Transcript PowerPoint

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
(1) Patient name
(9) Medications
(2) Sex
(10) Medication allergies
(3) Date of birth
(11) Laboratory test identifiers
(4) Race
(12) Laboratory values/results
(5) Ethnicity
(13) Vital signs: height, weight, BP, BMI
(6) Preferred language
(14) Care plan: goals, instructions, team
(7) Smoking status (VS) (15) Procedures
(8) Problems
(16) Immunizations (HM)
©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
Measure
Not extracted
Documentation 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
Measure
Not Extracted
Cervical Cancer Screening Health Maintenance
Title Lines
(Pap Smear in 3 years)
Documentation Recommendation
• 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
Measure
Not Extracted
Documentation Recommendation
Abdominal aortic
aneurysm screening
(for men, once since
65th birthday)
Health Maintenance
• Dx
• Procedures
-US Exam, Abdom
Annual Chlamydia
Screening for Women
Health Maintenance
• Lab table
• Procedures
-Chlamydia Culture
Osteoporosis screening Health Maintenance
Title Lines
(for women, Bone
Densitometry since 65th
birthday)
Depression screening
(for adults in 2 years)
Health Maintenance
Title Lines
• Dx
• Procedures
-DXA Bone Density Study
• Dx
• Procedures or • Risks table
-Health Risk Asses [99420, CPT]
-Ann Depress Screen, 15 min [G0444,
HCPCS]
©PPRNET 2014
TOBACCO, ALCOHOL SCREENING & COUNSELING
Measure
Not Extracted
Documentation 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