transitioning from pp extract to a vendor neutral data extraction approach ruth jenkins, phd august...
TRANSCRIPT
TRANSITIONING FROM PP EXTRACT TO A VENDOR NEUTRAL DATA EXTRACTION APPROACH
R U T H J E N K I N S , P H D
A U G U S T 2 2 , 2 0 1 4
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AGENDA
Why a new extract is needed
Explain new extract process
Data Extracted and Not Extracted
Data Documentation recommendations
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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
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NEW DATA EXTRACT AND UPLOAD PROCESS
Initial Setup
oDownload 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) © P P R N E T
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INITIALLY - EXPORT FULL PATIENT DEMOGRAPHICS
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EXPORT MEDICAL SUMMARY
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EXPORT MEDICAL SUMMARY
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DATA FILE UPLOAD UTILITY
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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
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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
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DATA NOT EXTRACTED Health Maintenance (except Immunizations)
Clinical Elements (except Adv Directives &
Funct Status)
“Title” lines
User Defined Vital Signs
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QUALITY MEASURES DOCUMENTATION CHANGES
Diabetes Foot and Dilated Eye Exams
Cancer Screening
AAA, Chlamydia, Osteoporosis, Depression screen
Tobacco cessation intervention
Alcohol screen & counseling
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CODE DOCUMENTATION
Diagnosis codes (ICD-9-CM, ICD-10-CM, SNOMED-CT)
Entered in Practice Partner in:o Major Problemso Other Problemso Diagnoseso Risks
Procedure codes (CPT, CPT II, HCPCS-G codes)o Procedures
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DIABETES FOOT AND DILATED EYE EXAMS
Measure Not extracted Documentation Recommendation
Diabetes Mellitus: Annual Foot Exam
Health MaintenanceClinical Elements
• Procedures Foot exam perform [2028F, CPT]
Diabetes Mellitus: Annual Dilated Eye Exam
Health MaintenanceClinical Elements
• Procedures Dil Retina Exam [2022F, CPT]
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CODES INCLUDED IN QUALITY MEASURES
** Will be provided in instructions and tutorial **
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CANCER SCREENINGMeasure Not Extracted Documentation Recommendation
Cervical Cancer Screening (Pap Smear in 3 years)
Health MaintenanceTitle Lines
• Lab table• Procedures or •Dx
-Screen for malig neopl of cervix [V76,2, I9]
Breast Cancer Screening(Mammogram in 2 years)
Health MaintenanceTitle Lines
• Dx• Procedures
-Screening Mammogram
Colorectal Cancer Screening(Annual FOB orSigmoidoscopy in 5 years orColonoscopy in 10 years)
Health MaintenanceTitle Lines
FOB: Lab table -FIT
Sigmoidoscopy or Colonoscopy: • Procedures or •Dx
-Screening Colonoscopy-Colon Screening [V76.51, I9] -Sigmoidoscopy
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SCREENINGAAA, 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 (for women, Bone Densitometry since 65th birthday)
Health MaintenanceTitle Lines
• Dx • Procedures
-DXA Bone Density Study
Depression screening (for adults in 2 years)
Health MaintenanceTitle Lines
• Dx• Procedures or • Risks table
-Health Risk Asses [99420, CPT]-Ann Depress Screen, 15 min
[G0444, HCPCS] © P P R N E T
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TOBACCO, ALCOHOL SCREENING & COUNSELING
Measure Not Extracted Documentation Recommendation
Tobacco Use: Screening plus cessation intervention if identified as user in 2 years
Health MaintenanceClinical 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 MaintenanceVital SignsTitle 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]
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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
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