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Advanced Certification in Heart Failure Measures

Pilot Test Training

Part II: Tuesday, November 15, 2011

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Outpatient Setting

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ACHF-04a Hospital Outpatient Assessment of Functional Status for Heart Failure

Denominator: All heart failure patients

Numerator: Patients for whom a NYHA Class OR completion of a valid, reliable disease-specific instrument was documented at the time of the initial outpatient visit.

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ACHF-04a Included Populations

E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and

An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

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ACHF-04a Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure CodeOutpatient Encounter Date

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ACHF-04a Data ElementsNumerator:

Disease-Specific Instrument

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ACHF-04a Algorithm Highlights

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ACHF-05a Hospital Outpatient ICD Counseling for LVSD

Denominator: Heart failure patients (NYHA Class II and III) AND documentation of a current LVEF < 35%, despite optimal medication (ACEI/ARB/BB) management for at least 3 months

Numerator: Patients who receive ICD counseling when seen in the outpatient setting and have documentation of the discussion with a healthcare provider present in the medical record

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ACHF-05a Included PopulationsE/M Code for hospital outpatient encounter

as defined in OP Appendix A, OP Table 1.0, and

An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Documentation of LVSD < 35%Documentation of Optimal Medication

Management for at Least 3 MonthsNYHA Class II / III

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ACHF-05a Excluded PopulationsPatients with NYHA Class I or IV heart

failurePatients with a documented Reason for

No ICD Counseling in the Outpatient Setting

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ACHF-05a Data ElementsDenominator: BirthdateClinical TrialDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code LVSD < 35%

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ACHF-05a Data ElementsDenominator: Optimal Medical Management For at least 3

MonthsOutpatient Encounter DateReason for No ICD Counseling in the Outpatient

Setting

Numerator: ICD Counseling

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ACHF-05a Algorithm Highlights

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ACHF-05b Hospital Outpatient Cardiac Resynchronization Therapy (CRT, CRT with pacing CRT-P, CRT with defibrillator CRT-D)

Denominator: Heart failure patients (NYHA Class II, III, or IV) with most recent LVSD < 35%, QRS duration on ECG of 150 ms or above, left bundle branch block (LBBB), and receiving optimal medication management for at least 3 months

Numerator: Patients who have cardiac resynchronization therapy (CRT) when seen in the outpatient setting

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ACHF-05b Included Populations

E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and

An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

Documentation on ECG of Left Bundle Branch Block (LBBB) and QRS duration of 150 ms

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ACHF-05b Included Populations

Documentation of LVEF < 35%Documentation of New York Heart

Association Classification II, III, or IVDocumentation of Optimal Medication

Management for at Least 3 MonthsDocumentation on ECG of QRS

duration of 150 ms or above

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ACHF-05b Excluded PopulationsPatients with NYHA Class I heart

failurePatients with a documented Reason for

No Cardiac Resynchronization Therapy (CRT)

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ACHF-05b Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code LVEF < 35%Optimal Medical Management For at least 3

Months

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ACHF-05b Data ElementsDenominator: Outpatient Encounter DateReason for No Cardiac Resynchronization

Therapy (CRT) in the Outpatient Setting

Numerator:Cardiac Resynchronization Therapy (CRT)

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ACHF-05b Algorithm Highlights

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ACHF-06a Hospital Outpatient Activity Recommendations

Denominator: All heart failure patients

Numerator: Outpatients who have received a document describing individualized activity recommendations tailored to their needs. This document must be present in the outpatient record

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ACHF-06a Included Populations

E/M Code for hospital outpatient encounter as defined in OP Appendix A, OP Table 1.0, and

An ICD-9-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1

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ACHF-06a Excluded PopulationsPatients with a documented Reason for

No Activity Recommendations

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ACHF-06a Data ElementsDenominator: BirthdateDischarge StatusE/M Code ICD-9-CM Other Procedure Codes ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure CodeOutpatient Encounter DateReason for No Activity Recommendations

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ACHF-06a Data ElementsNumerator:

Activity Recommendations Document

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ACHF-06a Algorithm Highlights

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Navigating the Advanced Certification

Heart Failure ProjectData Collection Tool

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GET STARTED

Access the project website at: http://manual.jointcommission.org

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LOG IN TO THE PROJECT SITE

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ADVANCED CERTIFICATION HEART FAILURE PROJECT

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ACHF PROJECT PAGE

From this page you can:• Access your hospital page• Access the Measure and Data Element info• Find data submission dates• Submit questions and provide feedback• Find news, tools and other resources that may become available during the project

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YOUR HOSPITAL PAGE

From this page you can: Add or update your hospital information Enter new records View and update existing records Mark records as “complete” Review records that have been completed Identify records that have been flagged for re-abstraction

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Updating Hospital Demographic Information

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Updating Hospital Demographic Information

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Entering New Records

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View and update existing records

Click the Pencil icon to “Edit” an existing record

Click the UBCI number to “expand” an existing record

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Mark records as complete

Click the empty box to “Complete” and

“Lock” a record

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Review records that have been completed

Click the “Complete” radio button and then click “Filter”

to view completed records

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Identify records flagged for re-abstraction

The “Lock” icon means the record is complete. The blue

flag icon means the record will be re-abstracted.

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ENTERING NEW RECORDSNote: hovering over the green ‘i’ next to a data element will show you the question and allowable values associated with that data element.

Clicking on the green ‘i’ will link to the data element page.

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ENTERING NEW RECORDS

Once you have completed data entry for this record, save the data record.

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DATA ENTRY CASE SCENARIOS general patient data elements

Blue arrows show elements used by

Inpatient and Green arrows

Outpatient.

Red arrows show elements used by both Inpatient and

Outpatient.

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general patient data elements

Red arrows show elements used by both Inpatient and

Outpatient.

Blue arrows show elements used by

Inpatient and Green arrows Outpatient.

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INPATIENT SECTION

All elements from ‘Bisoprolol’ down to ‘Post-Discharge’ are

Inpatient only. If Inpatient record, please fill in ALL elements.

If an Outpatient record – you can leave all Inpatient

elements blank

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OUTPATIENT SECTIONAll elements from ‘Bisoprolol in Outpatient

Setting’ down to ‘Reason No Activity’ are Outpatient only. If Outpatient record,

please fill in ALL elements.

If an Inpatient record – you can leave all Inpatient

elements blank

Click “Save Data Record” when all data entry is finished for the patient

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FIND EXISTING RECORDS

To find a record by Unique Blinded Case Identifier (UBCI), enter the UBCI and ignore the “Complete” and “Incomplete”,

then click “Filter” button.

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VIEW RECORD’S DETAILSTo view an existing record, click on the UBCI number. You can contract the drop down

by clicking on the ‘-’or expand by clicking on the ‘+’ before the different sections.

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EDIT EXISTING RECORDS

To edit the “General and other patient-level data elements”, click on the pencil icon.

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MARKING RECORDS AS “COMPLETE”

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VIEW EXISTING RECORDS

To view the complete records, check the “Complete” radio button then click “Filter” button.

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REVIEWING COMPLETED RECORDS

The completed records are LOCKED and can not be edited. The blue flag indicates that record will be re-abstracted.

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UNLOCK A RECORD

To send an e-mail request to unlock a record, click on the “lock” icon and an e-mail form will appear. In the e-mail, please briefly explain why the record needs to be

unlocked (e.g., Accidentally clicked the “Complete” checkbox).

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ASK A QUESTION

On the ACHF project page – the very bottom

has a link to ask a clinical or technical

question. The FAQ table also will display the common questions.

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