26 January 2012 Data Quality Management Control Program Service-Level Breakout Session UNCLASSIFIED.

26 January 2012 Data Quality Management Control Program Service-Level Breakout Session UNCLASSIFIED

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Slide 2 of 82 Overview Regulatory Guidance Program Management Organizational Factors System Inputs, Processes, and Outputs –CHCS –ADM –MEPRS/EAS –TPOCS –MEWACS Patient Records Accountability

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Overview Coding Audits –Sampling Size and Techniques –Inpatient Records –Outpatient Records Workload Comparison Regulatory Guidance System Security System Design, Development, Operations, and Education and Training Slide 3 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Regulatory Guidance DODI 6040.40 Military Health System Data Quality Management Control Procedures Department of Defense INSTRUCTION Slide 4 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Regulatory Guidance DODD 6040.41 Medical Records Retention and Coding at Military Treatment Facilities Department of Defense DIRECTIVE Slide 5 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Regulatory Guidance DODD 6040.42 Medical Encounter and Coding at Military Treatment Facilities Department of Defense DIRECTIVE Slide 6 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Regulatory Guidance DODD 6040.43 Custody and Control of Outpatient Medical Records Department of Defense DIRECTIVE Slide 7 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Data Quality Manager Data Quality Assurance Team Intermediate Command DQ Manager Service Data Quality Manager DQMC Review List Commanders Monthly Data Quality Statement (internet based) Program Management Slide 8 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Composite Health Care System (CHCS) Armed Forces Health Longitudinal Technology Application (AHLTA) Ambulatory Data Module (ADM) Medical Expense and Performance Reporting System (MEPRS) / Expense Assignment System (EAS) MEPRS Early Warning and Control System (MEWACS) Defense Medical Human Resources System –Internet (DMHRS-i) Third Party Outpatient Collection System (TPOCS) System Inputs, Processes, and Outputs Slide 9 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Written Procedures Current Versions Upgrades & Updates Rejected Records End of Day Processing –Percentage of Clinics –Percentage of Appointments Timely Coding Completion Data Input MEPRS/EAS, ADM, CHCS, TPOCS Slide 10 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 1. What percentage of appointments was closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.a) Commander’s Data Quality Statement Slide 11 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 2. In accordance with legal and medical coding practices, have all of the following occurred: –a) What percentage of Outpatient Encounters, other than APVs, have been coded within 3 business days of the encounter? (B.6.a) –b) What percentage of APVs have been coded within 15 calendar days of the encounter? (B.6.b) –c) What percentage of Inpatient records have been coded within 30 calendar days after discharge? (B.6.c) Commander’s Data Quality Statement Slide 12 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil EAS –Financial Reconciliation –Inpatient and Outpatient Workload Reconciliations –MEWACS Review –Timely Data Transmittal –Workload Comparison Data Output MEPRS/EAS, ADM, CHCS, TPOCS Slide 13 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.a,c,e,f) –a) Was the monthly MEPRS/EAS financial reconciliation completed, validated and approved by the MTF Resource Manager (i.e. Navy/Army Comptroller or Air Force Budget Officer/Analysts) prior to MEPRS monthly transmission? Commander’s Data Quality Statement Slide 14 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.) –b) Were the data load status, outlier/variance, WWR-EAS IV, and allocation tabs in the MEWACS document reviewed and explanations provided in the comments section for flagged data anomalies? Commander’s Data Quality Statement Slide 15 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 3. Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities Manual (MEPRS Manual) DoD6010-13-M, dated April 7, 2008, paragraph C3.3.4, requires report reconciliation (C.1.) –c) For DMHRS-i, what is the percentage of submitted timecards by the suspense date? –d) For DMHRS-I, what is the percentage of approved timecards by the suspense date? Commander’s Data Quality Statement Slide 16 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil CHCS –Duplicate Records –Timely Data Transmittal Standard Inpatient Data Record (SIDR) Worldwide Workload Report –Inpatient Records Accountability Documentation Coding SIDRs completed (in a “D” status) –Workload Comparison Data Output MEPRS/EAS, ADM, CHCS, TPOCS Slide 17 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.a,b,c,d). –a) MEPRS/EAS (45 calendar days) Commander’s Data Quality Statement Slide 18 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.). –b) SIDR/CHCS (5 th and 20 th calendar day of the following month) Commander’s Data Quality Statement Slide 19 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.). –c) WWR/CHCS (10 th calendar day following month) Commander’s Data Quality Statement Slide 20 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3). – d) SADR/ADM (daily) Number of successful daily transmissions / Number of days in the month. Commander’s Data Quality Statement Slide 21 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Data Output A minimum of 30 records/encounters should be pulled randomly from the entire population of MTF inpatient medical records for the audit data month. A random audit of 30 records per MTF will provide a statistical confidence level of 90%, with a confidence interval/sampling error range of plus or minus 15%. The PASBA is considering the development of pull-list for auditing purposes. –* Beginning in FY12 PASBA will start providing an audit pull list for inpatient coding audits. Slide 22 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Coding –DRG Codes –Related Data Elements (C.5) All Diagnoses Any Procedures Sex Age Discharge/Disposition Percentage of SIDRs Completed (D-Status) Data Output Inpatient Coding Slide 23 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,) – a) Percentage of inpatient medical records whose assigned DRG Codes were correct? Commander’s Data Quality Statement Slide 24 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h) – b) Percentage of Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct? Commander’s Data Quality Statement Slide 25 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,) –c) Percentage of Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? Commander’s Data Quality Statement Slide 26 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,) –d) Percentage of Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct? Commander’s Data Quality Statement Slide 27 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j) –e) What percentage of completed and current (signed within the past 12 months) DD Form 2569s are available for audit? –f) What percentage of available, current and complete DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS? Commander’s Data Quality Statement Slide 28 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil ADM –Timely Data Transmittal Standard Ambulatory Data Record (SADR) –Error Logs –Workload Comparison Data Output MEPRS/EAS, ADM, CHCS, TPOCS Slide 29 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Sample Size Accountability –Percentage Located or Properly Checked Out –Checked-out Over 30-Days? DD Form 2569 (Third Party Insurance Information) Data Output Outpatient Coding Slide 30 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.6. Outpatient Records. (c.6.a,b,c,d) – a) Is adequate documentation of the encounter selected to be audited available? Documentation includes documentation in medical record, loose (hard copy) documentation or an electronic record of the encounter in AHLTA? (Denominator equals sample size.) Commander’s Data Quality Statement Slide 31 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 6. Outpatient Records. –b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) –c) What is the percentage of ICD-9 codes deemed correct? –d) What is the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) Commander’s Data Quality Statement Slide 32 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Question 7 Ambulatory Procedure Visits (C.7.a,b,c) Questions 7.a,b,c, are the same as Questions 6.a,b,c Commander’s Data Quality Statement Slide 33 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Commander’s Data Quality Statement Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f) Inpatient dispositions: – a) What percentage of completed and current (signed Within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review? – b) What percentage of available, current and completed DD Form 2569s is verified to be correct in the Patient Insurance Information (PII) module in CHCS? Slide 34 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Commander’s Data Quality Statement Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f) Outpatient encounters: – c) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review? – d) What percentage of available, current and complete DD form 2569s is verified to be correct in the Patient Insurance Information (PII) Module in CHCS? Slide 35 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Commander’s Data Quality Statement Question 8. DD-2569 forms. (C.8.a,b,c,d,e,f) APVs: – e) What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for review? – f) What percentage of available, current and complete DD form 2569s is verified to be correct in the Patient Insurance Information (PII) Module in CHCS? Slide 36 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 9. Comparison of reported workload data (C.9). – a) # SADR Encounters (count only visits / # WWR visits – b) # SIDR Dispositions / # WWR Dispositions – c) # EAS Visits / # WWR Visits – d) # EAS Dispositions / # WWR Dispositions – e) # IPSR SADR encounters (FCC=A***)/# Sum WWR (Bed Days + Dispositions + Live Births + Bassinet Days) Note: Question e, FY11 Goal is 80%. Commander’s Data Quality Statement Slide 37 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.9a SADR Visits / WWR Visits –Should have an equal number of visits. –Encounters – Omit Appt. Status of “No-Shows,” “Canceled,” and Disposition Code “Left Without Being Seen”. –Encounters – Include Appt. Status “TelCon” – Only SADR Records Marked with an Appt. Status of “C” (complete) Are To Be Included. –Only “count” encounters are included. Data Output Workload Comparison Slide 38 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.9b SIDR Dispositions / WWR Dispositions –Must Match –Only SIDRs With a Disposition of Status of “D” Are To Be Included –SIDRs – Exclude Carded for Record Only (CRO) and Absent Sick Records Data Output Workload Comparison Slide 39 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 9c EAS Visits / WWR Visits –Must Match –Include MEPRS Functional Cost Code B** (Outpatient) and FBN (Hearing Conservation) –Include APVs Data Output Workload Comparison Slide 40 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 9d EAS Dispositions / WWR Dispositions –Must Match –Only SIDRs with a Disposition Status of “D” are to be included Data Output Workload Comparison Slide 41 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 9e IPSR encounters (FCC=A***)/# Sum WWR (Bed Days + Dispositions + Live Births + Bassinet Days) –Must Match –Only SIDRs with a Disposition Status of “D” are to be included. –Insure WWR calculation includes live births (section 01) and Bassinet Days (section 00). Note: FY11 Goal is 80% Data Output Workload Comparison Slide 42 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.10. Use CHCS during the data month to identify potential duplicate patients and appointments. (C.2a) –For CHCS/AHLTA hosts only, what was the number of potential duplicate patient records in the data month for all MTFs under the host? List the DMIS IDs of the MTFs included in the comments section. Commander’s Data Quality Statement Slide 43 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.11. Provide the number of incomplete and non-transmitted SIDRs for the month. (F.1) Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA. Commander’s Data Quality Statement Slide 44 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.12.a. Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record. Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA. Commander’s Data Quality Statement Slide 45 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q.12.b. Provide the number of loose forms/documents/papers that are currently waiting to be filed, either electronically or in the hard-copy medical record, 30 days after an active duty soldier has retired or separated from the service. Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA. Commander’s Data Quality Statement Slide 46 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Q. 13. I am aware of data quality issues identified by the completed Data Quality Statement and the Data Quality Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. Commander’s Data Quality Statement Slide 47 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Are there internal controls and procedures in place to approve and manage assignment of security key privileges? Have all security key holders been identified and their need for security key privileges validated by the CIO or designee? Security Slide 48 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil System Administrator Appointed In Writing for Each System Training and Education Procedures and Documentation System Change Request Process System Incident Report Routine Maintenance Points of Contact for Equipment Failure Issues Contingency Plans Trouble tickets 49 System Design, Operations, and Education/Training Slide 49 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil The collection of health statistics began during the Revolutionary War. The first Surgeon General’s Report was printed in 1822 and was published annually until 1942. In 1942 the Medical Statistics Agency was created to maintain statistics relating to all theaters of war, and continued for the next 30 years. In 1970 the agency was renamed the Patient Administration and Biostatistics Section, under Plans, Supply and Operations Directorate, OTSG. In 1973 the AMEDD was reorganized to create the U.S. Army Health Services Data System Agency, and the PA&B Section was placed under this agency. In 1974 there was another reorganization within the Health Services Command (HSC), which later became the U.S. Army Medical Command (MEDCOM) at Ft. Sam Houston, Texas. In 1977, another reorganization took place and the Patient Administration Systems and Biostatics Activity (PAS&BA) was created. In 1989 the PAS&BA acronym was changed to PASBA. Since 1989 the PASBA has been re-aligned under several different activities and in 2009 was aligned under the Program Analysis and Evaluation Directorate, Office of the Surgeon General. PASBA Slide 50 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Mission To deliver actionable analytics, applications and coding services in order to optimize clinical outcomes, data quality and business operations. We provide customer-focused products and expertise to strengthen decision-making at all levels of the MHS. Vision The MHS leader in the transformation of clinical and business operations through optimization of decision making tools and processes Mission and Vision Slide 51 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil PASBA Homepage Slide 52 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Coding Section Slide 53 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Coding Section Slide 54 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Online Applications Slide 55 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil CARA Slide 56 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil CARA Slide 57 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Clinical Operations Metrics Slide 58 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil IRT3 Slide 59 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil EOD Slide 63 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil PASBA METRIC POCs: E-Mail: dataanalysis-help@pasba2.amedd.army.mil METHODOLOGY The End of Day (EOD) Processing Compliance Metric is intended to assist MTFs identify systematic problems and need for training of EOD standards. The data source for this metric is the PASBA Daily Outpatient Workload Detail Report (DOWDR) file, which is the appointment file transmitted daily by the CHCS Hosts. The emphasis of this metric is on EOD completed TIMELY (by end of business day) and CORRECTLY. The last updated record is assumed to reflect the most current information, therefore the correct one. This is important to mention as MTFs do not have the capability to check both conditions in their EOD compliance report. If an appointment was closed on time, but the information gathered from most current records indicates it was done incorrectly, it will be reported as noncompliant. The underlying assumption of this metric is that the DOWDR is transmitted daily and that the appointments closed out at EOD are extracted in the DOWDR no later than the day following the appointment. An exception is given to the Emergency Room which should have until 7 AM the next day to complete the EOD. All appointments with statuses other than "A" (Admin) or "O" (Occ-Svc) in "B***" and "FBN*" clinics are monitored for compliance with the "Every Appointment - Every Day" requirement. In addition "B***" and "FBN*" clinics are monitored for compliance with the "Every Clinic - Every Day" requirement. Records with appointment statuses of "T" (T-con) that are not countable are excluded. During the PASBA DOWDR processing, the following key elements are captured, and enable us to monitor compliance: a) the date when the record was first extracted by the CHCS host. b) the date when the record was first extracted with a populated provider ID and an appointment status other than "P" (Pending) or "B" (Booked - non MTF). c) appointment statuses on the initial record and the most current record. d) date when the appointment was made and the date of the appointment. A record is flagged as NONCOMPLIANT if any of the following is true: a) it was first transmitted more than one day after the appointment date, or more than two days later for ER. Exception is given to "T-cons" for which a record is considered late only if it was transmitted for the first time more than one day after the appointment date or the date it was entered in the system, whichever is later. (an extra day is given to ER). b) it was extracted with a filled provider ID and an appointment status other than "Pending" or "Booked" more than one day after the appointment, or more than two days later for after hours services. EOD Methodology Slide 65 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil EOD Methodology (Cont) Exception is given to "T-cons" for which a record is considered late only if it was transmitted with an other than pending stauts more than one day after the appointment date or date it was entered in the system, whichever is later. (an extra day is given to ER). c) the most current record has a missing provider ID or an appointment status of "Pending" or "Booked". d) the appointment record was received with an appointment status of "Kept", "Walk-in", "Sick-call " before the appointment date. e) the date when the appointment was made indicates it was booked after the appointment date, except ER, "T-cons" and records with inpatient status. f) the most recent appointment status contradicts the initial appointment status. Exception is given to "T-cons" and to "Kept", "Sick-call" and "Walk-in" appointment statuses which may be interchanged in AHLTA or CHCS. The compliance with "Every Appointment - Every Day" is reported at the RMC, Parent, Child and Clinic level. The compliance with "Every Clinic - Every Day" is reported at the RMC and Parent MTF level. If a clinic didn't report any appointments for a particular day, it was considered closed for that particular day. OPEN CLINIC DAYS is the sum across all clinics of the number of days for which an appointment was found in the DOWDR. COMPLIANT CLINIC DAYS is the sum across all clinics of all dates with 100% EOD compliance. The reasons for noncompliance are summarized at the RMC, Parent, Child and Clinic level. The tables list the inverse order in which each criteria is checked. Appointments that fail multiple criteria are reported under the last criteria that would fail them. For example, if an appointment was closed late with an appointment status of "Kept", but the last record received indicates a status of "Cancelled", it will be reported as "Closed Late", not "Incorrect Initial Status", as that would be the last criteria that was checked. Aditional links include summaries of noncompliance reasons by last appointment status and of records which indicate that the appointment statuses were changed; each at the respective levels mentioned above. In addition, for each day, a report by clinic and appointment date is provided with counts of compliant and noncompliant appointments. Scale used: Green : >= 95% Amber: 90% - 94.99% Red : < 90% Because of the large file size, individual noncompliant records are provided in a separate workbook by Parent MTF. Users interested in those records should return to the PASBA website and open the accompanying workbook. Limitations: The methodology relies on the timely and correct transmission of the DOWDR file. Slide 66 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil New vs Established Patient Slide 68 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil New vs Established Patient Methodology Established Patient E&M Code (99211 -99215) Utilization Metric PASBA METRIC POCs: Francie McQueeney: (210) 295-8922, DSN: 421 E-Mail: dataanalysis-help@pasba2.amedd.army.mil METHODOLOGY This metric tracks the utilization of E&M codes 99211 -99215 for count visits of privileged providers in ‘B***’ or ‘FBN’ clinics. It is intended to assist MTFs in training and identifying potential workload loss due to the misuse of these codes. In particular it monitors 'new patient' vs. 'established patient' code usage. Definitions: NEW CODED AS ESTABLISHED is the number of codes in records of patients who were found to be new patients using the algorithm described below. ESTABLISHED CODED AS ESTABLISHED is the number of codes in records of patients who were found to be established patients using the algorithm described below. TOTAL RECORDS is the number of records with E&M of 99211-99215. Using the Standard Ambulatory Data Record (SADR) and the Daily Outpatient Workload Detail Report (DOWDR) the following steps were taken: a) Step 1. Extracted records with “Kept”, “Walk-in”, and “Sick-call” (except LWBS) appointment statuses in “B***”, “A***” or “FBN*” clinics of privileged providers. Excluded encounters with E&M code indicating the encounter was a “Non-Face-To-Face” service (E&M 99441-99444), IPSR (rounds) with an E&M of 99499 and no CPT. Additionaly 'BIA* ' and ‘BFF*’ clinics were excluded. MEPRS authorized substance abuse (BFF*) clinics are included. b) Step 2. Obtained the count visit flag from the DOWDR and kept only the countable visit records and Inpatient Professional Services Rounds (IPSR). IPSRS were considered ‘countable visits’. c) Step 3. Created an established patient flag by looking at all encounters and IPSR records within the previous 3 years (3 x 365 days) of each encounter. In creating this flag, all “A***” clinics were converted to “B***”. The encounter was flagged as “Established” if, for the same patient, a previous encounter was found in the same DMISID and MEPRS, and by a privileged provider (skill type 1 & 2) regardless of specialty OR in any DMISIDs belonging to the same PARENT by the same PROVIDER ID. Otherwise, the encounter was flagged as “New.” This is the interpretation of the coding guidelines for classifying new and established patients. “A new patient is one who has not received any professional services from the privileged provider or another privileged provider of the Slide 71 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil New vs Established Patient Methodology same specialty who belongs to the same group practice in the previous three years”. (MHS Professional Services and Specialty Coding Guidelines, June 2010). A patient will also be considered established also if he or she was seen by the same provider in the last 3 years. We can only capture this looking at records by PROVIDER ID, which is unique only within a PARENT. d) Step 4. Kept records with E&M 99211 – 99215. If a patient was found to be "New", the record was flagged as "New Coded as Established". e) Step 5. Calculated RVU LOSS by adding the Enhanced RVU difference between the value of the Established Patient E&M code and the value of the New Patient E&M code. The assumption was that the correct E&M code would be of the same level as the E&M code on the record (i.e. 99211 supposed to be 99201). The dollar amounts loss was calculated by multiplying the number of RVUs by current amount amount used for PPS. f) Step 6. Summarized records in the following monthly and rolling 12 months tables: RMC Parent MTF Child MTF Clinic Provider ID* (for each MTF) Miscoded records* (for each RMC) Note*: monthly tables only. The monthly tables include only the records of the report month, while rolling 12 months tables include records of previous 12 months, including the month of the report. (i.e. Aug 2009 to July 2010 for July 2010 metric.) Scale used: Green : >= 95% Amber: 90% - 94.99% Red : < 90% Slide 72 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil ORT3 Slide 74 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil ORT3 Methodology Outpatient Record Transmission (ORT) Summary Report PASBA METRIC POCs: Vicki Vestal: (210) 295-8931, DSN: 421 E-Mail: dataanalysis-help@pasba2.amedd.army.mil The ORT Summary is a monthly report of the outpatient records transmission. Methodology is the same as ORT3: only outpatient clinics ('B***' clinics, with the exception of 'B**0') and Hearing Conservation Clinics (FBN*) are included in this metric. The data sources used to capture total records are the PASBA Standard Ambulatory Data Record (SADR) and the Daily Outpatient Workload Detail Report (DOWDR). Appointments with statuses of 'kept', 'sick-call', 'walk-in' and 'pending' in the DOWDR are matched with SADR records regardless of appointment status by DMISID and appointment identification number (APPTIEN). Radiology records outside Interventional Radiology Clinics and telephone consults are excluded from the DOWDR. Each record is verified if it is in compliance with the PBAM transmission timeliness of 30 calendar days. The report contains summaries at RMC, PARENT MTF, CHILD MTF, CLINIC and PROVIDER level for both report month, and rolling 12 months. The rolling 12 months reports include 12 month restrospectively starting with the month of the report. For each MTF a table at the provider level is provided separately. The RVU loss is calculated using the Enhanced Total RVU extracted from M2 SADRs. The average RVU per encounter at the MEPRS level is imputed to the missing SADRs. The amount lost is calculated by multiplying the RVU loss with the amount as used by PPS. Each summary reports the number of completed SADRs, number of PBAM timely records, number of Data Quality Management Program Control Program (DQMCP) timely records, and the total number of DOWDR records that were tracked. For each category a percentage is calculated. PBAM has a 30 days timeliness criteria, while DQMCP uses a 3 business days / 15 calendar days for non APV/APV records. Please consider that PBAM and DQMCP have different completion targets. PBAM = 99%. DQMCP = 95%. The conditional formatting for SADR completion is done using the following scale: 0%-99.59% RED, 99.6% -99.99% AMBER, and 100% GREEN. This was based on the AMEDD completion rate at the time of the development of the report. RED = under AMEDD completion rate, AMBER = above, but not 100% complete. The conditional formatting for PBAM timeliness was done using the 99% PBAM target. RED = not met, GREEN = met. For DQMCP is done using the following scale: 0%-98.99% RED, 99.00% -94.99% AMBER, and 95.00% - 100% GREEN. Limitations: The DOWDR captures the provider and/or clinic for which the appointment was booked, and may not always be the provider who saw the patient. This metric reports encounters under the provider and/or clinic captured in the DOWDR at the last transmission to PASBA. This should not be an issue if EOD is done correctly. The numbers reported under DQMCP timeliness may not match those under the DQMCP program run by the DQ section because of the difference in filtering criteria applied to the SADR records before matching them to the DOWDR and/or new records being transmitted Slide 77 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Data Quality Section, PASBA Director, PASBA Deputy Director, PASBA Chief, Data Quality Section PASBA Chief, Data Analysis Section Chief, Coding Section Chief, Development Section Slide 79 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil QUESTIONS? Slide 80 of 82

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil - Promote, Sustain and Enhance Soldier Health - Train, Develop and Equip a Medical Force that Supports Full Spectrum Operations - Deliver Leading Edge Health Services to Our Warriors and Military Family to Optimize Outcomes For more information go to: https://ke2.army.mil/bsc This has been a dynamic, living document since 2001 America’s Premier Medical Team Saving Lives, Fostering Healthy and Resilient People, and Inspiring Trust Army Medicine…Army Strong! Maximize Value in Health Services Effectively and efficiently provide the right care at the right time to promote a healthy population and ready force. Provide Global Operational Forces Agile and adaptive medical teams ready to execute relevant, responsive Health Services in any operational environment and in combination with any partnered team. Build the Team A compelling place to serve and a preferred partner in leading joint interagency health services. Balance Innovation with Standardization A culture of innovation which provides standardized solutions to support best practices and optimal outcomes. Optimize Communication and Knowledge Management Leverage Communication to impart knowledge and build meaningful, positive relationships. Patient/Customer/ Stakeholder CS 6.0 Inspire Trust in Army Medicine CS 4.0 Responsive Battlefield Medical Force CS 1.0 Improved Healthy and Protected Families, Beneficiaries and Army Civilians CS 3.0 Improved Healthy and Protected Warriors CS 5.0 Improved Patient and Customer Satisfaction IP 10.0 Optimize Medical Readiness IP 13.0 Build Relationships and Enhance Partnerships LG 18.0 Improve Training and Development IP 11.0 Improve Information Systems CS 2.0 Optimized Care and Transition of Wounded, Ill, and Injured Warriors IP 12.0 Implement Best Practices IP 14.0 Improve Internal and External Communicatio n LG 20.0 Improve Knowledge Management LG 17.0 Improve Recruiting and Retention of AMEDD Personnel Internal Process Learning and Growth LG 19.0 Promote and Foster a Culture of Innovation IP 8.0 Improve Quality, Outcome- Focused Care and Services IP 7.0 Maximize Physical and Psychological Health Promotion and Prevention IP 9.0 Improve Access and Continuity of Care IP 16.0 Synchronize Army Medicine to Support Army Stationing & BRAC R 21.0 Optimize Resources and Value R 22.0 Optimize Lifecycle Management of Facilities and IT Infrastructure R 23.0 Maximize Human Capital ENDS MEANS WAYS Resource IP 15.0 Leverage Research, Development and Acquisition Feedback Adjusts Resourcing Decisions

Select SLIDE MASTER to Insert Briefing Title Here 26 January 2012 Tim Bacon/MCHS-IQB/(210) 295-8725 (DSN 421) / joseph.bacon@amedd.army.mil Unclassifiedjoseph.bacon@amedd.army.mil Slide 82 of

26 January 2012 Data Quality Management Control Program Service-Level Breakout Session UNCLASSIFIED.

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26 January 2012 Data Quality Management Control Program Service-Level Breakout Session UNCLASSIFIED.

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