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Comprehensive Data System (CDS) Reports and Utilizing Data April 11, 2013. Carmela Estrada Bondad, MPH Hospital Engagement Network Health Research & Educational Trust American Hospital Association. Objectives. Gain understanding of what information is provided in the CDS Reports

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slide1

Comprehensive Data System (CDS)

Reports and Utilizing Data

April 11, 2013

Carmela Estrada Bondad, MPH

Hospital Engagement Network

Health Research & Educational Trust

American Hospital Association

objectives
Objectives
  • Gain understanding of what information is provided in the CDS Reports
  • Learn how to interpret and use your data to determine progress on the HEN project
agenda
Agenda
  • Review HEN Data Needs
  • Overview of Reports Available in CDS (Live Demo)
    • Individual Measures Reports
    • All Measures Report
    • Comparative Measures Report
    • Hospital Dashboard
  • Interpreting and Using your Data
    • Cynosure/HRET Improvement Calculator
  • Questions?
slide4

HEN Overview

  • ACA considerable focus on quality
  • Created the CMS Innovation Center
  • Public-private partnership
  • Set 40/20 goal
  • Tool: Hospital Engagement Networks
  • 26 contracts awarded
  • Contracted with 34 state and regional hospital associations
  • 1,600 + hospitals

Hospital HAC Teams

Clinicians & Front Line Staff

THE PATIENT

what is data management in hen
What is Data Management in HEN?
  • Surgical Site Infection (SSI)
  • Obstetrical Adverse Events/EED
  • Injuries from Falls & Immobility
  • Pressure Ulcers
  • VTE

Preventable Readmissions

Adverse Drug Events (ADEs)

CAUTI

CLABSI

Ventilator-Associated Pneumonia (VAP)

why collect report data
Why collect & report data?
  • To demonstrate hospitals have reduced their Hospital Acquired Conditions and Readmissions over the 2 year period
  • To monitor that interventions are working
    • Part of the PDSA cycle
    • Measures are used to assess the impact of changes
  • To identify areas of strengths, weaknesses, and challenges – guide your improvement efforts
data requirements
Data Requirements

For each of the ten clinical topics, submit:

  • 1 process measure (how we know our interventions are actually implemented)
  • 1 outcome measure (how we know our interventions are actually working)
data timeframes
Data Timeframes
  • Baseline Data
    • Prior to January 2012
    • Start/End date determined by user
    • One aggregate numerator/denominator
  • Monitoring Data
    • January 2012 – December 2013
    • One numerator/denominator for each month
slide9

More data submission?!

  • Things to consider…
  • What are you already measuring?
  • What are you planning to measure?
  • What other data sources exist?
  • Identify Existing Measures
  • Are they in the Encyclopedia of Measures?
  • If not, there is an option to add user-defined measures.
data needed
Data Needed

Patient Level Data

PHI

comprehensive data system
Comprehensive Data System
  • HRET’s project data collection system
    • Web-based
    • Secure
    • Flexible
  • https://www.hretcds.org
live cds demonstration
Live CDS Demonstration
  • Logging in
  • Measure “enrollment”
  • Organization-defined measures
  • Data entry
  • Reports
    • Individual Measure
    • All Measures
    • Comparative Measures Report
    • Hospital Dashboards
what type of report do i need
What type of report do I need?
  • Data and Run Chart for your hospital’s performance on a single measure?
    • Individual Measure Report
  • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance?
    • Measure Comparison Report
  • Data only for all Measures and data entered for your hospital?
    • All Measures Report
what type of report do i need1
What type of report do I need?
  • List of who has CDS access/type of access?
    • Organizational User*
  • Dashboard Report on data submission status, outcome measure results, and run charts for all EOM measures?
    • Hospital Dashboard
individual measure report
Individual Measure Report
  • The Individual Measure Report allows you to see a selected measure for a selected hospital across time.
  • Includes:
    • Timeframe (Baseline or Monitoring)
    • Start and End Date
    • Numerator and Denominator values
    • The rate for all timeframes where the data has been submitted.
individual measure report2
Individual Measure Report
  • Click on the ‘Reports’ tab
    • Then select ‘Individual Measure’
individual measure report3
Individual Measure Report
  • By selecting the ‘Chart’ tab after selecting a measure in the ‘Data’ section, you can see a run chart of the selected measure.
all measures report
All Measures Report
  • The All Measures Report is a report that allows you to see all measures across all topics where data has been submitted.
  • Includes:
    • Organization name
    • Topic
    • Measure Name
    • Timeframe (Baseline or Monitoring)
    • Start and End Dates
    • Numerator and Denominator Definitions
    • Numerator and Denominator Values
    • The rate for that timeframe
    • The date the data was last updated
    • The city and state
    • Medicare ID Number
    • HRET_MeasureID (Our designated ID for the measure)
    • Measure Type (Outcome or Process)
all measures report2
All Measures Report
  • Click on the ‘Reports’ tab
    • Then select ‘All Measures’
all measures report3
All Measures Report
  • The circled area shows the different elements you can use to filter the data
    • For example, if you only wanted to view Falls Data, you could use the dropdown menu for ‘Topic’ as pictured below.
all measures report4
All Measures Report
  • It can be filtered by any of the listed elements that are included
  • The full report can be exported to Excel
    • Filtered data can also be exported to Excel
  • Note: Depending on the amount of data you have, the All Measures Report may take longer to load
comparative measures report
Comparative Measures Report
  • Data and Run Chart for your hospital’s performance compared against the state performance and the HEN performance
  • Only Available for EOM and State-defined measures
measure comparison report
Measure Comparison Report
  • Measure Comparison Report—CHART view
measure comparison report1
Measure Comparison Report
  • The data used in the CHART can be found by clicking the DATA tab.
  • The variables included in the DATA view are
    • HRET_OrganizationID—the unique HRET identifier for your organization
    • HRET_MeasureID—the unique measure identifier
    • Measure-the measure name
    • Timeframe– Baseline (pre-2011) or Monitoring (2012-forward)
    • StartDate– timeframe start date. For BASELINE, this is YOUR organization’s start date
    • EndDate– timeframe end date. For BASELINE, this is YOUR organization’s end date
    • Numerator—your organization’s numerator
    • Denominator—your organization’s denominator
    • Rate– your organization’s rate
    • All State Hosps Rate—the rate for all hospitals in your state reporting this measure
    • # State Hosps—the number of hospitals in your state reporting this measure
    • All Project Hosps Rate—the rate for all hospitals in the project reporting this measure
    • # Project Hosps—the number of hospitals in the project reporting this measure
    • MeasureType—Outcome or Process
organization user report
Organization User Report
  • List of who has CDS access/type of access
  • Only Available for Data Administrators
what is the hospital dashboard
What is the Hospital Dashboard?
  • The Hospital Engagement Network Hospital Dashboard is a monthly report that contains data and information related to your hospital’s
    • Data submission status
    • Outcome measure results
    • Readmission Race data
    • Early Elective Delivery/Hard Stop Policy information
    • Run charts depicting your hospital’s progress towards the goal of reducing harm by 40% and reducing readmissions by 20% by the end of 2013.
  • Canned Monthly Report
  • Available for download under CDS Resources
slide38

Hospital

Hospital

Hospital

Hospital

slide39

Hospital

Hospital

Hospital

Hospital

slide40

Hospital

Hospital

Hospital

Hospital

slide41

Hospital

Hospital

Hospital

Hospital

interpreting and using your data and reports
Interpreting and Using Your Data and Reports
  • Using data to answer your questions
    • “Now that I have all of this data, what do I do with it?”
    • “What does my data mean?”
    • “Am I reaching my improvement goals?”
interpreting and using your data and reports1
Interpreting and Using Your Data and Reports
  • Preparing data for analysis
    • What question are you trying to answer?
    • What is the best way to present the data?
    • Who is your audience for your analysis?
    • Do you have any outliers or strange data?
      • Run chart points that are clearly out of line with others
      • Missing data points
interpreting and using your data and reports2
Interpreting and Using Your Data and Reports
  • Preparing data for analysis
    • What question are you trying to answer?
    • What is the best way to present the data?
    • Who is your audience for your analysis?
    • Do you have any outliers or strange data?
      • Run chart points that are clearly out of line with others
      • Missing data points
interpreting and using your data and reports3
Interpreting and Using Your Data and Reports
  • Run the analysis
    • Pull the data from CDS
      • Run chart
      • Export raw data from CDS and copy/paste into excel to create your own graphs
    • Assess trends
    • Draw conclusions
  • Quality Checks on your Results
  • Present your final results
    • Ensure that your graphs and data are understandable to your audience
    • Be creative!
tools for interpreting and using your data
Tools for Interpreting and Using Your Data
  • Cynosure/HRET Improvement Calculator
    • Developed to help translate data into Harms prevented and Estimated Costs Savings
    • Available for download in CDS Resources (excel file) or in Data tab of www.hret-hen.org
    • Live Demo
slide53

Once baseline data and at least one other data period is entered, these cells will auto-populate

instructions total harm
Instructions: Total Harm
  • Total Harm: Readmissions, ADE, Falls with Injury, Stage III/IV Pressure Ulcers, CAUTI, CLBSI, VAP, SSI, EED, VTE
slide55

If Falls with Injury or Falls are populated, patient days will auto-populate. Otherwise, click M5 and enter patient days for baseline period.

Harm will auto-populate summing Readmissions, ADEs, Falls with Injury, Stage III/IV Pressure Ulcers, CAUTIs, CLBSIs, VAPs, SSIs, EEDs, and VTEs for each time period entered.

instructions printing
Instructions: Printing
  • To print the worksheet, first review printer options and margins.
  • Then Select File-Print or Control-P.
slide57

To print only the graph, left-click on chart (notice box around chart indicating selection). Use File-Print or Control-P.

slide58

To copy graph, right click on white space of chart area, select Copy. You can paste graph (right click-paste, or Control-V) to another document, e.g. PowerPoint or Word.

other resources
Other Resources
  • CDS User Guide
  • Hospital Dashboard Resource Guide
  • HEN Data Support
    • hendatasupport@aha.org
    • (312) 373-0137
  • IL Hospital Association