CMS’ CROWNWeb Application
November 21, 2013
With Healthcare Management
Solutions, LLC
11/21/2013
O
Janis Grady, RHIT, CPHQ
Contract Officer’s Representative (COR)
CROWNWeb Outreach, Communication, and Training (OCT) Contract Centers for Medicare & Medicaid Services
Oniel Delva, BA, CTT
Communications and Training Manager
CROWNWeb Outreach, Communication, and Training (OCT) Contract
11/21/2013
Today’s Presenters
Healthcare Management Solutions, LLC
Alaina Shmeleva, MBA
Project Manager
Alaina Shmeleva is a project manager for End Stage
Renal Disease (ESRD) Quality Incentive Program (QIP) Data Validation and Reliability contract. In her role, Alaina is responsible for the effort to assess the validity and reliability of the CROWNWeb data reported by dialysis
facilities. She works closely with the CROWN Data Discrepancy Support contractor to provide support in resolving discrepancies involving
CMS-2728, CMS-2746, and CMS-2744 forms entered into CROWNWeb. Additionally, Alaina will lead the pilot validation process on Healthcare-Associated Infection (HAI) events reported by ESRD facilities into the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system.
Latest News
and Reminders
11/21/2013
5
•
CROWNWeb Patch release updates mainly impact the system’s
behind the scenes processing.
•
CMS released CROWNWeb version 4.1.7.1 on November 14,
2013 to allow CROWNWeb to directly exchange data with CMS’
Renal Management Information System (REMIS) database.
•
CMS currently has two “behind the scenes” updates scheduled
to take place in December 2013.
CROWNWeb version 4.3.1
CROWNWeb version 4.3.2
CROWNWeb Patch Releases
REMIS SIMS Central Database CROWNWeb
Users
11/21/2013
O
•
CROWNWeb new user training is held via WebEx each month.
•
December 2013 new user training is available.
CROWNWeb
11/21/2013
•
CMS utilizes multiple outlets to help ensure the accuracy and
validity of data reported via CROWNWeb.
•
CROWNWeb has built-in data verification features to inform
users of a missing or out-of-range value.
•
Various aspects of CROWNWeb’s data entry are cross-checked
by CMS-approved contractors or external CMS databases.
Data Validation
Error Messages
Warning Messages
11/21/2013
9
•
CROWNWeb receives discrepancy information each night from
CMS’ Renal
Management Information System (REMIS) database,
and assigns Notifications and Accretions to facilities based on
that information.
•
CROWNWeb uses the
Action List
screen to resolve discrepancies
between CROWNWeb and REMIS database.
CMS Databases
11/21/2013
Notification
• A discrepancy in
patient data between a CMS database and CROWNWeb. • CROWNWeb has “Identity” and “Event/Treatment” Notifications. Accretion • An ESRD patient identified in another CMS database that appears to be
associated with your facility in the CMS database.
• The patient is not currently admitted to your facility in
CROWNWeb.
•
Data discrepancies are viewable on the
Action List
screen as a
“Notification” or an “Accretion.”
•
All users are required to work to resolve Notifications and
Accretions within 30 days from when they are issued.
Why Notifications and Accretions?
11/21/2013
11
Accretions
ACCEPT – The user agrees with the external source and will admit the patient in CROWNWeb.
REJECT – The user doesn’t agree with the Accretion. He/she has researched and the patient is not ESRD.
INVESTIGATE – Informs other users that the Accretion is under review. ESCALATE – The facility submits the Accretion to the Network to be
reassigned to the correct facility.
Notification
ACCEPT – The user agrees with the patient data provided by the external source.
REJECT – After research, the user does not agree with the Notification. INVESTIGATE – Informs other users that the Notification is under review. ESCALATE – The facility cannot
resolve the Notification and reassigns it to the Network.
Users can take the following actions to resolve Notifications and
Accretions:
Resolving Discrepancies
11/21/2013
•
CMS employs various contractors to review
entries in the following areas:
CMS-2728 and CMS-2746 forms
Quality Measures
Facility attestations
Notifications and Accretions
And more
Approved Contractors
ESRD QIP
11/21/2013
About HMS
H
•
HMS is an 8(a) certified, small
disadvantaged, woman-owned
business.
•
HMS personnel have broad
experience in providing clinical, administrative, operations,
education, and information technology (IT) solutions to a variety
of health care related clients.
•
HMS currently provides service on multiple federal contracts
across the United States including, but not limited to:
Surveying healthcare facilities
Coaching state-based surveyors
11/21/2013
Goals and Objectives
•
Three main focus areas:
1. Access Clinical Performance Measures (CPM) data validity and reliability. We will sample and test clinical and administrative data 2. Work with CROWNWeb Data Discrepancy Services in resolving
discrepancies involving CMS forms submitted into CROWNWeb by facilities
3. Perform pilot validation process on ESRD Healthcare-associated Infection (HAI) events reported by facilities into the CDC’s NHSN system
11/21/2013
CPM Data Validation
•
Purpose – sample and test validity and reliability of CPM data
entered into CROWNWeb system:
We will randomly select 300 facilities
Participating facilities will be contacted and asked to submit source documentation from each patient’s medical record
Our medical reviewers will abstract the data and compare to the patient medical records
The patient record will be the “gold standard”
Reporting period used for validation: April – June 2013
Anticipated record request date: December 2013
11/21/2013
CMS Forms Change Request Reviews
•
Purpose – provide support to CDDS in resolving discrepancies
involving CMS-2728, CMS-2744, and CMS-2746 forms:
We will be reviewing correction requests submitted by users on an on-going basis
Facilities will be contacted to submit patient medical records for review
Our medical reviewers will review the record and provide data correction recommendation to CMS and CDDS
Requested records will be case dependent
11/21/2013
ESRD HAI Event Pilot
•
Purpose – develop validation process for CDC’s NHSN data:
Similar to the CMS Hospital IQR program
We are looking for 9 volunteer facilities to participate in the study
Volunteers will be able to get an insight on future CMS validation efforts and give feedback on the process
Max of 12 patients sampled per facility (based on the facility size)
Facilities will be asked to self-report effort/cost associated with the validation
Email [email protected] if interested in participating
11/21/2013
Project Timeline
Task
Estimated Period
CPM Record Requests December 2013
HMS CPM Review Process January 2014 – May 2014
CMS Forms Change Requests
Review Process On-going
NHSN Pilot Facility Recruitment December 2013
NHSN Pilot Study & Validation January 2014 – March 2014
11/21/2013
Opportunities and Lessons Learned
•
Identify areas for improvement to CROWNWeb System
functionality and End User experience.
•
Changes to improve system usability to reduce the number of
data entry errors. Examples:
Recent changes to single user interface
New facility attestation features
Ability to submit all forms directly into CROWNWeb without filling out a paper copy
•
Future changes to In-Center Hemodialysis Consumer
Assessment of Healthcare Providers and Systems (ICH CAHPS)
reporting where facilities will work with CMS approved vendors
to conduct the survey.
•
Future changes to Mineral Metabolism reporting.
11/21/2013
Opportunities and Lessons Learned
•
Learning opportunities to further educate facilities about
CROWNWeb data elements.
•
Training opportunities for the CROWNWeb Outreach,
Communication, and Training group.
•
Facilities are encouraged to complete CROWNWeb training
curriculum located at www.projectcrownweb.org.
•
Continuous feedback on process effectiveness and potential
areas for improvement.
•
Ability to drive the change and provide valuable input into the
process architecture.
11/21/2013
Project Contact
H
Please submit your questions to:
CMS
11/21/2013
C
11/21/2013
O 25
11/21/2013
O
CMS Community Town Hall:
Topic: TBD
Date: December 19, 2013
Time: 2pm - 3pm ET
11/21/2013
O 27
For Further Information…
Help Me Form:
http://help.projectcrownweb.org/
QualityNet Help Desk:
1-866-288-8912
Website:
http://www.projectcrownweb.org
This material was prepared by FMQAI, the CROWNWeb Outreach, Communication, and Training contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. OCT contract # HHSM-500-2011-00157G.
Publication Number: FL-OCT-2013OCTT2-11-1467
