1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov State Pilots: Adding Clinical Data to Administrative Data Roxanne Andrews, Ph.D. March 9, 2009

2. Advancing Excellence in Health Care 2 Outline Rationale for AHRQ contracts to add clinical data to administrative data Rationale for AHRQ contracts to add clinical data to administrative data Overview of AHRQ-sponsored projects Overview of AHRQ-sponsored projects Pilot project activities to date Pilot project activities to date

3. Advancing Excellence in Health Care 3 Limitations of Administrative Data for Quality Measurement Lack clinically important information Lack clinically important information – Limited to ICD-9-CM diagnosis codes Often do not include present on admission (POA) indicator for diagnoses Often do not include present on admission (POA) indicator for diagnoses – CMS recently began requiring it – Most state data organizations do not require it on statewide data

4. Advancing Excellence in Health Care 4 Limitations in Administrative Data Lead to Questions for Hospital- Specific Reporting Inadequate for risk adjustment to predict individual patient’s risk of mortality Inadequate for risk adjustment to predict individual patient’s risk of mortality Concern about penalizing providers with the sickest patients Concern about penalizing providers with the sickest patients

5. Advancing Excellence in Health Care 5 Rationale for Adding Clinical Data AHRQ-sponsored study (Pine et al.) showed adding a few clinical data elements significantly improves quality assessment using administrative data AHRQ-sponsored study (Pine et al.) showed adding a few clinical data elements significantly improves quality assessment using administrative data Important, cost-effective, additions: Important, cost-effective, additions: – POA – Lab values (numeric) on admission – (Potentially) vital signs

6. Advancing Excellence in Health Care 6 AHRQ Contracts to Add Clinical Data to Statewide Administrative Data Purpose: Purpose: – Jumpstart the enhancement of administrative data – Expand data capacities for statewide data organizations that participate in AHRQ’s Healthcare Cost and Utilization Project (HCUP)

7. Advancing Excellence in Health Care 7 Two Types of Projects In-depth pilots In-depth pilots – To add or link hospital clinical information to administrative data – Sept. 2007 – Sept. 2009 Planning contract Planning contract – For organizations not yet ready to engage in pilots – But seek to enhance their administrative data – Sept. 2007 – Mar. 2009

8. Advancing Excellence in Health Care Awards to Statewide Data Organizations Pilots Florida Agency for Health Care Administration Florida Agency for Health Care Administration Minnesota Hospital Association (MHA) Minnesota Hospital Association (MHA) Virginia Health Information (VHI) Virginia Health Information (VHI)Planning Washington Center for Health Statistics, State Department of Health Washington Center for Health Statistics, State Department of Health

9. Advancing Excellence in Health Care AHRQ Adding Clinical Data Pilot & Planning Awards Key: Pilot State Planning State MN WA VA FL

10. Advancing Excellence in Health Care 10 Objectives of Pilots Establish feasibility of linking clinical and administrative data Establish feasibility of linking clinical and administrative data Develop reproducible approach Develop reproducible approach Set the stage for integrating clinical and administrative data streams in the future Set the stage for integrating clinical and administrative data streams in the future

11. Advancing Excellence in Health Care 11 Project Requirements Identify and select clinical data elements to add to administrative data; POA a must Identify and select clinical data elements to add to administrative data; POA a must Translate clinical data from electronic format Translate clinical data from electronic format Electronically transfer data from at least five hospitals to the data organization Electronically transfer data from at least five hospitals to the data organization Process data into a multi-hospital database Process data into a multi-hospital database Collaborate with stakeholders Collaborate with stakeholders Engage in peer-to-peer learning, information sharing, dissemination Engage in peer-to-peer learning, information sharing, dissemination

12. Advancing Excellence in Health Care 12 Activities To Date Develop Final Plan Develop Final Plan Recruit hospitals Recruit hospitals Develop data collection method Develop data collection method Standardize lab data using LOINC Standardize lab data using LOINC Provide education & data feedback on POA Provide education & data feedback on POA Begin data collection Begin data collection Participate in peer learning network Participate in peer learning network

13. Advancing Excellence in Health Care 13 Recruit Hospitals Build the business case Build the business case – Advantages of adding clinical data to admin data – Incentives for participation, e.g.  Data quality feedback  Hospital quality feedback reports Assess hospital readiness Assess hospital readiness – Electronic lab data – LOINC coding – HL-7 transmission

14. Advancing Excellence in Health Care Recruitment Very Successful Project Number of Hospitals Expected Contract Requirement 5 Florida20+ Minnesota25-30 Virginia30+

15. Advancing Excellence in Health Care 15 http://www.fhin.net/FHIN/HITinitiatives/AHRQaddingClinData.shtml

16. Advancing Excellence in Health Care 16 http://www.mnhospitals.org/index/ahrq-project

17. Advancing Excellence in Health Care 17 http://www.vhi.org/hybriddata.asp

18. Advancing Excellence in Health Care 18 Develop Data Collection Method Select data elements to be collected Select data elements to be collected – POA (already collected in FL) – Lab data elements – Linking data elements Develop standard data submission format Develop standard data submission format – LOINC coding of lab names Develop methods for transmitting data Develop methods for transmitting data – HL7 to be used by some Minnesota hospitals – HL7 fields to be used in Virginia Instruct hospitals on how to submit data Instruct hospitals on how to submit data

19. Advancing Excellence in Health Care Types of Lab Tests Included: Chemistry AST AST Albumin Albumin Alkaline Phosphatase Alkaline Phosphatase Amylase Amylase Bicarbonate Bicarbonate Bilirubin Total Bilirubin Total BNP BNP Calcium Calcium C-Reactive Protein C-Reactive Protein Creatine Kinase (CPK) Creatine Kinase (CPK) Creatine Kinase MB Creatine Kinase MB Creatinine Creatinine Glucose Glucose Lactic Acid Lactic Acid Potassium Potassium Pro-BNP Pro-BNP Sodium Sodium Troponin I Troponin I Troponin T Troponin T Urea Nitrogen (BUN) Urea Nitrogen (BUN)

20. Advancing Excellence in Health Care Types of Lab Tests Included: Other BLOOD GAS Arterial O2 Saturation Arterial O2 Saturation Arterial pCO2 Arterial pCO2 Arterial pH Arterial pH Arterial pO2 Arterial pO2 Base Excess Base Excess Bicarbonate Bicarbonate FIO2 FIO2HEMATOLOGY Hemoglobin Hemoglobin INR INR Neutrophil Bands Neutrophil Bands Partial Thromboplastin Time Partial Thromboplastin Time Platelet Count Platelet Count Prothrombin Time Prothrombin Time

21. Advancing Excellence in Health Care Type Information Collected on Lab Tests LOINC code for lab test name LOINC code for lab test name Observation value (lab result) Observation value (lab result) Observation unit of measure Observation unit of measure Date/time of observation Date/time of observation

22. Advancing Excellence in Health Care Standardize Lab Data Using LOINC Hospitals use different naming and coding conventions for their electronic lab data LOINC is an accepted EHR standard for lab data content Pilot projects are mapping individual hospitals’ lab coding to LOINC to have a standard approach for analysis

23. Advancing Excellence in Health Care Education and Feedback on POA Data MHA and VHI have provided education to hospital staff on POA collection – – MHA is developing a video for educating physicians VHI provided individual hospital data quality feedback report for the first wave of POA data collection (4 th quarter of 2007)

24. Advancing Excellence in Health Care 24 Participate in Peer Learning Network Monthly conference calls with other pilot and planning state data organizations Monthly conference calls with other pilot and planning state data organizations Document sharing Document sharing California and the Veteran’s Administration have joined to share their knowledge on similar activities California and the Veteran’s Administration have joined to share their knowledge on similar activities

25. Advancing Excellence in Health Care 25 Sharing Lessons Learned with Other Organizations Interim Information on HCUP-US Interim Information on HCUP-US – Implementation Plans – Project summaries – Links to project websites – Links to other relevant projects, documents and presentations – www.hcup-us.ahrq.gov/reports/clinicaldata.jsp

26. Advancing Excellence in Health Care 26 http://www.hcup-us.ahrq.gov/reports/clinicaldata.jsp

27. Advancing Excellence in Health Care 27 Future Activities Complete Projects Complete Projects – Collect clinical data and link with administrative data – Produce multi-hospital data set – Assess data quality – Use data to produce hospital-level reports on quality – Provide hospitals feedback Final Lessons Final Lessons – Final report from each site – Synthesis of lessons across sites by Thomson Reuters & National Academy for State Health PolicyNASHP) – Synthesis of lessons across sites by Thomson Reuters & National Academy for State Health Policy (NASHP)

28. Advancing Excellence in Health Care Contact information Roxanne Andrews Roxanne Andrews – roxanne.andrews@ahrq.hhs.gov roxanne.andrews@ahrq.hhs.gov – 301-427-1403