Data Quality Management Control Program

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Data Quality Management Control Program

• Joseph (Tim) Bacon
• Chief, Data Quality Section, PASBA

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Overview

• 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

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Regulatory GuidanceDODI 6040.40Military Health
System Data Quality Management Control Procedures
Department of Defense
INSTRUCTION
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Regulatory GuidanceDODD 6040.41Medical Records
Retention and Coding at Military Treatment
Facilities
Department of Defense
DIRECTIVE
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Regulatory GuidanceDODD 6040.42Medical
Encounter and Coding at Military Treatment
Facilities
Department of Defense
DIRECTIVE
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Regulatory GuidanceDODD 6040.43Custody and
Control of Outpatient Medical Records
Department of Defense
DIRECTIVE
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Program Management

• 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)

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System Inputs, Processes, and Outputs

• 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)
• Third Party Outpatient Collection System (TPOCS)
• MEPRS Early Warning and Control System (MEWACS)

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Data InputMEPRS/EAS, ADM, CHCS, TPOCS

• Written Procedures
• Current Versions
• Upgrades Updates
• Rejected Records
• End of Day Processing
• Percentage of Clinics
• Percentage of Appointments
• Timely Coding Completion

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CommandersData Quality Statement

• Q. 1. In the reporting month
• a) What percentage of clinics have complied with
  End of Day processing requirements, Every
  clinic Every day? (B.5.(a.))
• b) What percentage of appointments were closed in
  meeting your End of Day processing
  requirements, Every appointment Every day?
  (B.5.(b))

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CommandersData Quality Statement

• 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))

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CommandersData Quality Statement

• 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))

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS

• EAS
• Financial Reconciliation
• Inpatient and Outpatient Workload Reconciliations
• MEWACS Review
• Timely Data Transmittal
• Workload Comparison

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CommandersData Quality Statement

• Q. 3. In accordance with TMA policy,
  Implementation of EAS/MEPRS Data Validation and
  Reconciliation, dated 21 Dec 99 and MEPRS Early
  Warning and Control System, dated 28 May 02,
  along with the most current Service-Level
  Guidance (C.1.)
• a) Was monthly MEPRS/EAS financial reconciliation
  process completed, validated and approved prior
  to monthly MEPRS transmission?

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CommandersData Quality Statement

• Q. 3. In accordance with TMA policy,
  Implementation of EAS/MEPRS Data Validation and
  Reconciliation, dated 21 Dec 99 and MEPRS Early
  Warning and Control System, dated 28 May 02,
  along with the most current Service-Level
  Guidance (C.1.)
• b) Were the data load status, outlier/variance,
  WWR-EAS IV, and allocations tabs in the current
  MEWACS document reviewed and explanations
  provided for flagged data anomalies?

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CommandersData Quality Statement

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

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS

• 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

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CommandersData Quality Statement

• Q. 4. Compliance with TMA or Service-Level
  guidance for timely submission of data (C.3.).
• - b) SIDR/CHCS (5th and 20th calendar day of the
  month)

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CommandersData Quality Statement

• Q. 4. Compliance with TMA or Service-Level
  guidance for timely submission of data (C.3.).
• - c) WWR/CHCS (10th calendar day following month)

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CommandersData Quality Statement

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

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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.

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Data OutputInpatient Coding

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

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CommandersData Quality Statement

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

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CommandersData Quality Statement

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

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CommandersData Quality Statement

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

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CommandersData Quality Statement

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

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Data OutputMEPRS/EAS, ADM, CHCS, TPOCS

• ADM
• Timely Data Transmittal
• Standard Ambulatory Data Record (SADR)
• Error Logs
• Workload Comparison

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Data OutputOutpatient Coding

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

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CommandersData Quality Statement

• 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?

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Data OutputOutpatient Coding

• EM Codes
• ICD-9 Codes
• CPT Codes

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CommandersData Quality Statement

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

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CommandersData Quality Statement

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

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CommandersData Quality Statement

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

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CommandersData Quality Statement

• 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?

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CommandersData Quality Statement

• 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?

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CommandersData Quality Statement

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

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CommandersData Quality Statement

• Q. 8. Comparison of reported workload data (C.9).
• a) SADR Encounters / WWR visits
• b) SIDR Dispositions / WWR Dispositions
• c) EAS Visits / WWR Visits
• d) EAS Dispositions / WWR Dispositions
• e) IPSR SADR encounters (FCCA)/ Sum WWR
  (Total Bed Days Total Dispositions)
• Note FY07 Goal is 80

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Data OutputWorkload Comparison

• SADR Encounters / WWR Visits
• Should Have More Encounters Than 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

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Data OutputWorkload Comparison

• 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

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Data OutputWorkload Comparison

• EAS Visits / WWR Visits
• Must Match
• Include MEPRS Functional Cost Code B
  (Outpatient) and FBN (Hearing Conservation)
• Include APVs

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Data OutputWorkload Comparison

• EAS Dispositions / WWR Dispositions
• Must Match
• Only SIDRs with a Disposition Status of D are
  to be included

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Data OutputWorkload Comparison

• IPSR encounters (FCCA)/ Sum WWR (Total Bed
  Days Total Dispositions)
• Note FY08 Goal is 80
• Insure WWR calculation includes live births
  (section 01) and Bassinet Days (section 00).

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CommandersData Quality Statement

• Q.9. - System Design, Development, Operations
  and Education/Training (E.4.c).
• - AHLTA SADR encounters/ of Total SADR
  encounters
• Note FY08 not scored. For management use and
  tracking purposes only.
• ( It is understood that not all clinical modules
  are deployed in the current version of AHLTA.)

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CommandersData Quality Statement

• Q. 10. I am aware of data quality issues
  identified by the completed Commanders Statement
  and Review List and when needed, have
  incorporated monitoring mechanisms and have taken
  corrective actions to improve the data from my
  facility.

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Security

• Responsibilities for computer security formally
  assigned?
• Is there a Security/Privacy Program in place to
  address Security threats (internal/external) and
  HIPAA Compliance
• Password Protection?
• Access to systems?
• Confidentiality of data?
• Level of Access to MEPRS/EASi, CHCS, AHLTA, ADM,
  TPOCS, CCE, DMHRSi

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System Design, Operations, and Education/Training

• 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

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Data Quality Section, PASBA
Mr. Joseph (Tim) Bacon (Chief DQ Section, PASBA
/ Army DQ Mgr) Telephone [phone], DSN
421 Ms. Deborah Lundberg (NARMC / 18th
MEDCOM) [phone], DSN 421
Ms. Tama Oringderff (GPRMC /
WRMC) [phone], DSN
421 Mr. Joe Alley (ERMC / SERMC / PRMC) (210)
221-0467, DSN 421