DSS Basics for Providers: What It Is, How It Works, What It Does for the VA 232 8

1. 1 DSS Basics for Providers: What It Is, How It Works, What It Does for the VA2328/10/201011:00 AM � 12:15 PM Presentation slides are a template. The eHealth University logo is in the center of the cover slide. It is located in the upper left hand corner of all other slides. Presentation slides are a template. The eHealth University logo is in the center of the cover slide. It is located in the upper left hand corner of all other slides.

2. 2 HOUSE KEEPING Cell Phones Please turn off or change to vibrate If you must answer a call or text message , please leave the room. Before we get started we need to take care of some Housekeeping issues. This is a XX hour XXXXX session. Please turn off or change your cell phones to vibrate. If you must answer a call, for the convenience of the other participants we ask that you please leave the roomBefore we get started we need to take care of some Housekeeping issues. This is a XX hour XXXXX session. Please turn off or change your cell phones to vibrate. If you must answer a call, for the convenience of the other participants we ask that you please leave the room

3. 3 HOUSE KEEPING Please, No questions during the presentation. Questions written on a 3X5 card will be answered at the conclusion of the presentation, time permitting. All questions and answers will be posted on the web including those not answered during class. No questions will be taken during the presentation. If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.No questions will be taken during the presentation. If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.

4. 4 Faculty Elizabeth (Betsy) Shortle, MSN, RN, VHA Decision Support Office Education Coordinator Nancy Lapointe, MSN, RN VHA Decision Support Office Director of Clinical User Support

5. 5 Learning Objectives Discuss the purpose of the VA Decision Support System Describe the three types of data in DSS Explain the core requirements of managerial cost accounting Discuss 4 ways that VHA clinicians and managers are using DSS information.

6. 6 DSS Basics for Providers: What It Is, How It Works, What It Does for the VA

7. 7 VA: Best Care Anywhere When asked what was the greatest medical advance in the last 100 years, surgeon and author Dr. Atul Gawande responded: �Antibiotics. Of the last 20 years, it would be statistics (or data)...The creation of a way to look at results and know whether certain kinds of care are working or not.� [Graphic: Numeral 1] If you look at what antibiotics have done for us over the past 100 years (such as penicillin saving lives) , the impact is huge. To recognize that data is now making a significant impact in health care delivery is crucial. VA has many data sources that have helped us offer the best care anywhere. A surgeon and a writer, Atul Gawande is a staff member of Brigham and Women's Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. He received his B.A.S. from Stanford University, M.A. (in politics, philosophy, and economics) from Oxford University, M.D. from Harvard Medical School, and M.P.H. from the Harvard School of Public Health. He served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. Since 1998, he has been a staff writer for the New Yorker magazine. In 2003, he completed his surgical residency at Brigham and Women's Hospital, Boston, and joined the faculty as a general and endocrine surgeon. He is also Associate Professor of Surgery at Harvard Medical School, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWH Center for Surgery and Public Health. He has published research studies in areas ranging from surgical technique, to US military care for the wounded, to error and performance in medicine. He is the director of the World Health Organization's Global Challenge for Safer Surgical Care. In 2006, he received the MacArthur Award for his research and writing. His book COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. He was editor of THE BEST AMERICAN SCIENCE WRITING 2006. His most recent book, BETTER: A SURGEON'S NOTES ON PERFORMANCE is a New York Times bestseller and one of Amazon.com's ten best books of 2007. [Graphic: Numeral 1] If you look at what antibiotics have done for us over the past 100 years (such as penicillin saving lives) , the impact is huge. To recognize that data is now making a significant impact in health care delivery is crucial. VA has many data sources that have helped us offer the best care anywhere. A surgeon and a writer, Atul Gawande is a staff member of Brigham and Women's Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. He received his B.A.S. from Stanford University, M.A. (in politics, philosophy, and economics) from Oxford University, M.D. from Harvard Medical School, and M.P.H. from the Harvard School of Public Health. He served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. Since 1998, he has been a staff writer for the New Yorker magazine. In 2003, he completed his surgical residency at Brigham and Women's Hospital, Boston, and joined the faculty as a general and endocrine surgeon. He is also Associate Professor of Surgery at Harvard Medical School, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWH Center for Surgery and Public Health. He has published research studies in areas ranging from surgical technique, to US military care for the wounded, to error and performance in medicine. He is the director of the World Health Organization's Global Challenge for Safer Surgical Care. In 2006, he received the MacArthur Award for his research and writing. His book COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. He was editor of THE BEST AMERICAN SCIENCE WRITING 2006. His most recent book, BETTER: A SURGEON'S NOTES ON PERFORMANCE is a New York Times bestseller and one of Amazon.com's ten best books of 2007.

8. What is DSS? Graphic: Smart art bullets stating : DSS is the VA�s official managerial cost accounting system that puts cost and workload together to tell us how much it costs to provide care and services to Veterans. Supports data-based decision making Primary Care, Home Based Primary Care, Geriatrics, and other programs use DSS data to evaluate performance DSS data supports resource management decisions Supports resource stewardship VA�s managerial cost accounting System As required by PL 101-576, Chief Financial Officer�s Act of 1990 A derived database that is compiled through the merging of standard VA cost data sources, such as the Financial Management System (FMS), and the workload capture systems of each VA Administration: Veterans Health Information Systems and Technology Architecture (VistA) � VHA DOORS and CWINRS � VBA MADSS - NCA The VA�s only system that provides detailed clinical and financial data at the patient level.Graphic: Smart art bullets stating : DSS is the VA�s official managerial cost accounting system that puts cost and workload together to tell us how much it costs to provide care and services to Veterans. Supports data-based decision making Primary Care, Home Based Primary Care, Geriatrics, and other programs use DSS data to evaluate performance DSS data supports resource management decisions Supports resource stewardship VA�s managerial cost accounting System As required by PL 101-576, Chief Financial Officer�s Act of 1990 A derived database that is compiled through the merging of standard VA cost data sources, such as the Financial Management System (FMS), and the workload capture systems of each VA Administration: Veterans Health Information Systems and Technology Architecture (VistA) � VHA DOORS and CWINRS � VBA MADSS - NCA The VA�s only system that provides detailed clinical and financial data at the patient level.

9. DSS Provides � Comparable cost and clinical information for use in: Making clinical decisions Managing workload Controlling health care costs Evaluating programs Measuring performance Graphic: photo of pencil and ruler on a pad of paper. Graphic: photo of pencil and ruler on a pad of paper.

10. Why do we have DSS? To meet Federal Managerial Cost Accounting (MCA) requirements To satisfy cost reporting requirements Congress Government Accountability Office (GAO) Office of Management and Budget (OMB) Others Graphic: Photo of US Capitol As required by PL 101-576, Chief Financial Officer�s Act of 1990 Other stakeholders include: Congress OMB GAO VA Secretary VA Office of Inspector General VA Office of the Under Secretary for Health Operations and Management VHA Office of Finance VHA Office of Business Oversight Allocation Resource Center VHA Office of Patient Care Services VHA Support Service Center Network directors and staff VA Medical Center directors and staff Freedom Of Information Act requests VHA Office of Research & Development Graphic: Photo of US Capitol As required by PL 101-576, Chief Financial Officer�s Act of 1990 Other stakeholders include: Congress OMB GAO VA Secretary VA Office of Inspector General VA Office of the Under Secretary for Health Operations and Management VHA Office of Finance VHA Office of Business Oversight Allocation Resource Center VHA Office of Patient Care Services VHA Support Service Center Network directors and staff VA Medical Center directors and staff Freedom Of Information Act requests VHA Office of Research & Development

11. Other Major Stakeholders Secretary of Veterans Affairs Under Secretary for Health Network and Facility Network Directors and staff Facility Directors and staff VA Offices and Programs Inspector General Operations and Management Allocation Resource Center (ARC) Business Oversight Patient Care Services Research and Development VHA Support Service Center (VSSC) Freedom of Information Act requests Office of Productivity, Efficiency and Staffing VA research includes HERC and VIREC. Resource Allocation Center (ARC) for VERA reimbursement Health Services Research & Development (HSR&D) VHA Support Service Center (VSSC) Office of Policy & Planning Primary Care Program Office Secretary of Veterans Affairs VA research includes HERC and VIREC. Resource Allocation Center (ARC) for VERA reimbursement Health Services Research & Development (HSR&D) VHA Support Service Center (VSSC) Office of Policy & Planning Primary Care Program Office Secretary of Veterans Affairs

12. DSS Data is Certified VISN Director provides annual certification to VHA Chief Financial Officer Under Secretary for Health Certifies that VISN uses DSS data for Budget formulation, allocationand execution Establishing prices for sharing Reporting cost to collect revenue Graphic: photo of pen writing signature on paperGraphic: photo of pen writing signature on paper

13. What DSS is Not: Billing System Not associated with Medicare or billing DSS calculates the actual cost to provide patient care services Costing is not driven by CPT codes CPT codes are recorded on encounters the same way ICD9 Codes and DRGs are Graphic: clip art picture of paper labeled �bill to� with red X over it. The Decision Support System (DSS) is VHA�s managerial cost accounting system. Managerial cost accounting is a costing methodology used to allocate costs to specific outputs. In VHA our business is taking care of patients. The �inputs� for doing this business include expenses for labor, supplies, equipment and overhead costs (all costs of doing business). The �outputs� of our business are the patient care activities delivered during a patient encounter. DSS is not a billing system, nor is it associated with Medicare reimbursement. DSS allows VHA to calculate the actual cost of providing care for every patient we serve, based on the resources used to provide the care. Graphic: clip art picture of paper labeled �bill to� with red X over it. The Decision Support System (DSS) is VHA�s managerial cost accounting system. Managerial cost accounting is a costing methodology used to allocate costs to specific outputs. In VHA our business is taking care of patients. The �inputs� for doing this business include expenses for labor, supplies, equipment and overhead costs (all costs of doing business). The �outputs� of our business are the patient care activities delivered during a patient encounter. DSS is not a billing system, nor is it associated with Medicare reimbursement. DSS allows VHA to calculate the actual cost of providing care for every patient we serve, based on the resources used to provide the care.

14. Managerial Cost Accounting 101 (Graphic shows clip art pictures of bakery items with price tags) Managerial cost accounting is all about figuring out the dollar amount of resources that is required to produce a product. This would be the dollar value of all labor, supplies, equipment and overhead required to produce a product. For example, different amounts of flour, sugar, eggs, and flavoring are used to produce various baked goods. These are the supplies. Different amounts of labor are needed for each of these bakery items. Different equipment is used to produce each of these items. And then, of course, there are the overhead costs such as gas, electricity, advertising, etc that are required to run the bakery. Managerial cost accounting principles are used to determine the dollar amounts of labor, supplies, equipment and overheard expenses for each product or service delivered to patients. As you can imagine, it should take more dollars to produce a simple glucose test than to produce an invasive radiology test. (Graphic shows clip art pictures of bakery items with price tags) Managerial cost accounting is all about figuring out the dollar amount of resources that is required to produce a product. This would be the dollar value of all labor, supplies, equipment and overhead required to produce a product. For example, different amounts of flour, sugar, eggs, and flavoring are used to produce various baked goods. These are the supplies. Different amounts of labor are needed for each of these bakery items. Different equipment is used to produce each of these items. And then, of course, there are the overhead costs such as gas, electricity, advertising, etc that are required to run the bakery. Managerial cost accounting principles are used to determine the dollar amounts of labor, supplies, equipment and overheard expenses for each product or service delivered to patients. As you can imagine, it should take more dollars to produce a simple glucose test than to produce an invasive radiology test.

15. MCA Requirements Smart Art graphic: shows three rectangular boxes with a long arrow at the bottom that crosses the three boxes. Left box has photo of ace bandage with a price tag and text that reads Cost of individual products and services Middle box has photo of hospital workers wearing white uniforms and text that reads Cost of specific work groups that provide products and services Right box has photo of hospital patients with neck brace and left arm bandaged, being cared for by a nurse. Text reads Full cost to treat patients. Cost of individual products and services means how much it costs to provide one blood test, a single x-ray or a nursing bedday of care. Cost of specific workgroups is a department cost. How much does it cost to operate the Blood Bank, or the Diagnostic Radiology department or a single nursing ward? Full cost to treat patients is the sum of all the individual items of care provided during an encounter. For inpatients this includes everything from the time the patient is admitted to the time they are discharged. The DSS encounter can tell you that the patient received an itemized list of products and services and the cost of each, then the total cost of the full encounter. These costs include overhead costs that trickle down to each product.Smart Art graphic: shows three rectangular boxes with a long arrow at the bottom that crosses the three boxes. Left box has photo of ace bandage with a price tag and text that reads Cost of individual products and services Middle box has photo of hospital workers wearing white uniforms and text that reads Cost of specific work groups that provide products and services Right box has photo of hospital patients with neck brace and left arm bandaged, being cared for by a nurse. Text reads Full cost to treat patients. Cost of individual products and services means how much it costs to provide one blood test, a single x-ray or a nursing bedday of care. Cost of specific workgroups is a department cost. How much does it cost to operate the Blood Bank, or the Diagnostic Radiology department or a single nursing ward? Full cost to treat patients is the sum of all the individual items of care provided during an encounter. For inpatients this includes everything from the time the patient is admitted to the time they are discharged. The DSS encounter can tell you that the patient received an itemized list of products and services and the cost of each, then the total cost of the full encounter. These costs include overhead costs that trickle down to each product.

16. How does DSS work? Graphic: picture of old man holding jars with lightening inside. Old woman is in the background pointing a stick at lightening and placing it in jars.Graphic: picture of old man holding jars with lightening inside. Old woman is in the background pointing a stick at lightening and placing it in jars.

17. DSS Meets MCA Regulations Accepts data from multiple sources Resources (cost and FTEE) Workload (products and services) Patients Blends this data Does not create data Graphic: clip art of blender with different types of fruit showing. In VA, patients receive many products and services. There are many software systems and databases in which data about patients, products and services are recorded. Graphic: clip art of blender with different types of fruit showing. In VA, patients receive many products and services. There are many software systems and databases in which data about patients, products and services are recorded.

18. 18 Three Main Types of DSS Data Costs Products (Workload) Patient [Graphics: Dollar sign beside the term ALB; photo of capsules beside the term DCM; silhouette of man in wheelchair with attendant, beside the term CCM.] There are 3 main categories of data in DSS Costs (ALB-Account Level Budgeter) Products which are workload-what your are producing (DCM-Department Cost Manager) Patient information (CCM-Clinical Cost Manager). Patient data includes cost and product data along with diagnostic and demographic information[Graphics: Dollar sign beside the term ALB; photo of capsules beside the term DCM; silhouette of man in wheelchair with attendant, beside the term CCM.] There are 3 main categories of data in DSS Costs (ALB-Account Level Budgeter) Products which are workload-what your are producing (DCM-Department Cost Manager) Patient information (CCM-Clinical Cost Manager). Patient data includes cost and product data along with diagnostic and demographic information

19. 19 DSS Gets Data from Extracts [Graphic: Computer with term �DSS Database� beneath it.] This slide displays some examples of DSS data sources. Data from these sources is extracted into DSS where it can be �mixed and matched.� Extracts from various locations are �fed� into DSS. Extracts include data from VistA packages, financial data, data from national databases such as NPCD, and other sources. [Graphic: Computer with term �DSS Database� beneath it.] This slide displays some examples of DSS data sources. Data from these sources is extracted into DSS where it can be �mixed and matched.� Extracts from various locations are �fed� into DSS. Extracts include data from VistA packages, financial data, data from national databases such as NPCD, and other sources.

20. Cost Inputs Dollars and hours from financial sources Payroll, equipment, supplies, overhead Must be linked to department where The employees work The supplies and equipment are used They are used to generate products Example: Cardiology Clinic Department What resources are needed to provide all the different types of clinic visits? [Graphic: Slide has green top and bottom margins, to represent Resources.] [Graphic: Bowl with �DCM� on it has 2 arrows pointing toward it � one from stack of dollar bills and one from a clock.] It is crucial that the resource data from financial sources is linked accurately with the deparment where they are used to product work.[Graphic: Slide has green top and bottom margins, to represent Resources.] [Graphic: Bowl with �DCM� on it has 2 arrows pointing toward it � one from stack of dollar bills and one from a clock.] It is crucial that the resource data from financial sources is linked accurately with the deparment where they are used to product work.

21. Workload Inputs Must have source system to capture workload (VistA) Workload is mapped to the department that produces the work Example: Cardiology Clinic DSS Workload called intermediate products Outpatient workload is associated with a stop code

22. Cardiology Clinic Example Resources Labor Supplies Equipment Workload 30 M MD visit 30 M EKG visit Graphics: Picture of clinicians Picture of Band-Aid Picture of sphygmomanometer Picture of stethoscope Picture of EKG machine Picture of file folders to represent patient clinic visit recordGraphics: Picture of clinicians Picture of Band-Aid Picture of sphygmomanometer Picture of stethoscope Picture of EKG machine Picture of file folders to represent patient clinic visit record

23. Workload Data Sources VistA Packages Source Examples Laboratory Mental Health Nursing IV Pharmacy Radiology Scheduling Surgery Workload Data Examples CBC lab test Group therapy visit Bed day of care IV Methicillin Chest x-ray 60 minute clinic visit 3 hours surgeon time Graphic � photo of hand holding pills Products and services provided to patients are termed workload. Most workload data comes from VistA packages.Graphic � photo of hand holding pills Products and services provided to patients are termed workload. Most workload data comes from VistA packages.

24. Patient Data Sources Sources VistA (CPRS) National Patient Care Database (NPCD) Patient Treatment Files (PTF) Resident Assessment Instrument (RAI) Alcohol Severity Index (ASI) Examples of Data SSN Age Eligibility DRG Treating specialty Provider Admit date Diagnosis Graphic: photo of person in wheelchair as seen from behind. Patient data is recorded in a number of different sources, including national patient databases and some VistA packagesGraphic: photo of person in wheelchair as seen from behind. Patient data is recorded in a number of different sources, including national patient databases and some VistA packages

25. No Single Source Has All Data Finance systems have resources but no workload VistA has workload but no resources Patient data is not connected with resource data

26. Sources Don�t Communicate Well Resources PAID Equipment Depreciation Payroll Accruals: Manual ... Workload VistA packages Nursing Pharmacy Radiology ... Graphic � box labeled Resources with PAID, Equipment Depreciation, Payroll Accruals, etc Graphic: box labeled Workload with VistA packages listed such as Nursing, pharmacy, radiology Graphic: box labeled Patient Data with sources of patient data listed such as NPCD, PTF, ASI We have sources of each type of data, but they are in different data systems and databases. It is difficult or impossible to combine them.Graphic � box labeled Resources with PAID, Equipment Depreciation, Payroll Accruals, etc Graphic: box labeled Workload with VistA packages listed such as Nursing, pharmacy, radiology Graphic: box labeled Patient Data with sources of patient data listed such as NPCD, PTF, ASI We have sources of each type of data, but they are in different data systems and databases. It is difficult or impossible to combine them.

27. Solution: Bring Source Data into DSS Graphic: Green bag labeled Resources � from financial sources Graphic: Blue bag labeled Workload � from VistA Graphic: purple bag labeled Patient Data from National patient databases We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records. Graphic: Green bag labeled Resources � from financial sources Graphic: Blue bag labeled Workload � from VistA Graphic: purple bag labeled Patient Data from National patient databases We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records.

28. Resources and Workload are �Married� Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records.

29. �Marriage� Happens in DSS Department Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows the dollar sign and test tube entering it We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows the dollar sign and test tube entering it We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records.

30. What is a DSS Department? Usually a subset of a service Examples: Nursing Wards, Primary Care Clinic, Clinical Lab, Unit Dose Pharmacy Manager Has responsibility Exercises control Distinct Workload Staff Graphic: cartoon showing business man going into cubical work environment A key concept in DSS is that of a department. In VHA there are many Services and Service Lines (Psychiatry, Radiology, Laboratory, Nursing, etc.) involved in patient care. Within each service there are distinct work areas that generate workload. For example, in Psychiatry Service there are mental health, psychiatry individual and group clinics to mention a few. In financial feeder systems, the costs and other resources (labor and supplies) tend to be grouped by Service. In DSS the resources are grouped by the distinct work areas that provide the products or services. These areas are called departments, and generally are smaller than Services. In the case of Laboratory, for example, there might be 3 departments: Chemistry, Microbiology and Pathology. If a lab technician works for the Chemistry lab, his or her salary and FTE/hours will be mapped specifically to that department. Costs of supplies and equipment used for Chemistry Lab testing will also be mapped to that department. Respiratory Therapy and Primary Care Clinic Team A are both DSS departments. In order to qualify as a department the work area must have distinct products or services, a discrete labor pool and a manager who has clearly defined areas of responsibility over which he/she exercises control. DSS departments are also known as Intermediate Product Departments, IPDs, IPD Numbers or production units. Graphic: cartoon showing business man going into cubical work environment A key concept in DSS is that of a department. In VHA there are many Services and Service Lines (Psychiatry, Radiology, Laboratory, Nursing, etc.) involved in patient care. Within each service there are distinct work areas that generate workload. For example, in Psychiatry Service there are mental health, psychiatry individual and group clinics to mention a few. In financial feeder systems, the costs and other resources (labor and supplies) tend to be grouped by Service. In DSS the resources are grouped by the distinct work areas that provide the products or services. These areas are called departments, and generally are smaller than Services. In the case of Laboratory, for example, there might be 3 departments: Chemistry, Microbiology and Pathology. If a lab technician works for the Chemistry lab, his or her salary and FTE/hours will be mapped specifically to that department. Costs of supplies and equipment used for Chemistry Lab testing will also be mapped to that department. Respiratory Therapy and Primary Care Clinic Team A are both DSS departments. In order to qualify as a department the work area must have distinct products or services, a discrete labor pool and a manager who has clearly defined areas of responsibility over which he/she exercises control. DSS departments are also known as Intermediate Product Departments, IPDs, IPD Numbers or production units.

31. DSS Department Receives dollars from finance sources Receives workload from VistA Uses cost and workload data to calculate cost for each product Also called DCM Department Managers need to know how information is organized in the DSS database. The key elements that make DSS a managerial cost accounting system are that all expenses are assigned (mapped) to the departments that produce patient care work. This is what allows us to associate cost with workload. In VHA we have many Services (Nursing, Medicine, Radiology, PM & R, Laboratory, etc) that provide patient care. Within each service there are distinct work areas that generate workload. For example, in Nursing Service there are many wards. In DSS each of those distinct wards is a DSS department and the resources (labor, supplies, equipment, overhead) used to produce the work (patient bedday) are associated with DSS department. Each piece of the work is captured and assigned to the department that produces it. Each piece of work can be costed, meaning that DSS can determine what it actually cost to produce each test or procedure. Each piece of work and its associated cost is recorded on a patient encounter record. Managers need to know which departments and products belong to them. Make sure that products are placed in the correct departments and are assigned product numbers from the nationally standardized list.Managers need to know how information is organized in the DSS database. The key elements that make DSS a managerial cost accounting system are that all expenses are assigned (mapped) to the departments that produce patient care work. This is what allows us to associate cost with workload. In VHA we have many Services (Nursing, Medicine, Radiology, PM & R, Laboratory, etc) that provide patient care. Within each service there are distinct work areas that generate workload. For example, in Nursing Service there are many wards. In DSS each of those distinct wards is a DSS department and the resources (labor, supplies, equipment, overhead) used to produce the work (patient bedday) are associated with DSS department. Each piece of the work is captured and assigned to the department that produces it. Each piece of work can be costed, meaning that DSS can determine what it actually cost to produce each test or procedure. Each piece of work and its associated cost is recorded on a patient encounter record. Managers need to know which departments and products belong to them. Make sure that products are placed in the correct departments and are assigned product numbers from the nationally standardized list.

32. Departments and Products: Examples Primary Care Clinic 15M Primary Care MD 45M Primary Care MD 30M Prim Nurse PA 15M Flu Shot 15M Pri Care Nurse Pract 30M Pri Care Nurse Pract 30M Adm/Screen Diagnostic Radiology Chest single view Chest 2 views PA&Lat Spine lumbosacral Hip 2 or more views Portable X-Ray Bone densitromity Chest include fluor

33. In the Department Products Receive Cost Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows the price tag on test tube We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows the price tag on test tube We�ve found sources for each type of data. But the resources have to be attached to the workload and placed on patient records.

34. Meanwhile, Patient Records are Created Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data We�ve found sources for each type of data. But the costed worklad must be placed on patient records. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data We�ve found sources for each type of data. But the costed worklad must be placed on patient records.

35. Product Cost Placed in Patient Records Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. The costed workload is placed on patient records. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. The costed workload is placed on patient records.

36. Result: Requirements Satisfied! Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information.

37. Result: Requirements Satisfied! Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information.

38. Result: Requirements Satisfied! Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information. Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags that shows test tube with price tag Graphic added � purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, now has test tube with price tag and cost of lab test and cost of other products listed on the patient record. Additional text added to graphic that states Specific work groups that provide products and services with arrow pointing to turquoise bowl, Cost of individual products and services with arrow pointing to test tube with price tag, Full cost to treat the patient with arrow pointing to patient folder that now has diagnostic, demographic and costed product information.

39. Each Department has a Companion Account Level Budgeter Cost Center (ALBCC) Holds resource hours and dollars Does not hold workload Allows reporting at account level Graphic: photo of elderly coupleGraphic: photo of elderly couple

40. The Final Piece: ALBCC Graphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags labeled Resources + Workload Graphic� purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, cost of products listed on the patient record Graphic added � clip art of piggy bank labeled with dollar sign and ALBCCGraphic: Green bag labeled Resources � from financial sources �with a dollar sign added Graphic: Blue bag labeled Workload � from VistA � with a test tube added Graphic: purple bag labeled Patient Data from National patient databases Graphic: turquoise bowl between green and blue bags labeled Resources + Workload Graphic� purple file folder labeled Patient X that lists age, diagnosis, and other demographic data, cost of products listed on the patient record Graphic added � clip art of piggy bank labeled with dollar sign and ALBCC

41. 41 What�s in DSS for You� Information to help you Manage your service or department Support resource requests Identify opportunities for improvement Prepare and monitor budgets Information about Patient groups and their care High risk/high cost populations Special populations (OEF/OIF, Women Veterans, etc) DSS is a decision support system. It provides information to support your decisions. Resource committees can use DSS information to help determine resource decisions.DSS is a decision support system. It provides information to support your decisions. Resource committees can use DSS information to help determine resource decisions.

42. How to get DSS information From local sources DSS team Clinical Coordinator Site Manager Local DSS Reports Database or dashboard From national sources Decision Support Office Program Designs reports based on requests DSS Reports available on the intranet

43. 43 DSS Reports DatabaseA source for local reports [Graphic shows a screen scrape from a DSS Reports Database listing Account Level Budgeter (ALB) Reports and Department Cost Manager (DCM) Reports.] This is a screen scrape of an Access Reports Database that some sites use for reporting local DSS data. You can see that the top left side of the screen is entitled �Account Level Budgeter (ALB) Reports� and that mapping, FTEE and cost type reports are available from this side. The top right side is entitled �Department Cost Manager (DCM) Reports�. Workload and cost are available from this side along with Relative Value Units and Productivity reports.[Graphic shows a screen scrape from a DSS Reports Database listing Account Level Budgeter (ALB) Reports and Department Cost Manager (DCM) Reports.] This is a screen scrape of an Access Reports Database that some sites use for reporting local DSS data. You can see that the top left side of the screen is entitled �Account Level Budgeter (ALB) Reports� and that mapping, FTEE and cost type reports are available from this side. The top right side is entitled �Department Cost Manager (DCM) Reports�. Workload and cost are available from this side along with Relative Value Units and Productivity reports.

44. What�s in it for VHA?FTEE Information Graphic: screen scrape of DSS FTEE Report for a primary care team. Graphic: screen scrape of DSS FTEE Report for a primary care team.

45. 45 Cost Reports: Salaries, Equipment, Supplies [Graphic: Costs by Account report for ALBCC 201LP1. Medical Machine Technician and Home Dialysis Equip & Supplies accounts are highlighted. Text box below: Partial Report.] This is an example of a cost report. Costs are indicated by month and by FYTD for accounts in ALBCC 201LP1.[Graphic: Costs by Account report for ALBCC 201LP1. Medical Machine Technician and Home Dialysis Equip & Supplies accounts are highlighted. Text box below: Partial Report.] This is an example of a cost report. Costs are indicated by month and by FYTD for accounts in ALBCC 201LP1.

46. Workload Report:Products, Volumes By Month [Graphic: Workload report for IPD MLP1. Text box below: Partial Report.] This workload report shows the volume of products used from IPD MLP1 during October, November and December.[Graphic: Workload report for IPD MLP1. Text box below: Partial Report.] This workload report shows the volume of products used from IPD MLP1 during October, November and December.

47. 47 National DSS Reports Support: Transformation 21 VA strategic initiatives Data-driven decision making Compare, measure, trend Identify best practices Disparities, variances Predictive analysis Graphic: clip art of female executive with brief case in front of bar chartGraphic: clip art of female executive with brief case in front of bar chart

48. 48 Locate DSS Reports Home Page [Graphic: Screen Print showing a partial view of the VSSC (VHA Support Service Center) website home page with a red arrow pointing to the link to the DSS Website located under Resource Management.] DSS Website portal on VSSC Home Page One way of linking to the Reports from DSS Clinical User Support, and perhaps the way most familiar to those of you in the field, is to go through the �DSS Portal� on the VHA Support Service Center (VSSC) home page on the VA Intranet. Using this link will take you to the �DSS Reports Home Page�. [Graphic: Screen Print showing a partial view of the VSSC (VHA Support Service Center) website home page with a red arrow pointing to the link to the DSS Website located under Resource Management.] DSS Website portal on VSSC Home Page One way of linking to the Reports from DSS Clinical User Support, and perhaps the way most familiar to those of you in the field, is to go through the �DSS Portal� on the VHA Support Service Center (VSSC) home page on the VA Intranet. Using this link will take you to the �DSS Reports Home Page�.

49. Locate DSS Reports Home Page Locate the DSS Reports Home Page [GRAPHICS: Illustration of DSS Reports Home Page. White text box with black text �https://vssc.med.va.gov/dss_reports/index.asp� superimposed near top of page to show URL for website. �VHA Reports Home� link in left side bar circled in red.]Locate the DSS Reports Home Page [GRAPHICS: Illustration of DSS Reports Home Page. White text box with black text �https://vssc.med.va.gov/dss_reports/index.asp� superimposed near top of page to show URL for website. �VHA Reports Home� link in left side bar circled in red.]

50. 50 Report Access Required forms: Graphic is computer with picture of lock Report Access Local Information Security Officer (ISO) is Point of Contact (POC) for the Access Process National Data Systems (NDS) is POC for Network and National SSN Access Required forms: VA Form 9957, �ACCESS FORM� - FPD � 110AL99 task code for ALL users - Additional levels of access available Department of Veterans Affairs (VA) Privacy Statement Agreement Not to Disclose DSS Data Nationwide Real SSN Justification Memo (VA Form 2105) for National Access Graphic is computer with picture of lock Report Access Local Information Security Officer (ISO) is Point of Contact (POC) for the Access Process National Data Systems (NDS) is POC for Network and National SSN Access Required forms: VA Form 9957, �ACCESS FORM� - FPD � 110AL99 task code for ALL users - Additional levels of access available Department of Veterans Affairs (VA) Privacy Statement Agreement Not to Disclose DSS Data Nationwide Real SSN Justification Memo (VA Form 2105) for National Access

51. Two Categories of DSS Clinical Reports Two Categories of DSS Clinical Reports GRAPHICS: Image of DSS VHA Reports Home Page with mouse-over to the right of �Reports from Clinical User Support� left sidebar link. Two white text boxes with red text. Upper right text box, with red broken-lined arrow pointing to top part of mouse-over �Patient Centric�, contains text �Patient (SSN) specific utilization for the timeframe selected�. Lower text box with red broken-lined arrow pointing to bottom part of mouse-over �Station Centric�, contains text �Summary Level detail for the timeframe selected�. Two Categories of DSS Clinical Reports GRAPHICS: Image of DSS VHA Reports Home Page with mouse-over to the right of �Reports from Clinical User Support� left sidebar link. Two white text boxes with red text. Upper right text box, with red broken-lined arrow pointing to top part of mouse-over �Patient Centric�, contains text �Patient (SSN) specific utilization for the timeframe selected�. Lower text box with red broken-lined arrow pointing to bottom part of mouse-over �Station Centric�, contains text �Summary Level detail for the timeframe selected�.

52. 52 Patient Centric:Resource Utilization & Cost (Introduction) OEF/OIF Reports from Decision Support System (DSS) GRAPHICS: clip art picture of US Map with 7 dollar signs overlaid to show where a patient may have received care throughout the VA system. (Introduction) OEF/OIF Reports from Decision Support System (DSS) GRAPHICS: clip art picture of US Map with 7 dollar signs overlaid to show where a patient may have received care throughout the VA system.

53. Patient Centric Report Categories Patient Centric Report Categories [GRAPHICS: Illustration of DSS VHA Patient Centric Reports from Clinical User Support Page. Red circle around �Patient Centric Reports� title on page. Categories shown: Patient Total Cost Reports Medical (ICD-9) Specific Reports Mental Health Specific Reports Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Specific Reports Program Specific Reports ] Patient Centric Report Categories [GRAPHICS: Illustration of DSS VHA Patient Centric Reports from Clinical User Support Page. Red circle around �Patient Centric Reports� title on page. Categories shown: Patient Total Cost Reports Medical (ICD-9) Specific Reports Mental Health Specific Reports Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Specific Reports Program Specific Reports ]

54. DSS Report Data Definitions Data sources Time reference Inclusions, exclusions Data elements Glossary of terms Formulas or calculations Caveats Help Desk Graphic: clip art man in suit, talking on phone and looking at reportGraphic: clip art man in suit, talking on phone and looking at report

55. Co-Morbidity / Multiple Diagnoses: Resource Utilization and Cost by SSN Age and Cost Categories Report [Graphics: screen scrape of the Medical Co-Morbidity/Multiple Diagnosis: Resource Utilization and Cost by SSN report selection page][Graphics: screen scrape of the Medical Co-Morbidity/Multiple Diagnosis: Resource Utilization and Cost by SSN report selection page]

56. [Graphics: chart showing data from Co-Morbidity / Multiple Diagnoses: Resource Utilization and Cost by SSN Age and Cost Categories Report for years 2007-2009 highlighting diabetes, AMI and Hypertension.] [Graphics: chart showing data from Co-Morbidity / Multiple Diagnoses: Resource Utilization and Cost by SSN Age and Cost Categories Report for years 2007-2009 highlighting diabetes, AMI and Hypertension.]

57. [Graphics: chart showing data from Mental Health Co-Morbidity / Multiple Diagnoses: Resource Utilization and Cost by SSN Report for years 2007-2009 highlighting depressions, PTSD and Anxiety. PTSD includes Adjustment Disorders including PTSD. Anxiety includes Personality Disorders.][Graphics: chart showing data from Mental Health Co-Morbidity / Multiple Diagnoses: Resource Utilization and Cost by SSN Report for years 2007-2009 highlighting depressions, PTSD and Anxiety. PTSD includes Adjustment Disorders including PTSD. Anxiety includes Personality Disorders.]

58. Primary Care Report Selection Page �Primary Care� report Selection Page This is an illustration of the �selection page� for the Primary Care report (brief overview of selection process; left to right, top row then bottom row), options chosen based on the Service Chief�s assignment: to report on the kinds of diagnoses he is finding among his female OIF/OEF population aged 25-34 years for FY 2009. (You will be seeing that the DSS Reports� selection pages are all similar in appearance and function. For those of you familiar with VSSC�s reports, many of these are similar in appearance as well.) Notes: - �Reminder��FOR GOVERNMENT USE ONLY - �Data Definitions� top of each selection page (as well as in category list shown on previous slide) - Report name and a brief description of features top of each selection page - Option to download to standard web report, as we will use for this presentation; or to Excel Spreadsheet format - Once all choices made, click �SUBMIT� GRAPHICS: Image of DSS �Primary Care� Report selection page from VA Intranet. Red circle around �Data Definitions�, center top of page. Selections indicated by blue rectangles in each selection box: Fiscal Year 2009; Summary Level Station; Finest Breakout Level (none selected�Station level only report) (white text box with black text �Network, Station, Division� added under �Finest Breakout Level� to show its availability when various �Summary Levels� chosen); Population OEF/OIF; Report Selection �Medical Diagnosis Groupings; Age Groupings 24-35; Gender Female; Select Facility (none shown); Cohort Groupings (Last 4 Quarters) SELECT ALL OEF/OIF; Major Diagnosis (selection not shown). Blue text box with white text added under �Major Diagnosis� box indicating �14 Medical Diagnoses� and �10 Mental Health Diagnoses Categories� are available. Red curved double arrow to right of box containing words �Standard Web Report� over �Download to Microsoft Excel�; arrow pointing �from� �Standard Web Report� to �Download to Microsoft Excel� to highlight availability of these two report formats. Hand with index finger over gold-colored shape pointing to �Submit� button to emphasize this final step in report selection process.�Primary Care� report Selection Page This is an illustration of the �selection page� for the Primary Care report (brief overview of selection process; left to right, top row then bottom row), options chosen based on the Service Chief�s assignment: to report on the kinds of diagnoses he is finding among his female OIF/OEF population aged 25-34 years for FY 2009. (You will be seeing that the DSS Reports� selection pages are all similar in appearance and function. For those of you familiar with VSSC�s reports, many of these are similar in appearance as well.) Notes: - �Reminder��FOR GOVERNMENT USE ONLY - �Data Definitions� top of each selection page (as well as in category list shown on previous slide) - Report name and a brief description of features top of each selection page - Option to download to standard web report, as we will use for this presentation; or to Excel Spreadsheet format - Once all choices made, click �SUBMIT� GRAPHICS: Image of DSS �Primary Care� Report selection page from VA Intranet. Red circle around �Data Definitions�, center top of page. Selections indicated by blue rectangles in each selection box: Fiscal Year 2009; Summary Level Station; Finest Breakout Level (none selected�Station level only report) (white text box with black text �Network, Station, Division� added under �Finest Breakout Level� to show its availability when various �Summary Levels� chosen); Population OEF/OIF; Report Selection �Medical Diagnosis Groupings; Age Groupings 24-35; Gender Female; Select Facility (none shown); Cohort Groupings (Last 4 Quarters) SELECT ALL OEF/OIF; Major Diagnosis (selection not shown). Blue text box with white text added under �Major Diagnosis� box indicating �14 Medical Diagnoses� and �10 Mental Health Diagnoses Categories� are available. Red curved double arrow to right of box containing words �Standard Web Report� over �Download to Microsoft Excel�; arrow pointing �from� �Standard Web Report� to �Download to Microsoft Excel� to highlight availability of these two report formats. Hand with index finger over gold-colored shape pointing to �Submit� button to emphasize this final step in report selection process.

59. Station/Division Summary Level �Primary Care� report Station/Division Summary Level �Primary Care� report Here is a sample of the left portion of the report in the Standard Web download format, based on the selections that were made on the selection page in order to assist the Primary Care Line Service Chief with the task he has been assigned (to report on the kinds of diagnoses he is finding among his female OEF/OIF population aged 25-34 years in FY 2009. What observations or questions do you have about this report? (Comment on: report labeled for selections made (as described), OEF/OIF data source, �rolling four quarters�, multiple co-morbidities, numbers and percents, red underlined numbers = drilldown) GRAPHICS: Image of right (�Medical Diagnosis�) portion DSS �Primary Care: Multiple Diagnoses, Utilization and Workload� Report, showing 14 Medical Diagnoses seen at any stop code; Station Summary for FY 09, OEF/OIF Population, Female only, 25 to 34 years, All Diagnosis. In Report title, �any Stop Code�, �Station Summary� (Station identity obscured for privacy), �FY09�, �OEF/OIF Patient Population�, �Female�, �25 to 34 years�, and �rolling 4 quarters� highlighted gray. �OEF/OIF Data Source Release: 71 Updated Thru: October, 2009 Total OEF/OIF Count of: 1,094,502� circled in red, with �OEF/OIF Data Source Release� and �Count of: 1,094,502� highlighted in gray. �Medical Diagnosis above column headers circled in red. Cells in the sixth column from the left with �CAD� header, enclosed in red rectangle. Red arrow points from�4.1%� in �bottom (�Station�) row to �8.5%� in top (�National�) row. Cells in the third column from the right with �Lipid Disorder� header, enclosed in red rectangle. Red arrow points from�19.7%� in �bottom (�Station�) row to �12.6%� in top (�National�) row.Station/Division Summary Level �Primary Care� report Here is a sample of the left portion of the report in the Standard Web download format, based on the selections that were made on the selection page in order to assist the Primary Care Line Service Chief with the task he has been assigned (to report on the kinds of diagnoses he is finding among his female OEF/OIF population aged 25-34 years in FY 2009. What observations or questions do you have about this report? (Comment on: report labeled for selections made (as described), OEF/OIF data source, �rolling four quarters�, multiple co-morbidities, numbers and percents, red underlined numbers = drilldown) GRAPHICS: Image of right (�Medical Diagnosis�) portion DSS �Primary Care: Multiple Diagnoses, Utilization and Workload� Report, showing 14 Medical Diagnoses seen at any stop code; Station Summary for FY 09, OEF/OIF Population, Female only, 25 to 34 years, All Diagnosis. In Report title, �any Stop Code�, �Station Summary� (Station identity obscured for privacy), �FY09�, �OEF/OIF Patient Population�, �Female�, �25 to 34 years�, and �rolling 4 quarters� highlighted gray. �OEF/OIF Data Source Release: 71 Updated Thru: October, 2009 Total OEF/OIF Count of: 1,094,502� circled in red, with �OEF/OIF Data Source Release� and �Count of: 1,094,502� highlighted in gray. �Medical Diagnosis above column headers circled in red. Cells in the sixth column from the left with �CAD� header, enclosed in red rectangle. Red arrow points from�4.1%� in �bottom (�Station�) row to �8.5%� in top (�National�) row. Cells in the third column from the right with �Lipid Disorder� header, enclosed in red rectangle. Red arrow points from�19.7%� in �bottom (�Station�) row to �12.6%� in top (�National�) row.

60. Primary Care Report Drill-Down Primary Care report Drill-down This illustrates the information available in the �drill down� on the Medical Diagnosis selection for the �Primary Care� report, this time in the �Standard Web Report� format. What observations or questions do you have in looking at this slide? While obscured for this presentation, Actual SSNs for individual patients are shown�What value might this feature have? What drawbacks? (Notes�possible comments) -Female population selected, thus only female gender on this report. -Drill down was from red underlined number in a column labeled �Arthritis & Arthropathy�, so this is first diagnosis to appear among the 14 represented on the �drill down�. -Multiple co-morbidities in some cases. -Relatively young age group to be coded with some of these diagnoses? -Preponderance of �Depression� in OEF/OIF population? GRAPHICS: Illustration of portion of DSS �Primary Care�� �Drill down� Report in Standard Web format from VA Intranet showing columns for 14 Medical Diagnosis associated with records of OEF/OIF female patients, ages 25 to 34 years, seen at any Stop Code at a Station in FY 08. Orange text in �Arthritis/Arthroscopy� column (15th from left) indicates drill down is from that column. Network, Station identity and �Real SSN� data (individual patient identity) obscured for privacy of data. Gray highlight in rows 8 and 10 where there are six out of a possible 14 diagnoses shown for these two individuals. Primary Care report Drill-down This illustrates the information available in the �drill down� on the Medical Diagnosis selection for the �Primary Care� report, this time in the �Standard Web Report� format. What observations or questions do you have in looking at this slide? While obscured for this presentation, Actual SSNs for individual patients are shown�What value might this feature have? What drawbacks? (Notes�possible comments) -Female population selected, thus only female gender on this report. -Drill down was from red underlined number in a column labeled �Arthritis & Arthropathy�, so this is first diagnosis to appear among the 14 represented on the �drill down�. -Multiple co-morbidities in some cases. -Relatively young age group to be coded with some of these diagnoses? -Preponderance of �Depression� in OEF/OIF population? GRAPHICS: Illustration of portion of DSS �Primary Care�� �Drill down� Report in Standard Web format from VA Intranet showing columns for 14 Medical Diagnosis associated with records of OEF/OIF female patients, ages 25 to 34 years, seen at any Stop Code at a Station in FY 08. Orange text in �Arthritis/Arthroscopy� column (15th from left) indicates drill down is from that column. Network, Station identity and �Real SSN� data (individual patient identity) obscured for privacy of data. Gray highlight in rows 8 and 10 where there are six out of a possible 14 diagnoses shown for these two individuals.

61. 61 Station Centric:Resource Utilization & Cost (Introduction) OEF/OIF Reports from Decision Support System (DSS) GRAPHICS: clip art picture of the state of OHIO with a single dollar sign to represent patient treatment at a single VA facility. (Introduction) OEF/OIF Reports from Decision Support System (DSS) GRAPHICS: clip art picture of the state of OHIO with a single dollar sign to represent patient treatment at a single VA facility.

62. Station Centric Report Categories Station Centric Report Categories [GRAPHICS: Illustration of DSS VHA Station Centric Reports from Clinical User Support Page. Red circle around �Station Centric Reports� title on page. 14 Categories shown, each with a list of reports: Outpatient Cost (10 reports) Inpatient Cost (11 reports) Patient Total Cost (2 reports) Mental Health Specific (2 reports)and OEF/OIF Related (22), Program Specific (7), Procedure Specific (2), Laboratory (9), Pharmacy (3), Radiology (7), Audit Reports (7), Staffing Specific (4), Department/Cost Center (ALBCC) (link to Financial User Support Reports here), and NDE File Download. Outpatient Cost Reports Inpatient Cost Reports Patient Total Cost Reports Mental Health Specific Reports Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Specific Reports Program Specific Reports Procedure Specific Reports Laboratory Reports Pharmacy Reports Radiology Reports Audit Reports Staffing Specific Reports Department/Cost Reports (ALBCC) NDE File Download] Station Centric Report Categories [GRAPHICS: Illustration of DSS VHA Station Centric Reports from Clinical User Support Page. Red circle around �Station Centric Reports� title on page. 14 Categories shown, each with a list of reports: Outpatient Cost (10 reports) Inpatient Cost (11 reports) Patient Total Cost (2 reports) Mental Health Specific (2 reports)and OEF/OIF Related (22), Program Specific (7), Procedure Specific (2), Laboratory (9), Pharmacy (3), Radiology (7), Audit Reports (7), Staffing Specific (4), Department/Cost Center (ALBCC) (link to Financial User Support Reports here), and NDE File Download. Outpatient Cost Reports Inpatient Cost Reports Patient Total Cost Reports Mental Health Specific Reports Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Specific Reports Program Specific Reports Procedure Specific Reports Laboratory Reports Pharmacy Reports Radiology Reports Audit Reports Staffing Specific Reports Department/Cost Reports (ALBCC) NDE File Download]

63. Cost and Workload for Selected DSS Clinic Stop / Credit Stop [Graphics: screen scrape of the Cost and Workload for Selection DSS Clinic Stop/Credit Stop report selection page] [Graphics: screen scrape of the Cost and Workload for Selection DSS Clinic Stop/Credit Stop report selection page]

64. [Graphics: screen scrape of the Cost and Workload for Selection DSS Clinic Stop/Credit Stop report output from selections from previous page] Number unique no shows Average act enctr per unique[Graphics: screen scrape of the Cost and Workload for Selection DSS Clinic Stop/Credit Stop report output from selections from previous page] Number unique no shows Average act enctr per unique

65. Drill-Down Features Partial report Graphic: screen scrape of partial report that shows the drill down to real SSN information (SSNs removed for privacy) along with stop code, geographic indicator, date of encounter, enrollment priority, patient type, zip code and ICD9 code.Graphic: screen scrape of partial report that shows the drill down to real SSN information (SSNs removed for privacy) along with stop code, geographic indicator, date of encounter, enrollment priority, patient type, zip code and ICD9 code.

66. Total Cost by Treating Specialty (TRT) by Major Components Report [Graphics: screen scrape of the Total Cost by Treating Specialty (TRT) by Major Components report selection page] [Graphics: screen scrape of the Total Cost by Treating Specialty (TRT) by Major Components report selection page]

67. [Graphics: screen scrape of the Total Cost by Treating Specialty (TRT) by Major Components report output from selections made from report from previous page][Graphics: screen scrape of the Total Cost by Treating Specialty (TRT) by Major Components report output from selections made from report from previous page]

68. Total Cost by Diagnostic Related Groups (DRG) by Major Components [Graphics: screen scrape of the Total Cost by Diagnostic Related Groups (DRG) by Major Components report selection page] [Graphics: screen scrape of the Total Cost by Diagnostic Related Groups (DRG) by Major Components report selection page]

69. Cost by DRG - NationalOEF/OIF � DRG 885 Psychosis Graphic: Partial report screen of DRG 885 national level report that lists DRG, Total Cost, Total bed days, number of discharges, average length of stay, unique patients and the national average cost per discharge.Graphic: Partial report screen of DRG 885 national level report that lists DRG, Total Cost, Total bed days, number of discharges, average length of stay, unique patients and the national average cost per discharge.

70. Network by Station Data Partial Report Graphic: Screen scrape of partial report that now shows DRG 885 for a network by station. Station identification removed for privacy. This allows managers to compare DRG costs across facilities within a network, and to national average cost.Graphic: Screen scrape of partial report that now shows DRG 885 for a network by station. Station identification removed for privacy. This allows managers to compare DRG costs across facilities within a network, and to national average cost.

71. Communication is Key Regular discussions between managers and DSS staff Review and validate report data Correct any mapping/workload errors Discuss report information with top leaders Understand Source data Data definitions Graphic: clip art picture of business people at meeting tableGraphic: clip art picture of business people at meeting table

72. 72 What you can do now� Examine your DSS report data Verify the accuracy of the data Discussions with DSS staff Proper coding input = Reliable data output [Graphic depicts a man and a woman looking at a computer screen.] Use your data because it is being used by others. When DSS data is used it is often improved! (Instead of new and improved, think used and improved!) Real life example: GI (Gastrointestinal or Gastroenterology) service told DSS staff to map their employees performing GI endoscopies to the DSS Endo department with the result of GI staff being mapped to Endocrinology.[Graphic depicts a man and a woman looking at a computer screen.] Use your data because it is being used by others. When DSS data is used it is often improved! (Instead of new and improved, think used and improved!) Real life example: GI (Gastrointestinal or Gastroenterology) service told DSS staff to map their employees performing GI endoscopies to the DSS Endo department with the result of GI staff being mapped to Endocrinology.

73. How is the data used by VA? Identify Cost and workload Resource utilization Vulnerable patients Variances; disparities Best practices Measure for Program outcomes Predictive analysis Graphic: Clip art picture shadow of man in suit using measuring tape Congressional reports How much does it cost to treat OEF/OIF patients Evaluate program effectiveness Do HBPC patients have fewer hospitalizations? Does telehealth care reduce cost and prevent exacerbations Monitor trends and plan for future treatment programs Female Veterans Polytrauma Graphic: Clip art picture shadow of man in suit using measuring tape Congressional reports How much does it cost to treat OEF/OIF patients Evaluate program effectiveness Do HBPC patients have fewer hospitalizations? Does telehealth care reduce cost and prevent exacerbations Monitor trends and plan for future treatment programs Female Veterans Polytrauma

74. 74 Why should you care? [Graphic shows person wearing a hat with there face covered by a newspaper they are holding. The newspaper has a hole in it with the person�s eye visible.][Graphic shows person wearing a hat with there face covered by a newspaper they are holding. The newspaper has a hole in it with the person�s eye visible.]

75. 75 Why should you care? Even if you aren�t using your DSS information, someone else is! [Graphic shows person wearing a hat with there face covered by a newspaper they are holding. The newspaper has a hole in it with the person�s eye visible.][Graphic shows person wearing a hat with there face covered by a newspaper they are holding. The newspaper has a hole in it with the person�s eye visible.]

76. DSS Data and DSS Reports Congressional reports VA Secretary reports Undersecretary Annual Report 10N Facility Profile Report VHACO Program Offices National summary level VISN summary level Station summary level Graphic: Picture of blue ribbon with first place written on it.Graphic: Picture of blue ribbon with first place written on it.

77. 77 Summary Summary Decision Support System ( DSS) Managerial Cost Accounting (MCA) System for the Department of Veterans Affairs Provides Reports on the DSS Reports Website User Friendly Helpful for data driven decision making Identify and Analyze Resource Utilization, Workload, Cost Co-Morbidities: Medical and Mental Health Patient Demographic Data Graphic logo is specific for the 2009 DSS User Conference: Discover DSS Treasures. There is a picture of an open treasure chest on a beach. In the background are crashing waves from the ocean. In the lower left hand corner is the VA logo and Department of Veterans Affairs. Summary Decision Support System ( DSS) Managerial Cost Accounting (MCA) System for the Department of Veterans Affairs Provides Reports on the DSS Reports Website User Friendly Helpful for data driven decision making Identify and Analyze Resource Utilization, Workload, Cost Co-Morbidities: Medical and Mental Health Patient Demographic Data Graphic logo is specific for the 2009 DSS User Conference: Discover DSS Treasures. There is a picture of an open treasure chest on a beach. In the background are crashing waves from the ocean. In the lower left hand corner is the VA logo and Department of Veterans Affairs.

78. 78 Learn More Visit the DSO Learning Community at http://vaww.teamshare.finance.va.gov/sites/dso/default.aspx Training available in LMS Use this keyword to locate national DSS training: DSO

79. Questions Graphic: clip art showing character with box of parts and question marks.Graphic: clip art showing character with box of parts and question marks.

80. Acronym Reference ACCOUNT LEVEL BUDGETER (ALB) A financial subsystem of DSS used to record actual and budgeted expenses and hours at the ALBCC, account and job code level. ACCOUNT LEVEL BUDGETER COST CENTER (ALBCC) A unique code assigned in DSS to identify a unique organizational unit (e.g., 204MM1 is Primary Care). ALBCCs are centers of function for which expenses and hours are accumulated. ALBCCs are generally associated one-for-one with DSS Departments (e.g., ALBCC 204MM1 = IPD AMM1). An exception to this rule is department 5WW1, which has more than one ALBCC associated with it. ACCOUNT CODE A seven-digit (VHA) or eight-digit (VBA, NCA) identifier comprised of a four-digit VA Budget Object Code (BOC), followed by a three-or-four digit VA cost center (e.g., 2631224, where 2631 is the BOC, and 224 is VHA cost center). Account code is part of the input data from financial extracts (feeder key) and the ALB structure. Account codes are also referred to as General Ledger (GL) accounts. Consolidated Memorandum of Receipt (CMR) Record of facility equipment maintained locally

81. Acronym Reference DEPARTMENT COST MANAGER (DCM) A cost accounting module in DSS, providing reports that assist with controlling costs and improving productivity at the department level. DCM retains budget and actual volumes (workload), costs, and hours for facility departments. DEPARTMENT Within DSS, a subset of a service, an organizational unit in which the manager has clearly defined areas of responsibility (e.g., Medicine may have multiple departments like Cardiology, Pulmonary, Endocrine, etc. DIAGNOSIS RELATED GROUP (DRG) A system to classify hospital cases into one of approximately 500 groups, expected to have similar hospital resource use. Initially developed for Medicare as part of the prospective payment system, DRG's are assigned by a "grouper" program based on diagnoses, procedures, and the presence of complications or co-morbidities. As of October 1, 2007, with version 25, the CMS DRG system re-sequenced the groups and the newly re-sequenced DRG are now known as MS-DRG. See MS-DRG DECISION SUPPORT OFFICE (DSO) The program office of the VHA Office of Finance that maintains the Veterans Affairs (VA) designated Managerial Cost Accounting System, DSS

82. Acronym Reference ENCOUNTER (DSS). A record of an inpatient stay or outpatient visit that includes clinical, demographic, and utilization information related to the stay or visit. Inpatient Encounter Records include all activities that take place during the VistA inpatient admission beginning on the date/time of admission and ending on the date/time of discharge. DSS defines outpatient encounters as each unique combination of SSN + Julian Date + Primary Stop Code. ENCOUNTER (HIMS) An encounter is a professional contact between a patient and a practitioner vested with responsibility for diagnosing, evaluating, and treating the patient�s condition. Encounters occur in both the outpatient and inpatient setting. Contact can include face-to-face interactions or those accomplished via telecommunications technology. Financial Management System (FMS) VA Financial system FISCAL YEAR (FY) The VA accounting year covering the period October 1st through the following September 30th. FISCAL PERIOD (FP) In DSS, the fiscal periods correspond with the months in the VA�s fiscal year. For example, FP 1 = October, FP 2 = November, etc. INTERMEDIATE PRODUCT (IP) Number The procedures and services used in treating patients that make up the majority of the business done within each department. Examples of intermediate products are lab tests, nursing hours, or operating room time. Each intermediate product has a unique number that identifies the product. Product numbers are nationally standardized. MAPPING In DSS this is the act of directing or pointing information to a location. The costs from FMS and PAID (i.e. labor, supply, and depreciated capital costs) are mapped to ALBCCs. NDE (NATIONAL DATA EXTRACT) Summarized data extracted from DSS production databases and stored in files at the AITC. The NDE provides information for national initiatives such as the VERA model, and is the basis for DSS reports on the VSSC website. Reconciled to FMS and other data feeds. Produced on a monthly and quarterly basis. Additional information is available at: http://vaww.dss.med.va.gov/nationalrptg/nr_extracts.asp

83. Acronym Reference PATIENT CENTRIC REPORTS A group of DSS reports based upon individual patient information for system-wide resource utilization and cost, reflecting national data for unique patients' encounters and cost. Patient-centric reports are useful in identifying VHA's patients with multiple co-morbid diagnoses, high resource utilization, and high cost indicating the most vulnerable patients, who may benefit from coordinated care services. PRIMARY STOP CODE The first three digits of the DSS Identifier represent the primary stop code. The primary stop code designates the main clinical group or production unit responsible for the clinic. See DSS Identifier RELATIVE VALUE UNIT (RVU) Weighted units of measure that allow for the relative comparison between different complexities and mixes of intermediate products. RVUs take into account the differing amounts of input, such as labor or materials, required for the different intermediate products. Supplies have RVUs measured in dollars. Personnel (labor) RVUs would be measured in minutes. SECONDARY STOP CODE/CREDIT STOP The last three numbers of the DSS Identifier contain the secondary or credit stop code, which the VA Medical Center may use as a modifier to further define the primary work group. See also CREDIT STOP. STOP CODE/ DSS IDENTIFIER DSS Identifiers are used to identify workload for all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient billable professional services. They are the single and critical designation by which VHA defines clinical work units for costing purposes. DSS identifiers indicate the primary work group that is responsible for providing the specific set of clinic products and serve as an identification method that can be used to compare costs between facilities. The DSS Identifier is a six-character descriptor , consisting of a primary stop code and a secondary stop code, which is transmitted to the National Patient Care Database (NPCD) with each separate outpatient encounter into the NPCD field "DSS Identifier."

84. Acronym Reference TREATING SPECIALTY (TRT) The numeric code for an inpatient service or special care area (such as General Medicine, Surgery, Psychiatry) which best describes the type of care needed by the patient. For more information: http://vaww.va.gov/NDS/PatientTreatmentFile.asp UNIQUE PATIENT (Unique SSN) One person (individual patient), historically identified by Social Security Number. Any DSS encounter with a valid SSN that has workload and cost attached will be identified as a unique SSN. A patient that receives medications from the CMOP or receives a prosthetic device from the DDC without having an actual face-to-face encounter will be counted as a unique. On the DSS reports that do not remove deceased patients, a deceased patient is considered a unique patient if the SSN receives any cost or workload during the selected time period. VA COST CENTER Cost centers are standardized six character, non-budgetary, organization codes used to record expenditures of funds by various organizations within VA. Cost centers identify global service units such as Laboratory, Pharmacy, Social Work or Fiscal Service. For more information: http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=141&FType=2 WORKLOAD The volume of work (units of service) performed. The outputs of products and services resulting from the input of supplies, labor and equipment. Workload is recorded as an Intermediate Product in a DSS Department. (See Intermediate Product)