1. Data Quality Section, PASBA September 2009

2.  Regulatory Guidance  Program Management  Organizational Factors  System Inputs, Processes, and Outputs  CHCS  ADM  MEPRS/EAS  TPOCS  MEWACS  Patient Records Accountability  Coding Audits  Sampling Size and Techniques  Inpatient Records  Outpatient Records  Workload Comparison  System Security  System Design, Development, Operations, and Education and Training 2

3. 3 Department of Defense INSTRUCTION

4. 4 DIRECTIVE

5. 5 DIRECTIVE

6. 6 DIRECTIVE

7.  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) 7

8.  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) 8

9.  Written Procedures  Current Versions  Upgrades & Updates  Rejected Records  End of Day Processing  Percentage of Clinics  Percentage of Appointments  Timely Coding Completion 9

10.  Q. 1. What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?” (B.5.) 10

11.  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 days of the encounter? (B.6.(b)) 11

12.  Q. 2. In accordance with legal and medical coding practices, have all of the following occurred:  c) What percentage of Inpatient records have been coded within 30 days after discharge? (B.6.(c)) 12

13.  EAS  Financial Reconciliation  Inpatient and Outpatient Workload Reconciliations  MEWACS Review  Timely Data Transmittal  Workload Comparison 13

14.  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) Was monthly MEPRS/EAS financial reconciliation process completed, validated and approved prior to monthly MEPRS transmission? 14

15.  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 allocations tabs in the MEWACS document reviewed and explanations provided for flagged data anomalies? 15

16.  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 timecards submitted by the suspense date?  d) For DMHRS-I, what is the percentage of approved timecards by the suspense date? 16

17.  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 17

18.  Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3.).  a) MEPRS/EAS (45 calendar days) 18

19.  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 month) 19

20.  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) 20

21.  Q. 4. Compliance with TMA or Service-Level guidance for timely submission of data (C.3).  d) SADR/ADM (daily) 21

22.  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%. 22

23.  Coding  DRG Codes  Related Data Elements (C.5)  All Diagnoses  Any Procedures  Sex  Age  Discharge/Disposition  Percentage of SIDRs Completed (D-Status) 23

24.  Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j) - a) What percentage of inpatient records whose assigned DRG codes were correct? 24

25.  Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j)  - b) Inpatient Professional Services Rounds encounters E & M codes audited and deemed correct? 25

26.  Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j)  - c) Inpatient Professional Services Rounds encounters ICD-9 codes audited and deemed correct? 26

27.  Q. 5. Outcome of monthly inpatient coding audit: (C.5.c.f.g,h,i,j)  - d) Inpatient Professional Services Rounds encounters CPT codes audited and deemed correct? 27

28.  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? 28

29.  ADM  Timely Data Transmittal  Standard Ambulatory Data Record (SADR)  Error Logs  Workload Comparison 29

30.  Sample Size  Accountability  Percentage Located or Properly Checked Out  Checked-out Over 30-Days?  DD Form 2569 (Third Party Insurance Information) 30

31.  Q.6. Outpatient Records. (c.6.a,b,c,d,e,f)  a) Is the 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? 31

32.  E&M Codes  ICD-9 Codes  CPT Codes 32

33.  Q. 6. Outpatient Records.  b) What is the percentage of E & M codes deemed correct? (E & M code must comply with current DoD guidance.) 33

34.  Q. 6. Outpatient Records.  c) What is the percentage of ICD-9 codes deemed correct? 34

35.  Q. 6. Outpatient Records.  d) What was the percentage of CPT codes deemed correct? (CPT code must comply with current DoD guidance.) 35

36.  Q. 6. Outpatient Records.  e) What percentage of completed & current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit? 36

37.  Q. 6. Outpatient Records. - f) What percentage of available, current and completed DD Form 2569s are verified to be correct in the Patient Insurance Information (PII) module in CHCS? 37

38.  Question 7 Ambulatory Procedure Visits (C.7.a,c,d,e,)  Questions 7.a,c,d,e, are the same as Questions 6.a,c,d,e, 38

39.  Q. 8. 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 (Total Bed Days + Total Dispositions) Note: Question e, FY09 Goal is 80%. 39

40.  Q.8a 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 40

41.  Q.8b 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 41

42.  Q. 8cEAS Visits / WWR Visits  Must Match  Include MEPRS Functional Cost Code B** (Outpatient) and FBN (Hearing Conservation)  Include APVs 42

43.  Q. 8dEAS Dispositions / WWR Dispositions  Must Match  Only SIDRs with a Disposition Status of “D” are to be included 43

44. IPSR encounters (FCC=A***)/# Sum WWR (Total Bed Days + Total Dispositions) Note: FY10 Goal is 80% Insure WWR calculation includes live births (section 01) and Bassinet Days (section 00). 44

45.  Q.9. - System Design, Development, Operations and Education/Training (E.4.c). - # AHLTA SADR encounters/# of Total SADR encounters Note: FY09 compliance goal is 80%.. (* It is understood that not all clinical modules are deployed in the current version of AHLTA.) 45

46.  Q.10.- CHCS software used during the data month to identify duplicate patient registration records. (C.2a) - What was the number of potential duplicate records in the reporting month? 46

47.  Q.11.- Provide the number of incomplete and non-transmitted SIDRs for the month. Note: This question on the DQ Statement is only a requirement for Army sites and will not be reported to TMA. 47

48.  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. 48

49.  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. 49

50.  Q. 13. – I am aware of data quality issues identified by the completed Commander’s Statement and Review List and when needed, have incorporated monitoring mechanisms and have taken corrective actions to improve the data from my facility. 50

51.  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? 51

52.  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 52

53. 53 Data Quality Section, PASBA Chief DQ Section PASBA Tim Bacon, 210-295-8725 Joseph.Bacon@amedd.army.mil North Atlantic Regional Medical Command Ms. Tama Oringderff, 210-295-9289 Tama.Oringderff @us.army.mil Southeast Regional Medical Command, European Regional Medical Command, Western Regional Medical Command Mr. Joe Alley, 210-221-0467 Joe.Alley@us.army.mil Great Plains Regional Medical Command, Pacific Regional Medical Command Mr. Dwayne Mentis, 210-295-8943 Dwayne.Mentis@amedd.army.mil

54. 54 BACKUP SLIDES

55. 55 METRIC MANIA Department of Army Strategic Readiness System (SRS) Review & Analysis TMA metrics BALANCED SCORECARD OTSG Command Management System (CMS) Why should you care? What can you do to help?

56. 56 MEDCOM STRATEGY MAP GOALS: Improve overall health & wellness of enrolled beneficiaries. Improve patient access and satisfaction. Improve effectiveness of peacetime direct care system.

57. 57 KEYS TO SUCCESS Improve Data Quality Efforts Cultural Change Improve Access to Care Tie Financing to Performance PBAM – Performance Based Adjustment Model

58. Army Health System Medical Green-Suit Military Total MEDCOM DHP Human Resources WT Population ~ 12,000 Population Requiring Healthcare (Demand) MEDCOM Capacity (Human Capital) MEDCOM direct care capacity cannot meet the Healthcare demand of the around 3 million eligible beneficiaries (MEDCOM cares for 1.414 million enrolled & 300K users) Reasons include: -Population dispersion (especially among Retirees & their Families) -Efficiency demands (numerous small population centers) -Military structure supports Readiness – not peacetime healthcare AD ADFM 65+ Ret/RetFM (<65) Army Health System

59. Overall Satisfaction With Health Plans “ And the Winner is…” Managed Care Magazine, September 2008 pp 41-46 Data -Wilson Health Information LLC Annual Survey Jan-Feb 2008

60. 60 DATA QUALITY Increased emphasis on MTF submissions Improved reporting timeliness Improved accuracy SIDRs SADRs MEPRS

61. 61 Combines Multiple Data Systems Current Enrollment (ECM)- Assumes Historical Space-A work Potential Enrollment (MTF Business Plans) EBSM- Forecast population changes Ops- UNCLASSIFIED Deployments and Redeployments by location by month ARTS- Deployed personnel from MTF Provides Adjusted Enrollment for those Active duty deployed, and redeploying Adjusts MTF enrollment capacity based on deployed PCMs (1000/Per deployed PCM) Future Development to include: Adjustments for Backfilling PCMs from another MTF Forecast ARTS deployments- (Pending Deployments) Deployment to CMS Enrollment Capacity Forecast Model (ECFM)

62. 62 USE OF THE DATA TMA = Gospel “Garbage In, Garbage Out” OTSG = Disaster MTF = Nuclear Fire Storm

63. 63 The data matter Cultural shift Use the CMS Ask: What are we asking our staff to do? Priorities

64. 64 Standardize Core R&A for Medical Treatment Facilities No standard R&A approach in MEDCOM MTF Cdrs create their own “TOC” MTF’s spend a lot of time designing/developing the “TOC” Cdrs and staffs learn together at the expense of Organizational Performance R&A provides the Azimuth….critical to direction and success

65. 65 Core Measures for MTFs Enrollment Productivity Access Patient Satisfaction Coding Accuracy Prevention/HEDIS

66. 66 End-of-Day (EOD) Processing MTF staff will determine the status of each appointment as accurately as possible. EOD processing will be correctly completed at the end of each business day. Pending: The MTF appointment information system assigns this initial status for an appointment that has been booked for a patient for a future date or time. All pending appointments must be changed to one of the final encounter statuses in order to complete End-of-Day processing. Kept: The patient has a booked appointment, arrives at the MTF/clinic, and is treated by provider. Walk-in: The patient does not have a scheduled appointment, arrives at the clinic, and is assigned a time to see the provider the same day. This status will not be changed at End-of-Day processing. Sick Call: An Active Duty member arrives at a clinic for a pre-arranged block of time for care. This status will not be changed at End-of-Day processing.

67. 67 End-of-Day (EOD) Processing Patient Cancellation: A patient with a scheduled appointment notifies The MTF in accordance with local procedures that they will not keep the appointment. No-Show: A scheduled appointment that the patient does not keep. Determinations of no-shows will be in accordance with local procedures. Facility Cancellation: The MTF cancels an available/open appointment or cancels a patient’s scheduled appointment. Left Without Being Seen: The patient has a booked appointment, arrives at the clinic, and is checked in, but decides to leave without seeing the provider. Admin: The admin status is used on appointments or telephone consults that do not represent actual contact with a patient. The status must be Assigned in End-of-Day processing. A transaction with this status will not be passed to ADM or AHLTA and will not be coded or included in SADR.

68. 68 End-of-Day (EOD) Processing Occasions of Service: This status on a patient appointment indicates no medical decision was made by a privileged provider who is directly Responsible for the management of care for the patient. This status will no longer be used on telephone consults. This transaction will pass from CHCS to the Ambulatory Data Module (ADM), is always non-count, and may be used to assess level of effort. ADM and AHLTA do not recognize this status as an appointment for completion. Therefore this status will NOT prompt the provider to code the encounter and will avoid generating a Standard Ambulatory Data Record (SADR). Telephone Consultation: When a provider answers a telephone consult in AHLTA, the provider will be asked by the system, “Does this meet the out- patient visit criteria?” If the provider is a technician, nurse, or other non- count provider or the clinic is a non-count clinic, the workload type response will be defaulted to No (non-count) and cannot be changed in AHLTA. If the provider is a privileged provider and the clinic is a count clinic, the default will be Yes (count). The provider should change the response to No if it does not meet the visit criteria.

69. 69 Walk-ins 1. A walk-in is a patient who seeks care without a scheduled appointment, Arrives at the clinic, and is assigned a time to see the provider the same day. 2.There is no ATC Standard for walk-in appointments. 3.Walk-ins are not designed for use as a schedulable event. 4. High utilization of walk-ins can create data quality challenges for the MTF and make the process of measuring/explaining access, and assessing demand more complex. 5.High rates of walk-ins may also make business plan targeting difficult since they are unplanned events. 6.Excessive walk-in activity can reduce the appointments available to patients requesting care on the telephone. 7.However, if clinics utilize the walk-in function to get patients seen in a manner that is more timely/convenient for the patients, this is recognized as good customer service from the patient’s perspective.

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71. 71 Medical Expense and Performance Reporting System (MEPRS) 1.The DoD Manual 6010.13-M, MEPRS for Fixed Medical and Dental Treatment Facilities. Provides a definition of MEPRS codes (also know as functional cost codes, FCC). 2.Define your CHCS File-and-Build Hospital Locations so that each clinic has only one associated MEPRS code. 3.Ensure that each MEPRS code has the four characteristics of: a. A defined physical space (e.g., square footage) b. Associated expenses (e.g., supplies) c. Associated personnel time (e.g., work hours) and d. Associated workload (e.g., visits, procedures, etc.) 4.Manual provides definition and criteria of a visit (count vs. non-count) 5.Defense Medical Human Resources System – internet (DMHRS-i) is still a Significant issue for the Army. Missing, incomplete, incorrect time-cards.

72. 72 https://pasba3.amedd.army.mil/login/login.fcc

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78. 78 Questions ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?