1. Health Budgets & Financial Policy TRICARE Data Quality Training Course May 19, 2009 DATA QUALITY MANAGEMENT CONTROL (DQMC) PROGRAM

2. Health Budgets & Financial Policy 1 DQMC Program Briefing Purpose Provide an overview of the Data Quality Management Control (DQMC) Program in the Military Health System (MHS): Data quality concepts; Background of DQMC Program; Components of the DQMC Program; TMA Summary of Data Quality Statement metrics; Inspections and External Audit statistics; Highlight current topics and ongoing issues; and Conclusion.

3. Health Budgets & Financial Policy 2 DQMC Program Data Quality Concepts Attributes … Accuracy CompletenessConsistency Timeliness

4. Health Budgets & Financial Policy 3 Why Worry about Data Quality? One reason is external scrutiny... DoD IG GAO Audit Agencies Congress DQMC Program Data Quality Concepts

5. Health Budgets & Financial Policy 4 Problems with Information Technology (IT) Typically, Data Quality is formulated as an IT problem...  Some of our problems with data quality can be attributed to problems with Information Technology (IT);  Examples: – Errors in transmission of data; – Errors in processing data; – Unsynchronized databases; But …  The most difficult problems we face with data quality are not directly attributable to IT, nor readily fixed by IT solutions. DQMC Program Data Quality Concepts

6. Health Budgets & Financial Policy 5 A few examples of non-Information Technology problems causing problems with data quality: Lack of standardized business rules and policies; Inconsistent choices of codes, weights and algorithms; Lack of adequate training and education; Lack of adequate local data quality assurance; and Failure to set and enforce tough performance expectations about data quality. DQMC Program Data Quality Concepts

7. Health Budgets & Financial Policy 6 Our people have to understand both the business and the technology… Training & Education: Quality data requires more than training data-entry personnel;  Data Quality Training Course - aimed at DQ Managers (offered 3 times a year);  MEPRS Application & Data Improvement (MADI);  Working Information Systems to Determine Optimal Management (WISDOM); and  Providers – Documentation and Coding. DQMC Program Data Quality Concepts

8. Health Budgets & Financial Policy 7 Solutions to effectively fix data problems: Reasonable feedback for Commanders and Users, such as:  Metrics - Fast feedback to Commanders about the quality of their data;  Rapid availability of data for use; Best Practices – literature, forums, conferences; and Core competency. DQMC Program Data Quality Concepts

9. Health Budgets & Financial Policy 8 DoD IG identified material management control weakness for MHS - Directed development of data quality assurance and management control program; 2 Specific Reports:  DoD IG report concerning the FY98 Retirement Liability Estimate;  GAO Medicare Subvention Demonstration report; ASD (HA) concurred with DoD IG material management control weakness findings; and ASD (HA) designated TMA Resource Management Steering Committee to oversee the development of an MHS DQ Management Control Program. DQMC Program Background TMA DQMC Program Implemented 01 Dec 2000 (FY 2001)

10. Health Budgets & Financial Policy 9 DQMC Program Background TMA Data Quality Management Control Program Development of DQMC involved multiple working groups to include major system representatives; DoD comptroller, DoD IG and GAO provided oversight in its development; Program has been staffed through the Services with substantial input from field (former Region 11 MTFs); and Policy Memorandum signed on 29 Nov 00 for implementation on 01 Dec 00. Subsequently updated by policy memorandums dated 09 May 01, 17 Oct 01, 05 Sep 02 and DoDI 6040.40 dated 26 Nov 02.

11. Health Budgets & Financial Policy 10 Department of Defense INSTRUCTION Regulatory Guidance DODI 6040.40 Military Health System Data Quality Management Control Procedures 2 Enclosures: -DQMC Review List -Data Quality Statement DQMC Program Background

12. Health Budgets & Financial Policy 11 DQMC Program Components of Program TMA DQMC Program improves data quality and ensures that the MTF receives credit for properly recording the workload. Data Quality Manager & Data Quality Assurance Team; DQMC Review List - Internal tool to assists MTFs monthly in identifying and correcting financial and clinical workload data problems. This list is prepared by the Data Quality Manager and Data Quality Assurance Team [Enclosure 1 of DODI 6040.40]; Monthly Data Quality Statement – Specific information from the DQMC Review List that the Commander approves for forwarding to Service DQ Managers and the TMA Management Control Program Manager [Enclosure 2 of DODI 6040.40]; and DQMC Workgroup - TMA Chair and Service DQMC POCs, meets monthly - Service and TMA wide issues discussed and documented.

13. Health Budgets & Financial Policy 12 Critical Success Factors Active Leadership Involvement Data Quality Managers Data Reconciliation and Audits Use of Data/Metrics by the MTFs Timely Coding/End- Of-Day Processing Rapid Feedback File/Table Build Data Base Management DQMC Program Components of Program

14. Health Budgets & Financial Policy 13 TMA DQMC webpage http://www.tricare.mil/ocfo/mcfs/dqmcp.cfm;http://www.tricare.mil/ocfo/mcfs/dqmcp.cfm Metrics and Report; and Important reference materials. TMA Summary of DQ metrics DQ Statements:  Received by TMA from Services on the 10th of the month for the preceding month’s report. (Applies to the prior month’s data.) Used to create the TMA Service Trends spreadsheets; TMA Summary:  Constructed from the Service Trends and briefed to both the Resource Management Steering Committee and TMA Senior Leadership and Service DSGs twice a year; Posted on the DQMC website; and Discussed at the Monthly DQMC Workgroup meetings. DQMC Program DQ Metrics

15. Health Budgets & Financial Policy 14 TMA DQMC webpage http://www.tricare.mil/ocfo/mcfs/dqmcp.cfm DQMC Program DQ Metrics

16. Health Budgets & Financial Policy 15 DQMC Program DQ Metrics The following “Data Quality Statement – TMA Summary” summarizes results of the DQ Statements submitted by each Service for data month Jan 09; Metric Standards (colors) are as follows:  Green - 95-100  Yellow - 80-94  Red - 0-79  Except 8e and 9 – 80% and above green, 10 is not colored Color coding generally moves from red to green as the fiscal year progresses and issues are ironed out.

17. Health Budgets & Financial Policy 16 DQMC Program DQ Metrics See TMA Summary Sheet handout - below is an example for FY 2009

18. Health Budgets & Financial Policy 17 DQMC Program Inspections/External Audits DoD IG inspected -- results (Apr 01-Oct 01) were published in a report signed 29 Aug 02. General Comments: Overall indifference toward the program; Lack of communication and timely feedback to identify shortfalls in performance; Inadequate preparation and training of the DQ Team for completion of the Control Review List; and Lack of monitoring to ensure proper implementation of the program.

19. Health Budgets & Financial Policy 18 DQMC Program Inspections/External Audits DoD IG MTF Specific Comments: Responses to the DQ Statement and Control Review Lists are unreliable. Need audit / validation of responses in the Data Quality Statement / Review List; Lack of audit trail - no supporting documentation; Lack of accountability; Lack of training; and Inadequate dedication of resources to data quality.

20. Health Budgets & Financial Policy 19 DQMC Program Inspections/External Audits The DOD IG Inspection raised concerns: Prevents Defense Health Program (DHP) and Office of Secretary of Defense (OSD) from receiving a “Clean Audit Opinion;” Puts future DHP funding in jeopardy; Puts Prospective Payment in jeopardy; Third Party Collections (TPC) placed in jeopardy; and Jeopardizes MTF Accrual Financing Reimbursement.

21. Health Budgets & Financial Policy 20 DQMC Program Inspections/External Audits External Audit – 2002 Iowa Foundation The audit consisted of 50 sites, 11,254 cases; Unavailability of records (47%); Specific encounter not found in 9% of the records; Coded incorrectly, 27%; 70% over coded, 30% under coded; and Coded correctly, 17%. AdvanceMed ended up with similar results National Capitol Region (NCR) availability of records (9%).

22. Health Budgets & Financial Policy 21 DQMC Program Inspections/External Audits External Coding Audit Response Rates FY 2008 (Data Records FY 2006) Audit sample consisted of 7,100 randomly selected records from FY 2006 data records Our goal was an 85% Response Rate

23. Health Budgets & Financial Policy 22 Very Low Violates DoDD 6040.41 (Apr 13, 2004, paragraph 4.2.3.1 – 95% availability of records) and DoDI 6040.43 (Jun 10, 2004, paragraph 5) DQMC Program Inspections/External Audits

24. Health Budgets & Financial Policy 23 NR = Includes Non-response records; graded using correct DRG as the only criteria DQMC Program Inspections/External Audits Coding Accuracy

25. Health Budgets & Financial Policy 24 NR = Includes Non-response records DQMC Program Inspections/External Audits Coding Accuracy

26. Health Budgets & Financial Policy 25 NR = Includes Non-response records DQMC Program Inspections/External Audits Coding Accuracy

27. Health Budgets & Financial Policy 26 DQMC Program Current Topics Some of the items currently being pursued: Training:  DQ Course;  Using M2 Data Quality Reports to Improve MTF Data Quality (hands-on tutorial);  Presented DQMC Program brief at Navy Patient Admin Course and UBO/UBU Conferences; Annual Data Quality Statement Update:  FY09 – Clarification of Coding Audit formulas;  FY09 – Addition of Duplicate Records reporting from Review List; and Internal Compliance, External Evaluation:  MHS External Coding Audit for FY09 (FY07 data records).

28. Health Budgets & Financial Policy 27 DQMC Program Ongoing Issues Issues being pursued: Medical Expense Performance and Reporting System (MEPRS) Timely Reporting Working issues with DMHRSi MHS Trouble-Ticket Management (Tier 2 & 3):  AHLTA Implementation Issues; Central System Table Synchronization (e.g., CPT Table):  AHLTA, CCE, CHCS; Coding Accuracy:  TMA External Coding Audits.

29. Health Budgets & Financial Policy 28 DQMC Program Conclusion There are many benefits to Data Quality: Records (with accurate documentation / coding):  Provide evidence of treatment and supports budget, reimbursement and billing;  Support training and education;  Facilitate quality assurance processes;  Provide the legal defense for patients, providers and the MHS; Availability of records provides the communications link between providers and continuity of care; and Credit for MTF quality work.

30. Health Budgets & Financial Policy 29 How Can You Help? Brief medical staff on command data  Executive Steering Committee  Department & Division Heads Develop Dashboards Provide feedback to staff and use the data Be well-read/knowledgeable in data quality  Reporting  Analysis Network and share information DQMC Program Conclusion

31. Health Budgets & Financial Policy 30 DQ POCs TMA Army Navy – (support team) Air Force DQMC Program Conclusion

32. Health Budgets & Financial Policy 31 Questions Questions?

33. Health Budgets & Financial Policy 32 Bonus Information

34. Health Budgets & Financial Policy 33 Source: Data is Post-Feedback % Records Correct from Final Report Coding Audit, Military Health System, 27 July 2007 by STI. Note: IP = DRG accuracy; OP and APV = E&M, CPT, and ICD-9 accuracy. N=3 0 N=2 9 N=2 6 N=3 0 N=2 4 N=3 0 N=2 3 N=3 0 External Coding Audit Results 2007 – Targeted 6 Hospitals New Study Rules DQMC Program Inspections/External Audits

35. Health Budgets & Financial Policy 34 These tables are excerpts from Final Report Coding Audit, Military Health System, 27 July 2007 by STI. DQMC Program Inspections/External Audits External Coding Audit Results 2007 (Data Records FY 2005)