: If vaccination encounter date is after date of death If date of death is after vaccination encounter MCIR reviews each vaccination event in the record being validated; reject if any encounter date is later than the date of death. Possible interpretations: Date of death is recorded Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

23 Business Rule Action Comment Vaccination encounter date must be less than or equal to (before or the same as) the Report submission date. The minimum/mandatory set of data items for a Vital Records submission includes: Patient Date of Birth Patient First Name Patient Last Name Gender Mothers Maiden Name Mothers First and Last Name Mothers Address Birth Facility Name and Location Reject the vaccination event submission Reject the Patient's record (complete rejection of submitted information). incorrectly or patient is not actually deceased Vaccination encounter date is incorrect Error in software used to report encounter to MCIR Two distinct patients are reported (one who received the vaccination and one who is deceased) The create date in MCIR should be the same as the date of the vaccine encounter or recorded in MCIR after the date of administration. MCIR does not accept birth records with the word Baby in the first name field or records containing Baby Boy or Baby Girl in the first name field. The minimum/mandatory set of data items for the Provider EHRs must include: Provider Organization Name/ID Patient Name, First Patient Name, Last Patient Date of Birth Patient Address Vaccine Encounter Date Vaccine Type Vaccine Eligibility Vaccine Lot Number Vaccine Manufacturer Responsible Party Last Name If the demographic data items are incomplete (patient can't be identified): Reject the Patient's record (complete rejection of submitted information) If the demographic data items are complete (patient can be identified): Reject those vaccination events that are incomplete (partial rejection of submitted MCIR will not accept a patient record unless all of the required fields are submitted from an EHR Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

24 Business Rule Action Comment Responsible Party First Name VFC-eligible children should have the manufacturer and lot number reported with vaccination event. Data items: Vaccination Encounter Date VFC Eligibility Vaccine Manufacturer Vaccine Lot Number Reject the vaccination event submission This applies to administered immunizations only. This information is required for inventory management and vaccine accountability. The percentage of vaccination event submissions from Vital Records with hepatitis B birth doses should be within an expected threshold level. Data items: Vaccine Type Submitter Type Vaccination encounter date should not be on the patient's date of birth unless it is on the list of vaccines recommended on the date of birth, e.g. Hepatitis B. Data items: Vaccination Encounter Date Patient Date of Birth Vaccine Type If threshold is deviated by 10%, then immediately follow up with vital records department. Electronic import: Accept and flag for investigation User Interface: Accept (after issuing a warning) The Perinatal Hepatitis B program measures all birth doses by vital records and hospital submission on a quarterly basis. MDHHS generates an annual report measuring how many MI birth records are added to the IIS, based on the number of births reported by Vital Records. When this error is discovered, MCIR staff may ask the provider office to: Review patient chart Ask office to contact patient to validate date of birth Possible interpretations: Clinical error The current date accidentally typed in the encounter date field Other typographical error For administered vaccinations, report submission date should be within 72 hours of vaccination encounter date for all patients under the age of 20. Accept and flag for investigation MCIR regions generate a 72- hour ad-hoc report and contact provider offices for training and develop a corrective action plan. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

25 Business Rule Action Comment Data Items: MCIR create date Vaccine encounter date Trade Name, Manufacturer, CVX Code, CPT Code and Vaccine Type should not contradict one another. Reject the vaccination event submission. MCIR will reject the electronic submission of vaccine type if it includes the wrong vaccine manufacturer. The same patient should not receive the same antigen more than once in single day. Data Items: Vaccination encounter date Vaccine Type (in order to derive the antigen) MCIR allows: Rabies RIG for wound management and Rabies Vaccine on the same day Two.25ml doses of Influenza on the same day Two.50ml doses of Hep A on the same day Two.50ml doses of Hep B on the same day Possible interpretations to this rule: Invalid dose or incomplete immunization Two separate pediatric doses on the same date to an adult Poor clinical practice Vaccination Encounter Date should not be after the lot number expiration date. Data items: Vaccination Encounter Date Lot Number Expiration Date Administered vaccinations should have specific Vaccine Types, e.g., Hib PRP-OMP; Unspecified vaccine types, e.g., Hib, NOS, are less desirable. Data items: Administered/Historical Indicator Electronic Import: Accept and flag for investigation. User Interface: Accept (after issuing a warning) Accept during production Investigate - during onboarding. MCIR allows the end user to submit an administered vaccine with an expired lot number. MCIR accepts unspecified vaccine types only for historical doses. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

26 Business Rule Action Comment Vaccine Type The volume of reporting from the Vital Records feed should be within an expected threshold level (to be determined by each IIS). Data item: Report Submission Date The percentage of rejected vaccination event submissions in a report should be within an expected threshold level. A patient should not have more than 6 DTaP vaccinations by age 7. * Data Items: Date of Birth Vaccination Encounter Date Vaccine Type A patient should not have more than 10 vaccinations per visit.* Data Item: Vaccination encounter date Michigan has 113,000 births a year. 96% of birth records should be entered into MCIR via the vital records feed. During the onboarding process if more than 10% of the vaccination event submissions are rejected for errors, initiate an investigation. Accept during production Investigate - during onboarding. Accept and flag for investigation If the rate of reporting significantly deviates from the threshold, the State MCIR Coordinator will follow up with the Division of Vital Records. MCIR regional staff will begin to review a random sample of DQA reports on a yearly basis to check for 10% or more error rejection rate. The regional staff will work with the provider office on a corrective action plan to eliminate existing data quality errors in the future. MCIR should have this query as an ad-hoc report and be generated on a quarterly basis. *Requires IIS Design & Development of the business rule [included in Table 6] MCIR should have this query as an ad-hoc report and generate this report on a quarterly basis? *Requires IIS Design & Development of the business rule [included in Table 6] Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

27 Table 6: MCIR Vaccine De-duplication Business Rules Business Rule Description Allow two.50ml doses of Hep B on the same day Allow two.50ml doses of Hep A on the same day Allow two.25ml doses of Influenza on the same day Allow a single Rabies RIG for wound management, per day Allow a single Rabies Vaccine, per day Allow Rabies Vaccine (not RIG) on successive days <5 day interval. Same vaccine product is required for all subsequent doses or record will be rejected as a duplicate. Allow Tdap on same day as Td, DT Allow Tdap within 5 days, if prior dose was a Td or DT Allow Hep B or HBIG if birth dose reported by Hospital and existing dose reported by Electronic Birth Certificate*. *Data reported by Hospital EHR provides a more complete vaccination record than EBC interface. Accept HL7 interface record if previously reported via HL7 by the same provider site and having change in eligibility or other clinical information. Action Taken Accept one additional record only. Flag as potential duplicate Accept one additional record only. Flag as potential duplicate Accept one additional record only. Flag as potential duplicate Accept dose of RIG or Rabies vaccine if an existing dose already recorded for that day is NOT recorded as a RIG or Rabies Vaccine Accept dose of RIG or Rabies vaccine if an existing dose already recorded for that day is NOT recorded as a RIG or Rabies Vaccine Allow additional doses of Rabies Vaccine to be reported within a 4 consecutive day window Allow the reporting of a Tdap vaccine the same day as a Td, DT Allow Tdap to be reported on same day or <4 days since last Td, DT (non Pertussis containing vaccine) Based on investigation, the regional MCIR office will determine:1) whether to replace EBC dose with Hep B dose data entered into the IIS, via a variety of external sources; and 2) to perform the required adjustment manually or through the vaccine deduplication queue Accept record and flag as potential duplicate. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

28 Business Rule Description Accept potential duplicate if lot# provided and existing record has no lot Reject potential duplicate if vaccine, manufacturer is the same and better lot information is not available. Reject potential duplicate if vaccine is the same and better lot information is not available Reject potential duplicate if record does not have better clinical information to offer. Action Taken Accept record and flag as potential duplicate Reject record Reject record Reject record Table 7: MCIR Data Integrity Standards Data Item Range/Codes Comments CPT Code Patient Name Should be chosen from the standard table of CPT (billing) codes Should not contain invalid name characters such as %^&*\, as well invalid names, e.g., "baby." Prefer CVX codes Prefer legal names instead of aliases Patient Date of Birth Dates should represent valid calendar dates. Patient Date of Death Dates should represent valid calendar dates. A user may document a patient as deceased via HL7 or through the user interface. Patient Gender Mothers Maiden Name Male, Female, Unknown Should not contain invalid name characters such as []{} ~!@#$ %^&*\ Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

29 Data Item Range/Codes Comments Vaccine Encounter Date Vaccination Event Site Vaccination Route Dates should represent valid calendar dates. Should be chosen from the standard table of vaccination sites and routes. Should be chosen from the standard table of vaccination sites and routes. with_mnf_cvx%20attach.pdf Specs.pdf with_mnf_cvx%20attach.pdf Specs.pdf Vaccination Event Dosage Includes 1) value and 2) unit of measurement; both have to be captured or known (e.g., presumed to be in ml) Value has to be a positive unit of measurement, e.g., ml. Value should be numeric. Value should not be negative. If value is zero; the presumption is that field was not filled. Vaccine Type Should be chosen from the standard table of vaccine codes. See CVX or CPT codes. Vaccine Lot Number Vaccine Lot Number Expiration Date Typically, an alphanumeric field. Dates should represent valid calendar dates. Vaccine Manufacturer Should be chosen from the standard table of Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

30 Data Item Range/Codes Comments State/Provinc e MVX codes. If country code is specified as 'US' (or not indicated and assumed to be 'US'), state code should be drawn from the USPS state codes list. This list should also include the Federal District (DC), insular areas, Freely Associated States, and Armed Forces codes. State/Province designations for other country codes must be valid. with_mnf_cvx%20attach.pdf Specs.pdf ZIP Codes For addresses with a US country code (or a blank US country code that is assumed to be US): ZIP codes may be either 5 or 9 digits and with a dash appearing after the first 5 digits.. Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

31 7. Data Quality Processes and Schedules Table 8: Scheduled Data Quality Processes Process Schedule Responsibility Tool(s) Patient deduplication algorithms Daily Immunizations Automated report Vaccine deduplication algorithms Daily Immunizations Automated report 72 hour submission report monitoring Quarterly MDHHS Division of Immunizations MDHHS Division of Immunizations, MCIR Regional Coordinators MCIR end user/ Immunizing Provider MDHHS: Accreditation Report (Business Objects) MCIR Regions: Accreditation Report (Business Objects) Immunizing Provider: EXT Transfer Report Vital records monitoring Quarterly Annually Quarterly-PHBPP Annually-MDHHS Division of Immunizations PHBPP: Quarterly Hep B Hospital measurement reports MDHHS: Immunization Information Systems Annual Report (IISAR) Duplicate patient records Daily MDHHS Division of Immunizations MDHHS Division of Immunizations, MCIR Regional Coordinators Regional patient deduplication queue Duplicate vaccine entries in a record Daily Immunizations, MCIR Regional Coordinators Regional vaccine deduplication queue Business Objects reports Monitoring of provider DQA reports Ongoing preproduction MDHHS Division of Immunizations, MCIR Regional Coordinators MPHI MCIR Regions: Vaccine Deduplication Business Objects reports MPHI: IIS DQA Tool, ESSR report Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

32 Process Schedule Responsibility Tool(s) Immunization Provider review of ESSR report and correct data quality errors listed report Review and modify ongoing data quality policies Daily MPHI MDHHS Division of Immunizations, MCIR Regional Coordinators MCIR end user/ Immunizing Provider Annual Review MDHHS Division of Immunizations MDHHS Division of Immunizations, MCIR Regional Coordinators MDHHS Division of Immunizations, MCIR Data Quality Workgroup members MPHI: IIS DQA Tool Report MCIR Regions & Providers: MCIR ESSR report Immunizations: Review of current policies Immunizations, MCIR Regional Coordinators: Review of current procedures as they relate to current Immunization policies Death record imports Monthly Immunizations Vital Record imports Daily Immunizations, Tech Team Manual monthly process from Medicaid Warehouse to IIS Automated report Batch assessment (updating forecast on all records in the database) Daily Immunizations, Tech Team Automated report Weekly HL7 message count Weekly Immunizations, Tech Team Automated report Sites having no weekly HL7 activity Weekly Immunizations, Tech Team Automated report First time HL7 submitters production Weekly Immunizations, Tech Team Automated report First time HL7 submitters Weekly Immunizations, Tech Automated report Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

33 onboarding Process Schedule Responsibility Tool(s) Team Meaningful Use Regional TRACKER Status Report Weekly Immunizations, Tech Team Automated report Table 9: Newly Identified Data Quality Procedures and Reports to be Implemented Process Schedule Responsibility Tool(s) Required Appropriate Vaccinations by Age A patient should not have more than:* 50 vaccinations recorded in MCIR before age 5 35 vaccinations recorded in MCIR before 2 years of age 70 vaccinations recorded in MCIR regardless of age. A patient should not have more than 6 DTaP vaccinations by age 7.* Data Items: Date of Birth Vaccination Encounter Date Vaccine Type Annually Quarterly Immunizations, MCIR Regional Coordinators Immunizations, MCIR Regional Coordinators IIS design and development of business rules Business Processes defined Business Objects IIS design and development of business rules Business Processes defined Business Objects A patient should not have more than 10 vaccinations per visit. Data Item: Vaccination encounter date Quarterly Immunizations, MCIR Regional Coordinators IIS design and development of business rules Business Processes defined Business Objects Algorithms to prevent documentation of Daily Immunizations, Tech MCIR Algorithm Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

34 Process Schedule Responsibility Tool(s) Required administered vaccines on DOB, excluding ACIP recommended birth doses Team Algorithms to prevent documentation of administered vaccines post Date of Death All vaccine encounters Immunizations, Tech Team MCIR Algorithm Algorithms to prevent documentation of duplicate vaccination type administered on same day All vaccine encounters Immunizations, Tech Team MCIR Algorithm Algorithms to prevent documentation of vaccines administered post the vaccine s expiration date All vaccine encounters for VIM users Immunizations, Tech Team MCIR Algorithm Algorithms to prevent documentation of Unspecified and/or NOS vaccines unless documented as Historical doses All vaccine encounters Immunizations, Tech Team MCIR Algorithm Compliance of Submission policy for Vital Records birth certification information, i.e., EBC creation Daily MDHHS- Immunization Division Immunizations, Tech Team MCIR Regional Coordinator Procedure Allow electronic transfer of death record data, without vaccination data attached* Ongoing Any immunizing provider using HL7 messaging Transfer specs HL7 guide *Requires Admission, Discharge Transfer (ADT) Messaging Canned IIS report of all immunization added to a person s record: by HL7 message per a specified time As required Immunizations IIS capacity/function Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

35 Process Schedule Responsibility Tool(s) Required frame including: patient s first and last name, DOB, MCIR ID, Vaccine Admin Date, Vaccine Type, Lot # and Manufacturer Onboarding approval process Go Live will occur within 30 days of approval MPHI MDHHS Division of Immunizations, MCIR Regional Coordinators MPHI and Regional Coordinators: Onboarding Procedure ESSR report IIS queue for Potential Patient deduplication, merging and approved IIS visibility Routinely Immunizations, MCIR Regional Coordinators IIS Potential Patient Deduplication Queue - business rules and functional specifications TBD Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR

36 8. ACRONYMS Table 10: ACRONYMS Acronym ACIP ADT AFIX AIRA CHEAR CDC CMS DQA EBC EHDI EHR EMR EPSDT HIE HEDIS IIS IISAR IISSB INE(s) IT LHD(s) MCIR Literal Translation Advisory Committee on Immunizations Admission, Discharge Transfer Messaging Assessment Feedback Incentives and exchange program American Immunization Registry Association Child Health Evaluation and Research Unit, University of Michigan Centers for Disease Control and Prevention Center for Medicaid and Medicare Services Data Quality Assurance Electronic Birth Certificate Early Hearing Detection And Intervention program Electronic Health Record Electronic Medical Record Early Periodic Screening Diagnosis and Treatment program Health Information Exchange Healthcare Effectiveness Data and Information Set Immunization Information System Immunization Information System Annual Report Immunization Information System Support Branch, CDC Immunization Nurse Educator(s) Information Technology Local Health Department(s) Michigan Care Improvement Registry Ongoing Data Quality Improvement Plan Version Michigan Care Improvement Registry/MCIR