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Partnering for Maternal Data Quality Improvement
Elliott Main, MD: CMQCC Medical DirectorAnne Castles, MPH, MA: CMDC Project Manager
Barbara Murphy, RN, MS: CMQCC Administrative DirectorSupported with grants from:Centers for Disease Control
California Health Care Foundation
Describe the initiatives in California to improve BC data quality
Describe the national multi-organization effort to standardize maternity terminology
Describe the importance of sharing data in order to improve the data quality
Objectives:
Presenter Disclosure(s): None
CMQCC and CPQCC
Mission: Improving care for moms and newborns
California Maternal Quality Care Collaborative (CMQCC) Expertise in maternal data analysis Developer of QI toolkits Host of collaborative learning sessions
California Perinatal Quality Care Collaborative (CPQCC) Expertise in data capture from hospitals Established secure data center Data use agreements in place with 130 hospitals with NICUs Model of working with state agencies to provide data of value
Both are Multi-Stakeholder Public/Private Quality CollaborativesWith DPH playing a leading role
: Transforming Maternity Care
The California Maternal Data Center(CMDC) Project Vision
Build a statewide data center to collect and report timely maternity metrics—in way that is low cost, low burden and high value for hospitals
Produce metrics that will support QI and L&D service line management
Improve quality of administrative data
Facilitate reporting to national performance organizations
Over time, publicly report select set of robust measures to inform decisions of childbearing women
: Transforming Maternity Care
PDD--Discharge Diagnosis File(ICD9 codes)
Birth Certificate File(Clinical Data)
1. Links Birth Data to OSHPD file2. Runs exclusions3. Identifies CS and Inductions 4. Prints list of charts for review
CMQCC Maternal Data Center: Data Flow
CMQCC Data Center
REPORTSBenchmarks against other hospitals
Sub-measure reports
Calculates all the Measures<39wk Elective Delivery
CHART REVIEWLabor?/SROM?
(~6% of cases for brief review)
Limited manual data entry for this measure
Uploads electronic files
Mantra: “If you use it, they will improve it”
Many IRBs!
Why Improve Maternity Data? HISTORICALLY: Maternity data in PDD and BC used by
researchers and public health professionals to track trends and practices
NOW: An additional focus on evaluating and improving the quality of maternity services CMS Inpatient Quality Reporting Program: reporting of
ED<39 weeks to start in 2013 Medi-Cal: Developing quality dashboard; likely to include
perinatal metrics TJC to require reporting of perinatal set for hospitals that
perform more than 1100 deliveries annually: to start 2014 QI Collaboratives: Patient Safety First and HENs
How Many Horses Are At Your Data Trough?
Key Principle:
The more users for the data, the greater the effort for improving
data quality.
Maternal Data QI in California: 5 Components
1) Standardize Definitions
2) Education (providers and staff)
3) Redesign / System Changes
4) Improving Data as QI Project
5) Create Value for Maternal Data QI for hospitals
Maternal Data QI in California: 5 Components
1) Standardize Definitions
reVITALize Project GA Toolkit (work with ACOG and Hospitals)
Obstetric Data Definitions Initiative
National ConferenceAugust 2-3, 2012Arlington, Virginia
Campaign Initiatives
To nationally standardize obstetric clinical data definitions.
To educate and advocate for national implementation of the standardized obstetric data elements and definitions in electronic medical records, birth certificates, and data registries
To increase and improve performance measurement and implementation of the national obstetric data standards and encourage data aggregation.
It’s the Language…
The World of
Clinical Obstetrics
The World of Public and
Admin Health
Communications
“Britain and America are two nations divided by a common language.” --George Bernard Shaw
It’s the Language…
Different regions of the country may use terms differently …
Even within an OB department, not everyone uses the same terms for the same condition…
Different notes on the same patient, can have different terms used (induced vs augmented)
Birth clerks and coders have to read the notes and then….guess? And then translate into their categorical systems
TimelinePre-Conference Preparation
Identified data elements from various sources, including: • 2003 Birth Certificate
• ACOG/National Committee for Quality Assurance/Physician Consortium for Performance Improvement – Maternity Care Set
• Agency for Healthcare Research and Quality – Birth Trauma Injury Rate
• California Maternity Quality Care Collaborative – Healthy Term Newborn
• The Joint Commission – Perinatal Care Core Set
Two rounds of surveys were completed by conference stakeholders to determine necessity of revision and priority
Provided existing definitions from ACOG, ICD-09, Williams Obstetrics, the National Center for Health Statistics, and others to serve as a basis for revision discussion
1
The data element definitions not reaching 85% of attendee support were brought back into workgroup conference calls for additional discussion and revision
50 refined data element definitions were sent forward for Public Comment
Public Comment was open NOV 2012 to JAN 2013 625 individuals, representing over 450 organizations
participated Nearly 11,000 responses were received in support of the
revised definitions
Public Comment Review and Finalization (In Progress)
Post-Conference Follow-Up3
Publications Data Dictionary Articles
Education
Incorporation into Integrating the Healthcare Enterprise (IHE) profiles for EMR certification and Meaningful Use
Clinical decision support EMR Patient Management Triggers Data quality auditing logic models
Incorporation into coding and nomenclature
Implementation (In Progress)4
Jennifer Bailit, MD, MPH, FACOGCleveland, OH
Debra Bingham, DrPh, RNWashington, DC
Gerald Carrino, PhD, MPHWhite Plains, NY
Suneet Chauhan, MD, FACOG Norfolk, VA
Rebekah Gee, MD, MPH, FACOGBaton Rouge, LA
Kimberly Gregory, MD, MPH,
FACOGWest Hollywood, CA
Tina Groat, MD, MBA, FACOGCanton, MI
Isabelle Horon, DrPHBaltimore, MD
David LaGrew, MD, FACOGFountain Valley, CA
David Lakey, MDAustin, TX
Thank You, Workgroup Leaders!
William Sappenfield, MD, MPHTallahassee, FL
Maternal Data QI in California: 5 Components
1) Standardize Definitions2) Education: Incent complete and accurate
documentation among Providers Coders Birth Clerks
Birth Data Quality Training Sessions (Vital Records)
GA Toolkit (CMQCC, ACOG and Hospitals)
Findings for Key Fields: NTSV* CSData Element Average
Missing1Average Missing or Inconsistent2
Birthweight 0.0% --Delivery Method 0.0% 0.7%OB-GA 0.2% --LMP 2.2% --Presentation 4.6% 10.1%Parity 0.0% 0.3%
*Nuliparous, Term, Singleton, Vertex; aka Low-risk, First Birth CS (HP 2020, Joint Commission, CMS measure)1CA BC data from Jan--Sep 2012 statewide all births2CA PDD vs. BC from Jan–Dec 2011 statewide all births
Conclusions for Key Fields
Definite Area for Improvement Fetal Presentation
Even though clerks score in medium range for ease of finding and frequency of contradictory information, large percentage of actual missing /contradictory suggest a problem
When asked to code less common clinical terminology (e.g. Occiput Anterior), BC clerks picked right answer only 14-31% of time. (Report p. 6)
Conclusions for Key Fields Fetal Presentation Terminology
Vertex = Occiput = Cephalic OA, OT, OP
Deep transverse arrestFace or compound
Presentation may be missing for CS deliveries
Birth Data Quality Improvement Project
2012
Tool Kit & Tip Sheets
• Agenda & Letter from CMQCC & SCCPHD• AVSS Data (January-June 2012)• Tip sheets• Worksheet• CD of all files and tip sheets• Contact information
Maternal Data QI in California: 5 Components
1) Standardize Definitions2) Education3) Redesign / System Changes: Improve clinical
documentation systems across hospital providers to facilitate complete and accurate data capture Standard Locations for Key Data Work with EMR vendors to generate worksheet Develop and disseminate coding best practices GA Toolkit (CMQCC, ACOG and Hospitals)
: Transforming Maternity Care
Data Issues for Gestational Age No EDD or GA in Doctor’s note(s)
Multiple EDD / GA’s in L&D chart (which is best?)
Multiple EDD’s in Prenatal chart (which is best?)
Transcription errors when copying from prenatal
Delivery occurring many days after the admission GA
Revision of EDD / GA after admission
Lack of a standard approach for using US to confirm/establish best EDD.
No wonder a Birth Certificate clerk may have difficulties!
Mandated Reporting of Maternity Measures
Organization Measure BC Data Elements NOT in PDD (ICD9 codes)
CMS Early Elective Delivery Best OB GA
The Joint Commission Early Elective Delivery Best OB GA
NTSV Cesarean Section Best OB GA, Parity
Antenatal Steroid Best OB GA
Neonatal Sepsis Birth Weight
Exclusive Breast Milk Feeding
Best OB GA
Again…Best EDD Best OB GA is the critical BC data element for QI
Consensus for Identifying Best EDD
Spong CY. Defining “Term” pregnancy: Recommendations from the defining “term” pregnancy workgroup. JAMA 2013 May 3:1-2. [E-pub of print]
Most Important Single Data QI Project is: Best EDD
Medical Policy Issues When to change Best EDD based on US Criteria for US (sac <7wks, CRL <14wk, BPD <20wk) How to reconcile multiple US reports Need to improve wording of US reports for EDD
Implementation/Process Issues Prenatal Best EDD Black Box on every record To be completed by 20 weeks Tweak new AMA/PCPI OB quality measure to capture this On admission, this EDD is transferred to a similar Hospital
Best EDD Black Box used by all (including BC clerks)
Maternal Data QI in California: 5 Components
1) Standardize Definitions2) Education3) Redesign / System Changes4) Improving Data as QI Project: Apply QI
principles to improving accuracy/completeness of dataHospital-BC Missing Data Reports Comparisons of BC to PDD for audit and feedbackQI Run Charts for Data Quality
Data Quality Reports• Identify discrepancies or missing data in Birth Certificate
and Discharge data files• Use to target data performance/quality improvement
34Screen shot from the California Maternal Data Center
35
36
Hospital Alpha with high rate
--Each individual hospital within Riverside County--
37
A hospital with a system for transferring clinical data to the BC
Maternal Data QI in California: 5 Components
1) Standardize Definitions
2) Education
3) Redesign / System Changes
4) Improving Data as QI Project
5) Create Value for Maternal Data QI for hospitals (“If you use it, they will improve it”)
Use BC/PPD data for internal QIUse BC/PPD data for QI reporting (e.g. to TJC)Use BC/PPD data for Public Reporting
: Transforming Maternity Care
New Joint Commission Decision As of July 2013, hospitals have option to use Birth
Certificate data for TJC Perinatal Set for: OB Estimate of GA Birthweight Parity
Implication Abstract one time (well!) and satisfy both Vital Records and TJC requirements Potential to make hospital data collection and reporting
activities more efficient Improves quality of data for use by state policymakers
FREE the DATA
Timely sharing of Vital Record data with partners invested in improving data quality is a winner for everyone!
A boy and his Killer Whale…
Thank You!