Welcome Mid-Atlantic Data Managers (MACDM) 2018 Spring Meeting - - PowerPoint PPT Presentation

Welcome Mid-Atlantic Data Managers (MACDM) 2018 Spring Meeting – Wednesday, May 2, 2018

Thanks to our host Lehigh Valley Hospital – Cedar Crest

House Keeping

• Rest rooms
• Breakfast
• Lunch and snacks
• Silence all smart/flip phones/electronic devices. Please try to stay off

phone texting during meeting

• Sign in and take name tags/lanyard
• Review and update the data managers listing
• You can follow along with this presentation on your smart phone by
• pening meeting presentation on MACDM.org Spring 2018 meeting
• Drop name tags/lanyard in container in rear of room when leaving for the

day

Agenda Review

Start Time End Time Item Presenter 8:00 am 8:30 am Sign-in, *coffee/tee/water, networking All 8:30 am 8:35 am Agenda Review David Carey 8:35 am 8:45 am Attendees Introduction All 8:45 am 9:15 am NCDR (National Cardiovascular Data Registry) Annual Data Managers Conference David Carey 9:15 am 10:15 am NCDR Cath/PCI – New Cath/PCI version 5 form (please bring a color printed copy of Cath/PCI version 5 for review) David Carey 10:15 am 10:35 am Break 10:35 am 10:55 am NCDR ICD – NCDR call in, updates and CMS decision Caroline Morgan 10:55 am 11:05 am NCDR ICD MACDM group open discussion All 11:05 am 11:10 am NCDR ACTION Registry All 11:10 am 11:30 am AHA Get With the Guidelines New Web Site and Reports Crystal Glodek 11:30 am 11:35 am DVSTS Group Status Candace Trace 11:35 am 11:45 am MACDM Updates David Carey 11:45 am 12:00 pm Break – Group Photo All 12:00 pm 12:30 pm *Lunch All 12:30 pm 1:00 pm MICRA Medtronic Transcatheter Leadless Pacemaker Presentation Steve Lu 1:00 pm 1:35 pm STS Adult Cardiac – Identify star rating fields, increase rating percentage, create a registry outcomes comparison report? David Carey 1:35 pm 1:45 pm STS Thoracic Updates Sarah Knorr 1:45 pm 2:00 pm Break 2:00 pm 2:25 pm STS (Society of Thoracic Surgeons) Adult Cardiac version 2.9 form and STS dashboard reporting Comments All 2:25 pm 2:55 pm EPIC Electronic Record System Chaz Strand Robin McKelvey 2:55 pm 3:00 pm Closing All

Attendees Survey

From spring 2018 MACDM registration, the following registries were selected as interest for registry discussion:

• STS Adult Cardiac – 75%
• NCDR Cath/PCI – 70%
• NCDR ICD – 40%
• AHA GWTG – 33%
• STS Thoracic – 30%
• NCDR ACTION – 15%

Two sites interested in TVT, two LAAO and one Impact registry

Attendees Locations

Attendees In Introduction

Around the room introduction (hint, read off your name tag):

• First name
• Last name
• Hospital, organization or retired status
• City
• State
• *Let us know if this is your first regional data managers meeting!

NCDR Annual Data Managers Conference 2018 Was COLD!!!!

NCDR 2018 Conference (c (continued)

NCDR 2018 Conference (c (continued)

NCDR Conference (c (continued)

• TVT Registry may add outside vendors to submit data, 4th quarter

2019.

• TVT procedures shifting from general anesthesia to conscience

sedation to reduce procedure costs.

• All registries pushing to public reporting.

NCDR Conference (c (continued)

• Linking Cath/PCI Data to CMS Data for 30 day mortality – NCDR to try connecting

to CMS data. If not sending most PHI, not sure what they will do.

NCDR Conference (c (continued)

• Cath/PCI bleeding complications – Big shift from PCI femoral to radial.

Projecting large savings on overnight stays due to bleeding complications.

NCDR Conference (c (continued)

Cath PCI Version 5

• Cath/PCI Frailty and Appropriate Use Score will need to be added to

your Cath/PCI documentation process. Frailty and Appropriate Use posters on NCDR site.

Cath/PCI Version 5 (c (continued)

Optional Sections/Fields Your hospital system must decide which of the following optional sections/fields to be completed!

Section A. Demographics

• Asian, Native Hawaiian, Hispanic Ethnicity further breakdown. If not, select other options under each?

Section B. Episode of Care

• Admitting Provider’s Name, NPI – Fields – If you collect these, they will also need to be maintained in the NCDR registry?
• Attending Provider’s Name, NPI – Fields – If you collect these, they will also need to be maintained in the NCDR registry?
• Patient Restriction?
• Research Study – Only includes any NCDR research studies, not outside research studies

Section D. Pre-procedure information

• Seattle Angina Questionnaire (SAQ) - Section
• Rose Dyspnea Scale - Section

Section L. Discharge

• Discharge Provider’s Name, NPI - Fields – If you collect these, they will also need to be maintained in the NCDR registry?

Section M. Follow-up (30 day and 1 year)(entire section M optional) Out of roughly 1400 attending NCDR conference, roughly less than 12 were planning to submit follow-up

• Assessment Information
• Events
• Medications
• Seattle Angina Questionnaire (SAQ) Follow-up
• Rose Dyspnea Scale Follow-up

Cath/PCI - Version 5 (c (continued)

From Procedure Inclusion: To Procedure Inclusion: Version 4 Version 5 To make our data collection process smoother, we will still collect a Left Heart Catheterization only and still submit?

Cath/PCI Version 5 (c (continued)

Syntax score, very important in evaluating the AUC (appropriate use criteria). Obtaining this calculation is going to be very cumbersome.

Cath/PCI Version 5 (c (continued)

Pre-Operative Evaluation fields are heavily dependent on physician documentation based on the detailed definitions in the data elements.

Cath/PCI Version 5 (c (continued)

Now only need to complete if stenosis is >= 50% in native or graft vessels, reducing the burden of completing all vessels.

Cath/PCI Version 5 (c (continued)

The NCDR webinar video of “Overview of the Cath/PCI Registry V5 Dataset”:

• Very good and very informative.
• Very difficult to navigate to the video on the NCDR website.
• My hospital web security blocked the video from playing on my work
• computer. I had to watch it from my home computer.

Cath/PCI Version 5 (c (continued)

Are there any specific questions on the Cath/PCI version 5 form to discuss? How is your vendor new version 5 working?

20 Minute Break

Be back in 20

NCDR IC ICD – NCDR Call In In

• Caroline Morgan
• ICD NCDR Registry updates
• ICD CMS registry decision

NCDR IC ICD - MACDM Group Open Discussion

ICD Open Discussion:

• How many hospitals participate in ICD registry?
• Do we need to continue to collect and harvest ICD data with NCDR?
• If not, what do we have to do to fulfill the requirements?

NCDR ACT CTION Registry ry

• Nothing new to discuss at this time.
• How many hospitals still participate in ACTION registry?
• Does someone want to present ACTION at future MACDM meetings
• r should we drop ACTION from registry discussion at this time?

AHA Get With the Guidelines New Web Site and Reports

Crystal Glodek, BSN, RN Director of Quality and Systems Improvement

Great Rivers Affiliate 1617 John F. Kennedy Blvd Suite 700 Philadelphia, Pa 19103 Crystal.Glodek@heart.org I www.heart.org P 215.575.5254 | Cell 215.779.5451

AHA Get With the Guidelines Data Deadline Dates

Once a year last quarter data deadline March 31st, of that following year (NCDR is April 17th). March 31st deadline is important for any annual awards based on prior years data. All other quarters can follow the NCDR Cath/PCI three other quarter deadlines.

Delaware Valley STS Group Status

DVSTS Regional Group Update Candace Trace

MACDM Updates

Mission Objectives:

• Enhance the quality outcome collection and reporting of cardiovascular

procedures throughout the Mid-Atlantic Region.

• Improve outcome collection and reporting by using collaboration, networking and

knowledge transfer with other data managers throughout the mid-Atlantic hospitals.

• Increase any participating Mid-Atlantic data managers incite into current and

future STS (The Society of Thoracic Surgeons), NCDR (National Cardiovascular Data Registry), AHA (American Heart Association) changes communicated at their

• meetings. This will be communicated by attending Mid-Atlantic participating data

managers.

MACDM Updates (C (Continued)

Web site address: MACDM.org

Rules to follow: No one in MACDM group is paid or compensated for any work No presenter is paid or compensated, other then free beverages/lunch No presenter can give political presentations What registries do we discuss: STS (The Society of Thoracic Surgeons) – Cardiac and Thoracic AHA (American Heart Association) – GWTG NCDR (National Cardiovascular Data Registry) – Cath/PCI NCDR ACTION? NCDR ICD? Any other registry the group would like to discuss

MACDM (C (Continued)

Number of planned onsite meetings per year:

• We hold two onsite meetings per year to discuss major STS, NCDR and AHA registry form changes, web

site updates, reporting and important presentations from the most resent spring/fall STS/NCDR annual meetings and any other sources.

• Spring meeting is a few weeks after the NCDR annual conference and focuses mainly on the NCDR

registries in the morning.

• Fall meeting is a few weeks after the STS annual conference and focuses mainly on the STS registries in

the morning. How must does it cost to attend the meetings?

• The cost is either an annual $100 per hospital fee or a $25 per attendee/per meeting fee.
• If a hospital pays the annual $100 fee, they can send any number of staff to the meetings at no charge. To

get added to annual voucher, go to MACDM.org and click enroll. There is no charge and you will get a voucher and be put on the annual voucher mailing in December for next year.

MACDM (C (Continued)

• Next STS Data Managers Conference September 26-28th 2018

Loews Hollywood Hotel, Los Angeles, CA

• Next MACDM meeting Tuesday, November 27, 2018 (main focus NCDR Cath/PCI, STS Adult Cardiac,

Thoracic registries AHA GWTG)

• Next NCDR Data Managers Conference March 13-15th 2019 – Hyatt Regency, New Orleans, LA
• MACDM.org Data Managers Listing – Print or download, Attendees (Go to Bottom), Download MACDM Data

Managers List

15 Minute Break and Group Photo

If weather is nice we will take picture outside in front of hospital in 15 minutes for group photo!

Half Hour Lunch Break

Lunch provided in back of room

MIC ICRA Medtronic Transcatheter Leadless Pacemaker Presentation

Medtronic - Steve Lu

STS In Internal Registry ry Vali lidation/Report

Using Microsoft Excel and SQL server query, build extraction file of the following fields:

Surgeon, Hospital, MRN, Last Name, Surgery Date, Procedure, Internal Mammary Artery Not Used, Mortality Before Discharge, Mortality 30 Day Operative, Any Reoperation, Reop Bleeding, Deep Sernal Wound, Permanent Stroke, Prolonged Ventilation, PostOpVentHours, Total Renal Failure, Readmission LT 30Days, Missed Preoperative Meds Beta Blockers, Missed Discharge Aspirin, Missed Discharge Beta Blockers, Missed Discharge Lipid Lowering, Confirm Negative Star Comments

Filters – From and To Dates

STS In Internal Registry ry Vali lidation/Report

SQL1 - SELECT Event_STS.Surgeon, IIf([Hospital]="Geisinger Wyoming Valley","GWV",IIf([hospital]="Geisinger Medical Center","GMC",IIf([hospital]="Geisinger Community Medical Center","GCMC",IIf([hospital]="Holy Spirit - A Geisinger Affiliate","HSH",[hospital])))) AS Hospital_, Demographics.Patient_ID AS MRN, Demographics.Last_Name AS [Last Name], Event_STS.Surgery_Date AS [Surg Dt], Event_STS.STSProcedureName AS [Procedure], IIf([CABIMANotusedreason] Like "*the IMA*" Or [CABIMANotusedreason] Like "*other*",IIf([STSProcedureName]="Cab",1,Null)) AS [Internal Mammary Artery Not Used], IIf([mortdcstatus]="Dead" Or [DischargeMortalityStatus]="died in hospital",1,Null) AS [Mortality Before Discharge], IIf([Mort30DayStatus]="Dead",1,Null) AS [Mortality 30 Day], IIf([reop_bleeding]=1 Or [Reop_valve_dysfunction]=1 Or [Reop_Graft_Occlusion]=1 Or [Reop_Other_cardiac]=1 Or [reopvalvedysfunction] Like "*Yes*" Or [ReopGraftOcclusion] Like "*Yes*" Or [postopaorticReint]=1 Or [PostOpReintMyocardIschemiatype]="surgery" Or [PostOpReintMyocardIschemiatype]="both",1,Null) AS [Operative, Any Reoperation], STS_290_02.PostOpReintMyocardIschemia, STS_290_02.PostOpReintMyocardIschemiaType, IIf([Reop_Bleeding]=0,Null,[Reop_Bleeding]) AS [Reop Bleeding], IIf([Infect_Sternum_Deep]=1 Or [postopdeepsternalmediastin] Like "*Yes*",1,Null) AS [Deep Sernal Wound], IIf([Neuro_Stroke_Permanent]=1 Or [PostopNeuroStrokePermanent] Like "*Yes*",1,Null) AS [Permanent Stroke], IIf([Pulm_Ventilator_Prolonged]=1,1,Null) AS [Prolonged Ventilation], IIf([Pulm_Ventilator_Prolonged]=1,[PostOpVentHoursTotal],Null) AS [Prolonged Vent Hours], IIf([STS_PostOp].[Renal_Failure]=1,1,Null) AS [Renal Failure], IIf([Readmission]="Yes",1,Null) AS ReadmLT30Days, IIf([STSProcedureName]="CAB" And [status] Not Like "*emergent*" And [PreOpMedBetaBlockers]="No",1,Null) AS [Missed Preoperative Meds Beta Blockers], IIf([PostOpMedAspirin]="Yes" Or [PostOpMedAspirin]="Contraindicated" Or [PostOpMedADPInhibitors]="Yes" Or [DCmedotherantiplatelet]="Yes" Or [MortDCStatus]="Dead" Or [DischargeMortalityStatus]="died in hospital" Or [STSProcedureName]<>"Cab",Null,1) AS [Missed Discharge Meds, Aspirin], IIf([STSProcedureName]="CAB" And [PostOpMedBetaBlockers]="No",1,Null) AS [Missed Discharge Meds, Beta Blockers], IIf([PostOpMedLipidLowering]="Yes" Or [PostOpMedLipidLowering]="Contraindicated" Or [DCmedlipidloweringstatin]="Yes" Or [DCmedlipidloweringstatin]="Contraindicated" Or [DCMedLipidLoweringNonStatin]="Yes" Or [DCMedLipidLoweringNonStatin]="Contraindicated" Or [MortDCStatus]="Dead" Or [DischargeMortalityStatus]="died in hospital" Or [STSProcedureName]<>"Cab",Null,1) AS [Missed Discharge Meds, Lipid Lowering], 1 AS [Counter], Year([Surgery_Date]) & ", " & Month([surgery_date]) AS MonthYear, IIf([Internal Mammary Artery Not Used]=1 Or [Mortality Before Discharge]=1 Or [Mortality 30 Day]=1 Or [Operative, Any Reoperation]=1 Or [Reop Bleeding]=1 Or [Deep Sernal Wound]=1 Or [Permanent Stroke]=1 Or [Prolonged Ventilation]=1 Or [Renal Failure]=1 Or [ReadmLT30Days]=1 Or [Missed Preoperative Meds Beta Blockers]=1 Or [Missed Discharge Meds, Aspirin]=1 Or [Missed Discharge Meds, Beta Blockers]=1 Or [Missed Discharge Meds, Lipid Lowering]=1 Or [ConfirmNegativeStar] Is Not Null,"Yes",Null) AS Include, STS_Extension.ConfirmNegativeStar, IIf([VSAorticTransCathReplace]=1 Or [status]="Emergent Salvage",1,0) AS Expr1, Event_STS.status FROM STS_290_02 RIGHT JOIN (STS_Extension RIGHT JOIN (STS_240 RIGHT JOIN (STS_ValveSurgery RIGHT JOIN (STS_270 RIGHT JOIN (STS_280 RIGHT JOIN (STS_280_02 RIGHT JOIN (STS_270_02 RIGHT JOIN (((((Demographics RIGHT JOIN Event_STS ON Demographics.SS_Patient_ID = Event_STS.SS_Patient_ID) LEFT JOIN STS_PostOp ON Event_STS.SS_Event_STS_ID = STS_PostOp.SS_Event_STS_ID) LEFT JOIN STS_98 ON Event_STS.SS_Event_STS_ID = STS_98.SS_Event_STS_ID) LEFT JOIN STS_252 ON Event_STS.SS_Event_STS_ID = STS_252.SS_Event_STS_ID) LEFT JOIN STS_260 ON Event_STS.SS_Event_STS_ID = STS_260.SS_Event_STS_ID) ON STS_270_02.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_280_02.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_280.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_270.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_ValveSurgery.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_240.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_Extension.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID) ON STS_290_02.SS_Event_STS_ID = Event_STS.SS_Event_STS_ID WHERE (((Event_STS.Surgery_Date) Between #1/1/2018# And #3/31/2018#) AND ((IIf([VSAorticTransCathReplace]=1 Or [status]="Emergent Salvage",1,0))=0) AND ((IIf([vadimplantedexplanted] Like "*yes*",1,0))=0));

STS In Internal Registry ry Vali lidation/Report

SQL 2 - SELECT [ZZ_Cardiac Major Comp STS Star Rating].Surgeon, [ZZ_Cardiac Major Comp STS Star Rating].Hospital_, [ZZ_Cardiac Major Comp STS Star Rating].MRN, [ZZ_Cardiac Major Comp STS Star Rating].[Last Name], [ZZ_Cardiac Major Comp STS Star Rating].[Surg Dt], [ZZ_Cardiac Major Comp STS Star Rating].Procedure, [ZZ_Cardiac Major Comp STS Star Rating].[Internal Mammary Artery Not Used], [ZZ_Cardiac Major Comp STS Star Rating].[Mortality Before Discharge], [ZZ_Cardiac Major Comp STS Star Rating].[Mortality 30 Day], [ZZ_Cardiac Major Comp STS Star Rating].[Operative, Any Reoperation], [ZZ_Cardiac Major Comp STS Star Rating].[Reop Bleeding], [ZZ_Cardiac Major Comp STS Star Rating].[Deep Sernal Wound], [ZZ_Cardiac Major Comp STS Star Rating].[Permanent Stroke], [ZZ_Cardiac Major Comp STS Star Rating].[Prolonged Ventilation], [ZZ_Cardiac Major Comp STS Star Rating].[Prolonged Vent Hours] AS PostOpVentHoursTotal, [ZZ_Cardiac Major Comp STS Star Rating].[Renal Failure], [ZZ_Cardiac Major Comp STS Star Rating].ReadmLT30Days, [ZZ_Cardiac Major Comp STS Star Rating].[Missed Preoperative Meds Beta Blockers], [ZZ_Cardiac Major Comp STS Star Rating].[Missed Discharge Meds, Aspirin], [ZZ_Cardiac Major Comp STS Star Rating].[Missed Discharge Meds, Beta Blockers], [ZZ_Cardiac Major Comp STS Star Rating].[Missed Discharge Meds, Lipid Lowering], [ZZ_Cardiac Major Comp STS Star Rating].Counter, [ZZ_Cardiac Major Comp STS Star Rating].MonthYear, [ZZ_Cardiac Major Comp STS Star Rating].ConfirmNegativeStar, [ZZ_Cardiac Major Comp STS Star Rating].Include FROM [ZZ_Cardiac Major Comp STS Star Rating] WHERE ((([ZZ_Cardiac Major Comp STS Star Rating].Procedure)="CAB" Or ([ZZ_Cardiac Major Comp STS Star Rating].Procedure)="AVR" Or ([ZZ_Cardiac Major Comp STS Star Rating].Procedure)="AVR + CAB") AND (([ZZ_Cardiac Major Comp STS Star Rating].Include)="Yes")) ORDER BY [ZZ_Cardiac Major Comp STS Star Rating].Surgeon, [ZZ_Cardiac Major Comp STS Star Rating].Hospital_, [ZZ_Cardiac Major Comp STS Star Rating].[Surg Dt];

STS In Internal Registry ry Vali lidation/Report

Workflow prior to registry data harvest completion close date:

• Input all data and validate missed fields using registry software validation
• Run export and review DQR reports until all data is completely validated
• Run STS internal registry validation report
• Data Manager reviews and validates any patients negative effect field values. If input
• r collected incorrectly, fixes in registry system. Makes comments in Confirm Negative

Star Comments field.

• Once completed with all patients, sends STS internal registry validation report to

surgeon/PA to review for any incorrect documentation and communicates with data

• manager. At by-monthly meeting, reviews STS internal registry validation report and

gives copy for M&M meeting to discuss.

STS In Internal Registry ry Vali lidation/Report

STS In Internal Registry ry Vali lidation/Report

In Internal Registry ry Rating Comparison

See Internal Registry Rating Comparison Document

STS Thoracic

• Lobectomy for Lung Cancer – Public reporting started 2017
• Star Rating Lung Resection Comparison
• Most current 3 years of data
• Esophageal CA Resection Will Begin Public Reporting This Summer (probably)
• Will need to average 5 resections a year
• STS says only about 50% of participants will receive a rating.
• 5 Year Follow-up
• 5 year follow-up on only Lung Cancer and Esophageal Cancer patients – Starting from 1-1-2015
• procedures. 2015 year will be used until year 2020.
• Suggestion - Reach out to your COC (tumor or cancel registry) to get your follow-up update electronically
• Pull this data the 1st quarter of each year starting in 2017. Per STS, long term follow-up data should be

updated/reported with each harvest.

• Once a year send an Excel file with MRN to get a follow-up date and mortality date (status (alive/deceased) can be

determined from mortality date).

STS Thoracic (c (continued)

• New thoracic version 2.4 proposed live date 7-1-2018.
• Per STS, the data managers handbook for the new form should be

available in June 2018.

• 8th Edition of the Classification of Lung CA begins January 2018. New

Form address these changes, but the STS did not have an answer in how to handle the new staging categories on the current form.

15 Minute Break

Be back in 15

STS Adult Cardiac

• 30 Day Post-op Surgery Status - If a hospital has 30 day post-op surgery status of more than 2%

missing/Unknown of eligible patients, that hospital will NOT receive a star ratings for that reporting period.

• Real Time Data Submission – New data submission allows near real time entry process. No sweat,

can use same old process going forward and start this new process at any time. Can submit data for past/present/real time.

• Version 2.9 new vendor screens, how’s it going?
• Version 2.9 Data Submission:
• DQR validation reporting anesthesia 3 pages of missing fields, even if you don’t participant in the

anesthesia submission

• Risk Scores Tables – Predicted risk values may not match at harvest, no match will display on
• report. STS will process as their rules and override No Match for CABG. This is due to unplanned

CABG due to suspected disease will no longer drop out of the category. Vendors are not required to update their tables.

STS Dashboard Reporting

Projected Live Dates:

• Adult Cardiac Dashboard Reporting –

Live

• Thoracic Dashboard Reporting –

1st half 2018

• Congenital Dashboard Reporting –

1st half 2018

STS Dashboard Reporting (c (continued)

Dashboard Reporting Access

• Only one Primary Data/File Contact

person from each hospital will have access – Will be able to see all reporting and patient levels (includes each surgeon level)

• Surgeons – Will be able to only see

their surgeon information

STS Dashboard Reporting (c (continued)

We had a Web-ex with 3 Geisinger hospitals and came up with the following things we are having difficulties with the STS reporting and asked STS to do a Web-ex with the MACDM group. Instead of Web-ex, Duke/STS sent the following email response:

• Data Quality Dashboard 2.9 Updated Nightly – Nothing comes up and this does not work. What are we doing wrong
• r do not understand?

You are correct. Upon receipt of your email, we reviewed the dashboard in question and identified the system is

• malfunctioning. Data vizualizations are not surfacing when they should be. We have made a fix and will be

updating the dashboards over the weekend. You should be able to log in on Monday and access this

• dashboard. Please note, this dashboard does take a significant amount of time to load up initially (greater than

60 seconds), but once loaded, should function quickly. Thank you for making us aware of this issue and please do contact the dcri service desk at dcriservicedesk@duke.edu in the future if something like this happens.

• Star Rating Current – We expected to see current data submitted and any patients star rating fields that fall out for

us to validate prior to data submission ending date, prior to report created. Unfortunately the functionality you are describing is not possible within the dashboards. The nightly refresh data quality dashboards, after the fix is implemented, should help you better assess the quality of your data for risk model variables. More information about the risk models can be found in your report overview. Additionally your data quality reports which you currently receive after every file submission should be used to assess and improve the quality of the data you are submitting which will be used to calculate composite measures and star ratings.

STS Dashboard Reporting (c (continued)

Duke/STS sent the following email response (continued):

• The filters show ending data range as 6-30-2017. Does that mean none of these reports can show

current data like 12-31-2017. That is correct. These data currently available in most of the dashboards reflect the 2017 Harvest 3 analysis lock time period, which had an analysis lock date of 6/30/2017. The 2017 Harvest 4 analysis lock time period will be available soon, which will have an ending date of 9/30/2017. The nightly refresh data quality dashboards, after the fix is implemented, will show records for more current time periods depending on when you submit a file and what data are in that file.

• The data managers were expecting to be able to see any current data submitted for recent data and

any that would have a negative star rating effect that could be reviewed and discussed with staff. No comment from Duke on this.

STS Project Proposal

STS Project Proposal: As a MACDM and Ohio state data managers group, review the following 3 adult cardiac reports created through the data validation processing. The objective of this project is to submit changes everyone agrees upon which make the validation reports much easier and more efficient to use. Instead of project STS sent the following email response:

• Risk Scores Report – Example: To sort the Not Matched risk scores to the top of the file so we do not have to sort or

filter each time. The sites can easily sort and filter in excel. This is really an internal process.

• Percent Missing Itemized Report – Example: Change the column order to Record ID, Surgery Date, Missing field

followed by added field of STS Field # (sometimes it takes some time to figure out what field the report is referring too), then following by the other columns. The Record ID is at the end so sites can easily see the number instead of looking in the middle of a bunch of columns. It is not feasible to add the Seq # since the data usually spans multiple versions for valves and Seq #s change from version to version.

• DQR Report – Example: If hospital is not participating in the anesthesia module of the adult cardiac, no anesthesia

fields will show up in the Data Completeness Issues section of the report. DCRI is working on this.

Epic & CV Registries

Chaz Strand, RN, Data Manager Robin McKelvey, RN, ACC Registrar

WWW.BAYHEALTH.ORG

WWW.BAYHEALTH.ORG WWW.BAYHEALTH.ORG

Bayhealth’s CathPCI Challenges

• Auto-population
• Ability to find data in chart
• Our auto-population for Diag Caths: ~60%
• Our auto-population for PCI: ~50%
• Meds: Pre, During, and Post cath
• Transfers from our own facilities
• We do not have structured reporting

WWW.BAYHEALTH.ORG

Epic’s CathPCI Challenges

• Auto-population
• Only discrete data can be imported
• Daily Worklist
• Master List
• Reports: Workbench vs Clarity vs Click
• Inability to have “notes”

WWW.BAYHEALTH.ORG

Other Registry Challenges

All the challenges from previous slides PLUS:

• STS
• Blood Transfusion information
• Extubation time
• ACTION – GWTG
• Identifying proper population
• EMS records/EKGs
• Pre hospital meds

WWW.BAYHEALTH.ORG

CathPCI v4.4, Page 1

Still cannot populate Had discrepancies with Arrival Times

WWW.BAYHEALTH.ORG

History: Post population

Cannot pull data from “outside” sources, such as non-Epic H&P or pre-Epic events.

Height & Weight must be filled in for each Encounter

WWW.BAYHEALTH.ORG

Cath Visit Tabs: Lab Visit

This data auto- populates Meds have to be built into a “grouper”, but then populates Stress tests do not populate

WWW.BAYHEALTH.ORG

DX Cath: Post Population

WWW.BAYHEALTH.ORG

Cath Visit Tabs

• Coronary anatomy does not populate
• We elected to auto default all grafts to N/A
• Very little PCI data populates
• No Lesion data crosses over
• Most Labs populate
• No Events populate

WWW.BAYHEALTH.ORG

Cath Visit Tabs: Discharge

Discharge Date and Status can populate. All

• ther data has to be

manually entered. Note: in v4.4, Discharge Meds could NOT be populated, although pre procedure meds (BB, CCB, etc, could populate). Use AVS for D/C meds.

WWW.BAYHEALTH.ORG

Snapshots

• Get friendly with your IT people
• Decide on how you want to view data
• ASK for what you want!
• Create your own Snapshot (1 for each registry)
• Get access to Session Information Report
• Print groups are your friend
• Link to After visit summary (AVS)

WWW.BAYHEALTH.ORG

Snapshot: Demographics, Care Timeline, ADT events

When you hover over blue events, results & other data is visible via a pop-up

• window. If you click on it the link, it will open up a half-screen view.

WWW.BAYHEALTH.ORG

Snapshot: ADT events, Class, Insurance

WWW.BAYHEALTH.ORG

Snapshot: Histories, Social, Recent tests (with links)

WWW.BAYHEALTH.ORG

Snapshot: Discharge data, Procedure Summary

WWW.BAYHEALTH.ORG

Admin: Maintenance, Export, Extract

Can open files in Excel

WWW.BAYHEALTH.ORG

Helpful Hints

• Don’t take NO for an answer. Ask WHY?
• Ask other departments questions (ED, other

registrars, etc)

• Hold Epic accountable- document it!
• Share your knowledge (internal & external)
• Ask to see how Cath Lab documents
• When all else fails: Detailed Report

WWW.BAYHEALTH.ORG

More Helpful Hints

• Default info as per your facility
• Especially “No” responses
• Example Cardiac Transplant = NO
• Epic does not like this option
• Use 90/10 rule to default
• Data is compiled by reports
• Give IT a copy of all reports with specifics
• Take Workbench Reporting class
• Learn to export into Excel
• It is OK to “poach” reports

WWW.BAYHEALTH.ORG

Our Wishlist

• Other Registry eligibility (TAVR, STS)
• Complications details
• Readmission date & details
• Transfers In or Out (with locations)
• Was it a “normal cath”?
• General notes
• Proposed solution: Flowsheet or “Healthy

Planet”

WWW.BAYHEALTH.ORG

STEMI Navigator Report

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To be able to view print groups:

Click on red EPIC box, Then click Session Information Report

Click on Show Report and Print Group IDs. A pop up box will show up saying “Enabled”, click OK

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Here is a sample of what we provided to IT by Print Group to edit our Snapshot:

CathPCI Print Group List (Based on Report 1180000020 ) Please add/re-order:

• 1. 45121: Demographics
• 2. 50111- Ethnicity & Race
• 3. 45111: Coverage Information
• 4. 51128: Vitals (Height & weight)
• 5. 55450: Medical history
• 6. 55456: Substances (Tobacco, alcohol, drug)

Please delete:

• 1. 51051: Facility
• 2. 45111: Guarantor Account
• 3. 50224: Employment History
• 4. 51114: HIM ROI Problem List
• 5. 56205: Meds: Current Meds with Sig for Plan of Care
• 6. 70020: Or/INV Log Med Summary

Questions?

Chaz Strand 302-744-6636 Sharon_Strand@Bayhealth.org Robin McKelvey 302-744-6452 Robin_McKelvey@Bayhealth.org If you or your IT staff need to reach out to our IT staff, let us know

MACDM Closing

• Would anyone like to volunteer to present one registry. I will help you with creating presentation and

the presentation itself?

• Do we want a registry vender presentation (Lumedx, etc)
• Any future topics would you like to hear for fall/spring meeting?
• Any additional registry to discuss, specific fields discussion and process improvement?
• AHA New Web Site and report review project. We could partner with Ohio data managers and do

web ex’s to come up with any AHA GWTG site or report suggestions.

• STS project canceled.
• Thanks again Lehigh Valley Hospital for hosting this meeting!
• Watch MACDM.org for meeting pictures and minutes to be announced!
• Please drop lanyard and name tag in container in rear of room when you leave