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TRANSITIONING FROM PP EXTRACT TO A VENDOR NEUTRAL DATA EXTRACTION APPROACH RUTH JENKINS, PHD AUGUST 22, 2014 ©PPRNET 2014
AGENDA Why a new extract is needed Explain new extract process Data Extracted and Not Extracted Data Documentation recommendations ©PPRNET 2014
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 ©PPRNET 2014
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) ©PPRNET 2014
INITIALLY - EXPORT FULL PATIENT DEMOGRAPHICS ©PPRNET 2014
EXPORT MEDICAL SUMMARY ©PPRNET 2014
EXPORT MEDICAL SUMMARY ©PPRNET 2014
DATA FILE UPLOAD UTILITY ©PPRNET 2014
DATA EXTRACTED (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) (1) Patient name (2) Sex (3) Date of birth (4) Race (5) Ethnicity (6) Preferred language (7) Smoking status (VS) (8) Problems ©PPRNET 2014
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 ©PPRNET 2014
DATA NOT EXTRACTED Health Maintenance (except Immunizations) Clinical Elements (except Adv Directives & Funct Status) “Title” lines User Defined Vital Signs ©PPRNET 2014
QUALITY MEASURES DOCUMENTATION CHANGES Diabetes Foot and Dilated Eye Exams Cancer Screening AAA, Chlamydia, Osteoporosis, Depression screen Tobacco cessation intervention Alcohol screen & counseling ©PPRNET 2014
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 ©PPRNET 2014
DIABETES FOOT AND DILATED EYE EXAMS MeasureNot extractedDocumentation Recommendation Diabetes Mellitus: Annual Foot Exam Health Maintenance Clinical Elements Procedures Foot exam perform [2028F, CPT] Diabetes Mellitus: Annual Dilated Eye Exam Health Maintenance Clinical Elements Procedures Dil Retina Exam [2022F, CPT] ©PPRNET 2014
CODES INCLUDED IN QUALITY MEASURES ** Will be provided in instructions and tutorial ** ©PPRNET 2014
CANCER SCREENING MeasureNot ExtractedDocumentation Recommendation Cervical Cancer Screening (Pap Smear in 3 years) Health Maintenance Title Lines Lab table Procedures or Dx -Screen for malig neopl of cervix [V76,2, I9] Breast Cancer Screening (Mammogram in 2 years) Health Maintenance Title Lines Dx Procedures -Screening Mammogram Colorectal Cancer Screening (Annual FOB or Sigmoidoscopy in 5 years or Colonoscopy in 10 years) Health Maintenance Title Lines FOB: Lab table -FIT Sigmoidoscopy or Colonoscopy: Procedures or Dx -Screening Colonoscopy -Colon Screening [V76.51, I9] -Sigmoidoscopy ©PPRNET 2014
SCREENING AAA, CHLAMYDIA, OSTEOPOROSIS, DEPRESSION MeasureNot ExtractedDocumentation Recommendation Abdominal aortic aneurysm screening (for men, once since 65 th birthday) Health Maintenance Dx Procedures -US Exam, Abdom Annual Chlamydia Screening for Women Health Maintenance Lab table Procedures -Chlamydia Culture Osteoporosis screening (for women, Bone Densitometry since 65 th birthday) Health Maintenance Title Lines Dx Procedures -DXA Bone Density Study Depression screening (for adults in 2 years) Health Maintenance Title Lines Dx Procedures or Risks table -Health Risk Asses [99420, CPT] -Ann Depress Screen, 15 min [G0444, HCPCS] ©PPRNET 2014
TOBACCO, ALCOHOL SCREENING & COUNSELING MeasureNot ExtractedDocumentation Recommendation Tobacco Use: Screening plus cessation intervention if identified as user in 2 years Health Maintenance Clinical Elements Tobacco screening: Vital signs Cessation Counseling: Dx or Procedures -Tob Use Cess 3-10min [99406, CPT] -Tob Use Cess >10min [99407, CPT] Alcohol misuse screening in 2 years Health Maintenance Vital Signs Title Lines Dx or Procedures or Risks -Alcohol consumption screening [V79.1, I9] -Alcohol questionnaire completed (finding) [413475007, SNOMED] -Drinks Alcohol [219006, SNOMED] -Problem drinker (finding) [228281002, SNOMED] Annual Alcohol counseling/ Brief Intervention for pts with alcohol diagnosis or at-risk drinking Health Maintenance 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] ©PPRNET 2014
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 ©PPRNET 2014
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