March 2019 Town Hall With CROWNWeb Outreach, Communication, and Training (OCT) March 28, 2019 2PM to 3PM ET
Submitting Questions Type questions in the Q&A section, located in the top right corner of your screen. Send all Q&A questions to All Panelists Note: Some questions may require additional research. Unanswered questions may be submitted to CRAFT@MyCROWNWeb.org. 2
Today s Host and Presenters P. Nicole Crenshaw, MPA Contract Officer s Representative (COR) EQRS Business Owner Kirsten Keating Communications Manager Michael Seckman Training Manager 3
Latest News and Reminders
Clinical Closures Clinical Month(s) January 2019 February 2019 March 2019 Date of Closure for Clinical Submissions April 1, 2019 at 11:59 PM PT April 30, 2019 at 11:59 PM PT May 31, 2019 at 11:59 PM PT Clinical closures apply to all Collection Types. Clinical data submission applies to all submission methods. 5
April System Maintenance The EQRS and CROWNWeb Systems will be unavailable for system maintenance from 8:00 PM ET until 8:00AM ET Friday, April 12th, 2019 until Sunday, April 14th, 2019 Friday, April 26th, 2019 until Sunday, April 28th, 2019 6
Data Management Guidelines
Poll Question #1 When was the last time you viewed the current Data Management Guidelines? A. Within the last week B. Within the last month C. Never 8
What is New? Document Name Removal of Out of Date Information Addition of New ESRD Systems Modification to CMS Initiatives Additional revisions throughout the document 9
The New Title End-Stage Renal Disease Systems Data Management Guidelines With the continued effort of combining the legacy systems (REMIS, ESRD Quality Incentive Program [QIP], CROWNWeb) into a single system (EQRS), the Data Management Guidelines (DMG) have been expanded to encompass all ESRD Systems. 10
The New Look A one stop guide for Data Monitoring, Measuring, and Managing within the ESRD Systems A new cover has been created to enhance it s uniqueness 11
The Purpose To standardize data management processes created, reviewed, and approved by CMS. System users should reference these guidelines when overseeing data entry and reporting efforts. Tasks to be completed by system users and submission timelines are identified in this ESRD Systems Data Management Guidelines document. These tasks fall into three categories: Data Monitoring consists of policies, processes, and practices that address the accuracy, validity, completeness, timeliness, and integrity of data (data quality). Data Quality Measuring quantifies quality of care through comparison to a criterion. Quality measurements typically focus on structures or processes of care that have a demonstrated relationship to positive health outcomes. Data Quality Managing consists of the business processes that ensure the integrity of an organization's data during collection, application (including aggregation), warehousing, and analysis. 12
ESRD Systems Data Manager A Data Manager is defined as any authorized user who oversees or assists with promoting data quality by monitoring, contributing to data effectiveness by measuring, and ensuring data reliability by managing accurate and timely data submissions. There are three tiers of Data Managers who complete monitoring, measuring, and managing activities that support accurate and timely reporting of data via ESRD Systems. These users are as follows: Tier 1 Individuals or groups that enter patient and facility details into ESRD Systems. Tier 2 Individuals or groups that provide technical data reporting assistance. Tier 3 Individuals or groups that support CMS data reporting 13 needs.
Tier 1 Data Manager Individuals or groups that manually enter patient and facility details directly into ESRD Systems, or those affiliated with an organization that electronically uploads information on behalf of a facility. Tier 1 Data Managers include facility-level users and Electronic Data Interface (EDI) submitters. Category Section Task Frequency Data Monitoring Facility Dashboard Facilities Personnel Reports Monitor Facility Dashboard Monitor Facility Attestation Monitor Facility Summary Review Personnel Generate Missing Forms and Saved Status Reports At least Weekly Between January 1 and the end of February of each year By December 31 of each year At least quarterly At least monthly 14
Tier 2 Data Manager Individuals or groups that provide technical data reporting assistance. Tier 2 Data Managers primarily monitor data reporting efforts to foster accurate and timely submissions by Tier 1 users. Tier 2 Data Managers input data directly into ESRD Systems to support data reporting requirements. Tier 2 users analyze report data to determine appropriate support activities for improving quality of both data and healthcare outcomes. Tier 2 Data Managers include ESRD Network-level users. Category Section Task Frequency Data Monitoring Facility Dashboard Facilities Reports Monitor Facility Dashboard Monitor Facility Attestation Monitor Facility Summary Monitor Saved Facilities Generate Duplicate Patients Report Generate Missing Forms and Saved Status Reports At least Weekly Weekly in January and February of each year By December 31 of each year By 1st business day of each month Monthly At least monthly 15
Tier 3 Data Manager Individuals or groups that support CMS data reporting needs, as well as monitor and analyze ESRD Systems data entry. Individuals or groups in this classification support Tier 1 and Tier 2 Data Managers. Tier 3 Data Managers include data support contractors such as those responsible for the QualityNet Help Desk, CROWN Data Discrepancy Support (CDDS), Production Data Management (PDM), and the Application Development Organization (ADO). Category Section Task Frequency Data Monitoring Data Measuring Facilities Reports Reports Monitor Facility Dashboard Generate Duplicate Patients Report Generate Clinical Data and Missing Labs Report Generate Open Accretions Report Generate Open Notifications Report Weekly in January and February of each year Monthly Monthly Monthly Monthly 16
Work Together In their respective roles, Data Managers: Foster timely and accurate reporting by analyzing data submission and quality Assist with or oversee data entry for Dialysis facilities, kidney transplantation centers, and Veterans Health Administration (VHA) facilities Work to resolve Action List discrepancies generated by the Renal Management Information System (REMIS) or reassigned by another Data Manager Generate, review, and finalize CMS-2744 ESRD Facility Survey submissions Monitor compliance with ESRD QIP Program reporting and performance measures Assist CMS and other ESRD stakeholders described in this document with monitoring, measuring, and managing all ESRD Systems data. 17
Poll Question #2 Which Tier Data Manager are you? A. Tier 1 B. Tier 2 C. Tier 3 18
Data Monitoring
Data Monitoring EQRS and CROWNWeb have multiple tasks that support efforts to promote data quality through data monitoring. They also offer multiple reports and search capabilities that provide users with the means to monitor and audit data entry efforts. Section Task Authorized Tier Facility Dashboard Monitor Facility Dashboard Tier 1 and Tier 2 Monitor Facility Attestation Tier 1, Tier 2, and Tier 3 Facilities Monitor Facility Summary Tier 1 and Tier 2 Monitor Saved Facilities Tier 2 Personnel Review Personnel Information Tier 1 Reports Generate Duplicate Patients Report Tier 2 and Tier 3 Generate Missing Forms and Saved Status Reports Tier 1 and Tier 2 Generate Transient Patients Report Tier 2 Generate Unverified Patient Attributes and Related Treatment (PART) Report Tier 2 20
Facility Dashboard Monitor Facility Dashboard Key Points The Facility Dashboard provides users with upcoming data submission reminders in EQRS. The Facility Dashboard presents users with a list of outstanding deliverables for the facilities within their scope. The Facility Dashboard provides users with the ability to click on the number of outstanding items to drilldown further to identify required submissions. Frequency How To Tier 1 and Tier 2 Data Managers monitor Facility Dashboard data at least weekly to help ensure that required data are completed within a timely manner. Visit http://mycrownweb.org/pcw_course/dashboard/ for instructions on how to monitor Facility Dashboard data. 21
Data Monitoring System Screenshot Each area task is followed by a system screenshot to assist users. Facility Dashboard Screenshot 22
Poll Question #3 When was the last time you monitored your facilities Dashboard? A. This Week B. This Month C. Last Month D. Never 23
Data Measuring
Data Measuring CROWNWeb has three tasks that support efforts to promote data relevancy through data measuring. The system also offers multiple reports and search capabilities that allow users to measure the length of time since last data entry, as well as the ability to determine if specific submission requirements were met. Section Task Authorized Tier Reports Generate Clinical Data and Missing Labs Report Tier 2 and Tier 3 Generate Open Accretions Report Tier 1, Tier 2, and Tier 3 Generate Open Notifications Report Tier 1, Tier 2, and Tier 3 25
Reports Generate Open Accretions Report and Open Notification Report Key Points All Data Managers utilize CROWNWeb to access the Open Notifications and Open Accretions Reports that measure discrepancies supplied by REMIS. CROWNWeb generates Notifications and Accretions on the Action List tab to enable facilities to troubleshoot and correct discrepancies between the two systems. All Data Managers resolve Notifications and Accretions within 15 days of when they are issued, unless placed Under Investigation. Notifications or Accretions placed Under Investigation must be resolved within 30 days of when they are issued. Frequency How To Tier 1, Tier 2, and Tier 3 Data Managers generate Open Notifications Reports and Open Accretions Reports monthly to identify Notifications or Accretions that have been Open or Under Investigation for >15 or 30 days, respectively. Visit http://mycrownweb.org/pcw_course/running-facility-reports for 26 instructions on how to generate Facility Reports.
Data Measuring System Screenshot Each area task is followed by a system screenshot to assist users. CROWNWeb and REMIS Communication Process TO FACILITY XYZ NOTIFICATION ACCRETION NOTIFICATION NOTIFICATION ACCRETION ACCRETION REMIS gathers information from various CMS databases, and compares that data to data in CROWNWeb. CROWNWeb receives discrepancy information each night and assigns Notifications and Accretions to facilities and ESRD Networks. 27
Poll Question #4 When was the last time you measured your facility by running an Accretion or Notification Report? A. This Week B. This Month C. Last Month D. Never 28
Data Managing
Data Managing The following 15 user tasks support efforts to promote accurate and timely data submissions through data managing: Section Task Authorized Tier Facilities Add new Facility Tier 2 Submit Facility Attestations Tier 1 Update Facility Summary Tier 1 and Tier 2 Patients Admit and Discharge Patients Tier 1 and Tier 2* Admit and Discharge Transient Patients Tier 1 Complete CMS-2728 and CMS-2746 Forms Tier 1, Tier 2, Tier 3** PART Verification Tier 1 Resolve Gap Patients Tier 1 and Tier 2 *Tier 2 Data Managers are authorized to complete patient admissions and discharges, and update records for kidney transplantation and Veterans Health Administration (VHA) centers. **Tier 3 Data Managers are authorized to delete and modify CMS-2728 forms and to delete CMS- 2746 forms. 30
Data Managing Continued Continued Task list from Previous Slide: Section Task Authorized Tier Personnel Add Key Personnel Tier 1 and Tier 2 Clinical Manage Clinical Tier 1 Action List Resolve Action List Notifications and Accretions Tier 1, Tier 2, and Tier 3 Form 2744 Add New CMS-2744A Forms Tier 1 Add New CMS-2744B Forms Tier 1 or Tier 2 Accept/Reject/Finalize CMS-2744 Forms Tier 2 Add New CMS-2744A Form for Closed Facilities Tier 1 31
Transient Patients Admit and Discharge Transient Patients Key Points A transient patient receives short-term dialysis at a facility other than his/her home facility for less than 30 days or fewer than 13 treatments. Tier 1 Data Managers admit and discharge transient patients upon arrival to and departure from the receiving dialysis facility. Change in the patient s transient status: Returns to Home Facility Discharge from transient facility. Transfers to New Facility Remains at Transient Facility >30 Days or 13 Treatments Discharge from transient facility. Admit as a Transfer-In Transient Status = No Frequency How To Tier 1 Data Managers admit transient patients to their respective dialysis facilities within 1 business day of treatment and discharge within 1 business day of last treatment. Visit http://mycrownweb.org/pcw_course/admitting-dischargingtransient-patients for instructions on how to admit and discharge transient patients. 32
Data Managing System Screenshot Each area task is followed by a system screenshot to assist users. Admit Transient Patient 33
Poll Question #5 When was the last time you managed your facility by admitting/discharging a Transient Patient? A. This Week B. This Month C. Last Month D. Never 34
Data Management Support
Tier 3 Data Managers Tier 3 Data Managers support Data Monitoring, Data Measuring, and Data Managing by using the ESRD Systems to acquire and report necessary data to CMS. Additionally, Tier 3 Data Managers provide support to Tier 1 and Tier 2 users by providing reports and other documentation that provide an overview of data entries. Data Monitoring Tier 3 Data/Report Frequency Tier 1 and Tier 2 Usage Near Match Error Reporting Missing Clinical Reporting EDI Batch Error Analysis, Trending, and Resolution Weekly Weekly Monthly Research and resolve data discrepancies between CROWNWeb and REMIS Research and resolve missing clinical data entries Research and resolve batch submission errors with Tier 1 36
Tier 3 Data Managers: Measuring Data Measuring Task list: Data Measuring Tier 3 User Task Tier 3 Remedy Ticket Resolutions REMIS Alert Resolutions Clinical Compliance Reporting Metrics Frequency Monthly Weekly Weekly 37
Tier 3 Data Managers: Managing Data Monitoring Task list: Data Monitoring Tier 3 User Task 2728 Form Deletion and Modification 2746 Form Deletion Erroneous Patient Deletion Acute Patient Maintenance Patient Merge Patient Unmerge Reopen 2744 Forms Frequency 10 business days after assignment to the Tier 3 Data Manager 5 business days after assignment to the Tier 3 Data Manager 5 business days after assignment to the Tier 3 Data Manager 5 business days after assignment to the Tier 3 Data Manager 10 business days after assignment to the Tier 3 Data Manager 5 business days after assignment to the Tier 3 Data Manager 5 business days after assignment to the Tier 3 Data 38 Manager
Appendixes
Facility-Level Reports Each report category listed has specific sub reports. Please see the example below: Facility-Level Reports Report Facility Reports Facility Personnel Report Patient Report Patient Roster Report Audit Reports Audit Forms Report Audit Additions Report Definition Allows users to run and print a report that includes facility details including location, status, shifts, and services. It also provides a detailed list of all personnel associated with the selected facility including full name, position, UPIN, email, and contact information for selected in-scope facilities. Allows users to run and print a report that includes all patients present at the selected facility or facilities within the user scope as of a specific date or date range. Allows users to run and print a report for 2728, 2746, or both form types submitted by specified facilities within an entered date range. Allows users to run and print a report by module(s) to show any newly submitted records within the selected module(s) by specified facilities 40 within an entered date range.
Network-Level Reports Each report category listed has specific sub reports. Please see the example below: Network-Level Reports Report Patient Reports Clinical Data and Missing Labs Report Duplicate Patients Report Patient Events Report Facility Reports Missing Forms Report Saved Status Report Definition Identifies the percentage of patients whose clinical results fall within, or outside, a specified range and missing clinical and lab data. Identifies patients with transposed names or near match names and Social Security Numbers. Identifies all patient events. Identifies CMS-2728 and CMS-2746 forms that have not been completed, based on the patient treatment information. Identifies all forms that are in a Saved status. 41
Data Manager Task List Each Data Manager Tier has a task list of all items included in this document. For example: Tier 1 Data Manager Task List Category Section Task Frequency Data Monitoring Facility Monitor Facility Dashboard At least weekly Dashboard Facilities Monitor Facility Attestation Monitor Facility Summary Between January 1 and the end of February of each year By December 31 of each year Personnel Review Personnel At least quarterly Reports Generate Missing Forms and Saved Status Reports At least monthly Data Measuring Reports Generate Open Accretions Report Monthly Generate Open Notifications Report Monthly 42
Questions 43
For Further Information Help Me Form: http://help.mycrownweb.org QualityNet Help Desk: 1-866-288-8912 Website: http://www.mycrownweb.org Please let us know what you think and what you would like to be covered in future Town Hall events, thank you! CRAFT@MyCROWNWeb.org 44
Thanks for Attending! Our next CROWNWeb Town Hall will be held: Date: April 18, 2019 Time: 2PM-3PM ET 45