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 (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 ©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 MeasureNot extractedDocumentation 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 MeasureNot ExtractedDocumentation Recommendation Cervical Cancer Screening (Pap Smear in 3 years) Health Maintenance Title Lines 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 MeasureNot ExtractedDocumentation Recommendation Abdominal aortic aneurysm screening (for men, once since 65 th 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 65 th birthday) Health Maintenance Title Lines Dx Procedures -DXA Bone Density Study Depression screening (for adults in 2 years) Health Maintenance Title Lines Dx Procedures or Risks table -Health Risk Asses [99420, CPT] -Ann Depress Screen, 15 min [G0444, HCPCS] ©PPRNET 2014

TOBACCO, ALCOHOL SCREENING & COUNSELING MeasureNot ExtractedDocumentation 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) [ , SNOMED] -Drinks Alcohol [219006, SNOMED] -Problem drinker (finding) [ , 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