Partnering for Maternal Data Quality Improvement Elliott Main, MD: CMQCC Medical Director Anne...

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


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



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


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


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)


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)


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

36

Hospital Alpha with high rate

--Each individual hospital within Riverside County--

A hospital with a system for transferring clinical data to the BC



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


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!

Partnering for Maternal Data Quality Improvement Elliott Main, MD: CMQCC Medical Director Anne...

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