Preparation for Using the BridgeIT 2016 UDS Clinical ReportsRCHC DATA GROUP

DECEMBER 13, 2016

BY BEN FOUTS MPH

AgendaPreparation for Clinical Reporting

1. Documents

2. BridgeIT Reports

Examination of Initial Results

1. Properly Run the Reports

2. Compare to Existing Data

Validate and Clean the Data

1. Instructions

2. Activities That Can be Done Now

Comprehensive Clinical Report Webinar• The webinar today is going to cover the basic information you need.

• Those with BridgeIT experience should immediately understand the steps they need to take.

• Those without much BridgeIT experience should also attend the Clinical Report Webinar December 20 at noon. See e-mail invitation from “RCHC_RCHN Calender” on December 8.

• More details and examples will be given during the December 20 webinar. I will demonstrate the reporting process step-by-step.

Preparation for Clinical ReportingBEFORE RUNNING THE REPORTS, MAKE SURE YOU HAVE ALL OF THE MOST RECENT VERSIONS DOCUMENTS AND BRIDGEIT REPORTS

Proper Preparation Begins Now

• Get the most recent documents

• Get the most recent reports

• Get supporting data (for comparison)

Important E-Mails from RCHC• Subject “Update to BridgeIT Reports and Documents, including UDS” (from

Colleen on November 22). Gives the location of documents on the IHIT Portal and the location of reports in the BridgeIT Warehouse.

• Subject “RCHC: UDS Season is Upon Us” (from Colleen on December 8). Description of RCHC UDS support this year (webinars and direct support)

• Subject “RCHC UDS Basic BridgeIT Financial Report Training” (from RCHC_RCHN Calendar on December 8). Contains the link and call-in information for the financial training on December 16

• Subject “RCHC Basic BridgeIT UDS Clinical Report Training ” (from RCHC_RCHN Calendar on December 8). Contains the link and call-in information for the clinical training on December 20

Most Recent Documents

The “Comparison Document”

• Defines the numerator and denominator of each measure, for each funder

• All measures have a corresponding BridgeIT report, except childhood immunization (UDS) and Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (ACO)

The “Report Index”• Gives the name and current

version number/sub-number of each report and document

• “New” reports and documents are highlighted in orange

• Also displays the month/year of the last update

The “Technical Document”Gives details on:

•Where in eCW the data comes from

•How data is manipulated by the report (calculations, etc.)

• In some cases, illustrates the logic flow of the report or measure

The “BridgeIT UDS Clinical Instructions”

•Describes how to run the BridgeITreports, validate the data, and summarize the data

•Goes through each report for each measure

•Two NEW appendices:

1. Comparison of 2015 and 2016 measure definitions

2. Cheat sheet for filters and outputs

Use Only the Latest Versions of Documents• The latest versions of the documents are compatible

with the latest versions of the reports

• If you use the old instructions and reports, you will not be accurately summarizing the 2016 UDS clinical measures

• If you a mix of old and new instructions and reports, you may get confused because some report columns, outputs and expressions have changed

Upcoming Documents (December)• Instructions for Using the BridgeIt Annual Clinical Report

Set (Version 12)

• System Set-Up For the BridgeIt Annual Clinical Report Set (Version 5)

Sources of Comparison Data• 2015 UDS Report (and rough data)

• Monthly Dashboard

• Quarterly Board Reports

• Performance Improvement Activities

• Be sure, as much as possible, to compare ‘apples to apples.’ Otherwise, know the differences among the apples you are comparing!

Prepare Your BridgeIT Toolbox

Newest Versions• Check the exact version

number by reading the Project Note for the report

• To display the Project Note, left-click on the report

• It can also be seen (including reports in the Warehouse) by right-clicking the report and choosing “About”

Compare Version Number Exactly

NOTE: Some of the “test” versions created over the Summer have new versions, even though their name might appear the same (for example, Child Weight Version 6.0, released in August, versus Child Weight Version 6.1, released in November).

Project Note Format• To help you understand the recent

changes to the reports in Summer and Fall 2016, a short summary of differences can be found in the Project Note

• For some reports, a description of the changes covers two versions. Most of the reports in the set only contain a description for the most recent version change

• The ACTUAL version number of the report is the LAST version number

Archive Recommendations• Keep the “old” versions (for example, Asthma_Pharma_v6)

• Move to a different folder (for example, “Old Clinical Report Archive”)

• You may want to compare old and new versions of the reports

• You may need to run the reports to get summaries of the “old” definitions

• You may still be using the “old” definitions on Dashboards or for other internal reports

• Recommendation: TRANSITION to the new definitions for all purposes. Exception: cervical cancer: keep the 2015 UDS definition because the 2017 UDS definition is the same

To Archive a Report

Gather Comparison Data• Ask: How do you know the results you get from the reports are

accurate and correct?

• Compare to the 2015 UDS (the UDS editor will!)

• Compare to your monthly or quarterly Dashboard (or other monitoring histories)

• For similar measures, compare to submitted PIP, ACO or QIP reports

Examination of Initial ResultsRUN THE REPORTS AND COMPARE TO OTHER SOURCES OF DATA

How to Use the RCHC UDS Instructions1. Run for measurement period 1/1/2016 to 12/31/2016 (all reports)

2. Apply the filters in the instructions

3. Open the proper output and refresh

4. Copy the output data to your own Excel document (you may also want to specify when you ran the report, what measurement period and filters you used, etc.)

Sources for Filters

Sources for Outputs

Entry Into the UDS TableResult summary: The Grand Total on this worksheet is the denominator (Columns a and b in UDS table) and the value in the row “Meets documentation criteria” is the numerator (Column c, “NUMBER OF PATIENTS WITH BMI CHARTED AND FOLLOW-UP PLAN DOCUMENTED AS APPROPRIATE”).

Compare Results to Other Sources• The new results should be “in the ballpark” with other sources of

information, unless there is a clear reason for change (i.e., performance improvement activities, etc.)

• Differences with 2015 should be explained logically by differences in definition, changes to clinical quality or data entry quality, etc.

• There will always be some level of variability in the data. If the difference is a concern, review some records in eCW

• Use the Technical Document to understand how data is being pulled

Relevance of Comparison DataKeep in-mind that comparison data may have differences in:

1. Length of measurement period used (e.g., monthly vs. annual data, etc.)

2. Data quality (e.g., data in 2015 may be before your health center performed specific performance improvement activities)

3. Patient populations (e.g., Partnership vs. all patients)

4. Measure definition (e.g., 2015 vs. 2016 cervical cancer numerator definition… most health centers will go DOWN on this measure)

Validate and Clean the DataUSE THE BRIDGEIT REPORTS TO IDENTIFY RECORDS THAT HAVE MISSING OR SUSPICIOUS DATA

Validation Report Instructions• Version 12 of the Instruction Manual will be released later this

month

• There will not be many changes to the “Supplementary Validation Report” appendix in the Instruction Manual

• Therefore, you can still follow the instructions in the old version if you want to start cleaning the data right now. Just keep in-mind that some reports have a new version number (e.g., use DM_Validation_v3 instead of _v2 because it has updated diagnosis codes)

Starting the Validation Process1. Check for patents who may have persistent asthma (evidenced by

use of a steroid medication), but do not have an appropriate code on their Problem List (Asthma_Validation_v3)

2. Make sure that all completed pap labs have been properly entered into Structured Data according to recommendations (Cervical Cancer Screen Validation_v5)

3. Make sure that A1c, LDL and FOBT/FIT labs are also completed correctly (DM_LabTest_Validation_v2 and ColRect_LabTest_Validation_v2)

Pregnancy DataEarly Entry Into Prenatal Care Measure

• Run the prenatal report (UDS_Prenatal_v5) and look for results in the column “TrimesterOfEntry” that don’t make sense (like a date or unhelpful text) or say “Bad Data”

Birth Weight From Deliveries Measure

• Run the deliveries report (UDS_Deliveries _v4) and look for pregnancies that should have already occurred (EDD_date in the past) but do not have completed documentation (no data in the columns “DeliveryDate” or “BirthWeightFinal”) or a reason why data was not entered (column OtherOutcome)

Medication Groups and Lab Groups• See Technical Document for group names

• Ensure that all appropriate medications are assigned to the Rx Groups used by the reports (report Clin_Medications and Med Groups)

• Ensure that all paps are assigned to the Pap Lab Group (report Clin_Lab Tests UDS Review LAB GROUP)

More Support!• Detailed BridgeIT Clinical Report Webinar on December 20

• Detailed BridgeIT Financial Report Webinar on December 16

• Reserve a block of time with Ben for a conference call or Join.Me session on December 21 or 22

• JANUARY: Ben will be available on an as-needed basis to answer questions

Questions?