MHS Data Overview
M2 Foundations Course
MHS Data Overview
1)Context: MDR is the primary source of management
data used in the MHS.
2)Purpose: This presentation will familiarize users with
the MDR project
3)Outcome: After attending this session, participants will
meet the objectives described on the next slide.
FOR OFFICIAL USE ONLY
2
Objectives
•
Attendees can:
1.
2.
3.
4.
Describe the major data collection systems in the MHS.
Describe data feeds from these systems to central
repositories.
Describe the MDR and its role in feeding MHS data
marts.
Identify key strengths of using MDR-based data vs. local
data.
FOR OFFICIAL USE ONLY
3
HIPAA Note
•
•
•
Examples in this presentation are based on live data.
However, some items have been changed to preserve the
privacy of patients!
(Nothing that changes the overall gist of what is being
displayed, however)
FOR OFFICIAL USE ONLY
4
Good News, Bad News
•
Good news:
•
•
•
Bad news:
•
•
•
The MHS has made significant advances in automation systems
We have tons of data that other health systems and providers wish for!
Some quality issues with the data
Very cumbersome development process
This presentation will highlight available data and
discuss strengths and weaknesses along the way!
FOR OFFICIAL USE ONLY
5
Kinds of Data The MHS Collects Centrally
Type of Data
Direct Care
Purchased Care
Other
Person Data (Elg, Enroll)
Deployment Information
Inpatient Hospital Records
Professional Records
OP Only
Lab/Rad Proc Codes
Lab/Rad Results
Vital Signs
Pharmacy Prescriptions
Inpatient Pharmacy
Case Management Records
Dental
And more and more and more
FOR OFFICIAL USE ONLY
6
Process for Making Data Available
•
Data are collected through a variety of systems in
the MHS.
•
•
•
Historically, the MHS operated many duplicate repositories
with similar data.
These systems would almost never agree so that users were
left stuck with “what’s the right answer?”
In CY 1999-2000, the MHS Data Repository was built.
FOR OFFICIAL USE ONLY
7
Inpatient Record Data Flow (Oct 98)
Data
Mart
CEIS IDB
M
T
(edit checks
include parser &
logical edits)
F
C
H
C
S
AIR Force
(uses
AFVAL edits)
Army
(uses PASBA
edits)
Legacy
SAS
DMIS
Processor
Navy
(none, may use
PASBA edits)
FOR OFFICIAL USE ONLY
RCMAS
RCMAS
V1
V2
DMIS-SS
8
Inpatient Record Flow (Apr 99)
CEIS IDB
(edit checks
include parser & IDBR
logical edits) (min edits)
M
T
F
C
H
C
S
Until 6/30/99
Feed
Nod
e
Data
Mart
RPU
(min
edits)
AIR
Force
(uses VRI
AFVAL edits)
Army
(uses PASBA
EDW
ETL
PASBA
FOR OFFICIAL USE ONLY
(min
edits)
(data transformed
to FAM-D standard)
Navy
(none, may use
PASBA edits)
RLP
SAS
EDW Stars
DMIS
Processor
edits)
RLP
ARS
Legacy
SAS
RCMAS
RCMAS
V1
V2
DMIS-SS
9
Inpatient Record Flow (Today)
M2
M
MDR
T
F
Feed
C
Node
H
C
S
Simplicity……….
FOR OFFICIAL USE ONLY
Other Data
Marts
10
MHS Data Repository
• A ‘data warehouse’ containing MHS data
• Most popular system you never heard of!
• Most comprehensive source of MHS data available
• Receives data from all MTFs, DEERS, Private Sector Claims Data,
and many other sources.
• Data are processed to create new data elements, and to enhance
the quality of data received.
• Constantly evolving to include new and relevant data.
• Serves as the primary source for M2 and other data marts.
• Also provides data to the Services for incorporation into Servicespecific systems.
FOR OFFICIAL USE ONLY
11
MHS Data Repository
•
Many data warehouses simply display source data
as provided.
•
•
•
The MDR always stores original values that are received
from sources,
But, when possible, programs have been written to add new
variables to correct source system errors or to standardize
data amongst sources.
Corrections are not always possible!
FOR OFFICIAL USE ONLY
12
Routine MDR Enhancements
•
Person Identification Enhancement:
• Many systems collect partial person identifying information
• Sometimes this is just by design, sometimes because some
identifiers are unknown or do not exist at the time records need to
be submitted.
• MDR repeatedly applies a “Master Person Index” file to add
missing information to its records.
• Allows for timing differences and omissions among disparate
sources.
• Ensures a consistent identification of patients, regardless of source
of data.
13
FOR OFFICIAL USE ONLY
Example of MPI Application
Person ID
Sponsor SSN
Type of Care
Service Date
DOB
999 99 9999
Admission
10/5/2011
10/5/2011
999 99 9999
Well Check
10/11/2011
10/5/2011
1111111111
999 99 9999
Well Check
11/4/2011
10/5/2011
1111111111
999 99 9999
Well Check
12/3/2011
10/5/2011
After MDR Processing
As received
Person ID
Sponsor SSN
Type of Care
Service Date
DOB
1111111111
999 99 9999
Admission
10/5/2011
10/5/2011
1111111111
999 99 9999
Well Check
10/11/2011
10/5/2011
1111111111
999 99 9999
Well Check
11/4/2011
10/5/2011
1111111111
999 99 9999
Well Check
12/3/2011
10/5/2011
FOR OFFICIAL USE ONLY
14
MHS Data Repository
• After correction of person identifiers, demographic and
enrollment information is appended.
• Generally represents status on the begin date of care.
• For files that do not represent health care, demographic or enrollment
information may represent different concepts. Consult data dictionaries
for more detail.
• Status information comes from DEERS, generally.
• Information is updated monthly (for 6 months) to enable late-arriving
changes in status of beneficiaries (called retroactive processing)
• May disagree with local source data but is considered legally accurate.
FOR OFFICIAL USE ONLY
15
Example
Person ID
Enroll MTF
Type of Care
Service Date
DOB
Admission
10/5/2011
10/5/2011
Well Check
10/11/2011
10/5/2011
1111111111
Bethesda
Well Check
11/4/2011
10/5/2011
1111111111
Bethesda
Well Check
12/3/2011
10/5/2011
After MDR Processing
As received
Person ID
Enroll MTF
Type of Care
Service Date
DOB
1111111111
Bethesda
Admission
10/5/2011
10/5/2011
1111111111
Bethesda
Well Check
10/11/2011
10/5/2011
1111111111
Bethesda
Well Check
11/4/2011
10/5/2011
1111111111
Bethesda
Well Check
12/3/2011
10/5/2011
. Person-identifier was not available when MTF submitted original record. Patient was
16
also not enrolled at that time.
FOR OFFICIAL USE ONLY
MDR Enhancements
•
Application of Organizational Hierarchies
•
•
•
•
Source data will often come in with DMIS IDs to represent
treatment locations, enrollment sites, or geographic areas.
MDR applies a consistent hierarchical mapping to allow users at
all levels to easily extract data
Branch of Service, Parent DMIS ID, Major Command, Region,
Multi-Service Market Area, etc.
Users choose which level meets their business questions the
best!
17
FOR OFFICIAL USE ONLY
MDR Enhancements
•
•
Application of Market Areas
• Source data often arrives with zip codes
• Residence zip vs. point of service zip
• Zip codes are cumbersome to analyze!
• MDR applies a standard set of market area definitions to
each incoming record
• Allows for convenient extraction of ‘local’ data
Catchment, PRISM, MTF Service Areas, Multi-Service
Market Areas, etc
18
FOR OFFICIAL USE ONLY
19
FOR OFFICIAL USE ONLY
MDR Enhancements
•
Grouping of health care records into similar categories:
•
•
•
•
MS-DRGs: Groupings of inpatient data into categories that are similar
in terms of clinical aspects and expected hospital resource utilization.
MDC: Groupings of inpatient data into categories based on primary
diagnosis.
APC: Groupings of ambulatory services into categories that are similar
in terms of clinical aspects and expected hospital resource utilization.
Product Lines; Groupings of direct and purchased care data,
determined by Health Affairs.
20
FOR OFFICIAL USE ONLY
MDR Enhancements
•
Application of Weights and Costs
•
•
•
•
•
Workload weights are added in MDR processing
Important to understand the value of care.
Relative Value Units (RVUs), Ambulatory Patient Classification
Weights (APC) and Relative Weighted Products (RWPs)
Direct Care Estimated Full and Variable Costs are also added.
These are the elements used in M2.
21
FOR OFFICIAL USE ONLY
MDR Enhancements
•
Application of Linkages in Direct Care Records
Records that originate from CHCS generally have imbedded linkages
in them to enable tracking of provider’s orders.
• For pharmacy, laboratory, radiology and referrals, the MDR adds
information about who ordered a particular service.
CAPER:
•
Person
MTF
Appt Date
Provider
Diagnosis
Record ID
A
0091
07/01/2010
Doc Jones
Abdominal Pain
X
MTF Labs/Rads:
Person
MTF
Related
Record ID
Ordering
Clinic
Service
Date
A
0091
X
BAG
07/01/2010
Comprehensive
Metabolic Panel
A
0091
X
BAG
07/01/2010
C-Reactive Protein
A
0091
X
BAG
07/02/2010
X-Ray Exam of
Abdomen
FOR OFFICIAL USE ONLY
Procedure
22
MDR Enhancements
Application of Linkages in Purchased Care Records
•
Currently, acute care episodes have been built for purchased care.
Enables users to tie hospital and professional bills together.
• Coming soon for Same Day Surgery as well.
TED-I
•
Person
Admitting TED #
Begin Date
End Date
MS-DRG
A
X
10/10/10
10/12/10
619
Diagnosis
MORBID OBESITY
Primary Procedure
LAPAROSCOPIC
GASTROENTEROSTOMY
Associated Professional Records:
Person
Admitting
TED No.
Service Date
Place of Service
Procedure
A
X
10/10/10
Inpatient
ANESTH, SURGERY FOR OBESITY
A
X
10/10/10
Inpatient
LAPARO,SX,GASTRIC RESTRCT PROC
A
X
10/11/10
Inpatient
EXTREMITY STUDY
A
X
10/11/10
Inpatient
CONTRAST X-RAY, ESOPHAGUS
A
X
10/12/10
Inpatient
RAD EXM,CHEST,2,FRONTAL & LAT;
FOR OFFICIAL USE ONLY
23
MDR Enhancements
•
Convenience fields:
•
•
•
•
Elements such as Calendar Year, Calendar Month, Fiscal Year, Fiscal
Month.
Things that are thought be commonly needed.
There are many other data-type specific enhancements.
Will discuss some of these as we go through the various
data types in M2.
FOR OFFICIAL USE ONLY
24
Basic Data Flow
Data sent to MDR 24/7
TED
CHCS/AHLTA
MDR
Feed Node
MDR File Storage &
Limited Access
Batches
Weekly
Monthly
DEERS
PDTS
Others
M2 and
Data
Marts
User Access in Data
Marts
25
FOR OFFICIAL USE ONLY
Survey of Available Data in M2
FOR OFFICIAL USE ONLY
26
Person Data
FOR OFFICIAL USE ONLY
27
Person Data
There are two systems focused on person data:
•
Beneficiary data –
•
•
•
•
DMDC/DEERS
Not operated by the MHS
Contains detailed data about sponsors and their beneficiaries
Staffing data –
•
•
•
DMHRS
Contains detailed information about staff who work at MTFs.
Not in M2. Will be discussed later in “Other Data” Session.
FOR OFFICIAL USE ONLY
28
Beneficiary Data
•
DMDC/DEERS:
•
•
•
•
•
Operates DoD personnel systems.
Keeps track of active duty, retirees, family members and
others with DoD relationships (i.e. civilians, contractors).
Is the legal “system of record” for MHS benefits.
Sophisticated data systems that interact with the MHS and
others on a real-time basis.
Update transactions, DEERS Eligibility checks, enrollments
into TRICARE, etc.
FOR OFFICIAL USE ONLY
29
Beneficiary Data
Data in DEERS
•
•
•
•
•
•
•
•
Person Identifiers: Name, SSN, DEERS Person ID
Sponsor Status (Active Duty, Retired, etc.)
Relationship to Sponsor
Sponsor Service, Rank, Unit, Occupation
Enrollment Location (not Medical Home), Primary Care
Manager
Geographic Data
Medicare and Other Health Insurance Information,
Etc.
FOR OFFICIAL USE ONLY
30
Beneficiary Data
•
•
•
DEERS maintains multiple records per person, when needed. Only
one is deemed “Primary” by the MHS.
Example: Jane and Joe are married. Jane is on Active Duty, Joe is a
Reservist.
Joe was activated in 2005/2006, and again in 2011/2012
Joe’s data between 2005/2006 and Oct 14, 2011
Name
Joe Smith
Joe Smith
Person ID Sponsor SSN
A
A
A
B
Relation to
Sponsor
Self
Spouse
Bencat
Reservist
AD Family
Elg Start Date
3/1/2005
6/2/2006
Elg Stop Date
6/1/2006
6/2/2026
Joe’s data beginning Oct 15, 2011
Name
Joe Smith
Joe Smith
Person ID
A
A
Sponsor SSN
A
B
Relation to
Sponsor
Self
Spouse
FOR OFFICIAL USE ONLY
Bencat
Reservist
AD Family
Elg Start Date Elg Stop Date
10/15/2011 11/15/2012
6/2/2006
6/2/2026
31
DEERS Eligibility Checks
•
DEERS Eligibility Checks:
•
•
•
•
•
•
Transaction that goes between DEERS and a direct care MTF or
purchased care payor that establishes a beneficiary’s eligibility and
coverage.
At MTFs, used to determine priority for access to care.
In purchased care, determines how a claim is paid.
Results in an automatic download of data from DEERS to the requestor.
Local systems are not routinely updated by DEERS except through the
eligibility check or during an enrollment transaction.
This means local data can be stale!
FOR OFFICIAL USE ONLY
32
DEERS Enrollment Transactions
•
DEERS
•
•
•
•
•
Operates the DEERS Online Enrollment System (DOES).
Used to conduct TRICARE Enrollment activities.
Legal system of record for TRICARE Enrollments.
Enrollment, Disenrollment, Address Updates and Other Health
Insurance Updates
An enrollment in DOES triggers a “reciprocal disenrollment”.
FOR OFFICIAL USE ONLY
33
Patient Information Transfer Errors
•
The process for updating data ensures that:
•
•
•
Enrollees and all other patients being actively treated have current
DEERS data in local system
Those not being treated actively will not have good local demographic
data!
“PIT Error” is the term used to describe an error in
DEERS information transfer.
•
MTFs that do not take care of PIT errors will have bad local data!
FOR OFFICIAL USE ONLY
34
DEERS Data to the MHS
•
DEERS Monthly Data Feed (VM-6):
•
•
•
•
•
•
Detailed monthly data file from DEERS indicating beneficiary status on
the first of the reported month.
Does not include DoD contractors or civilians.
Contains multiple records per person if needed.
Some people call this file the “PITE” (Point in Time Extract)
Is processed by TMA, made available in M2.
Processing is significant!
FOR OFFICIAL USE ONLY
35
DEERS VM-6 Processing
•
There are many reasons why DEERS data should
be processed prior to use:
•
•
•
It contains more than one record per person. Most people don’t need or
want data about ineligibles. TMA flags each record as “primary” and
“eligible” or not.
It contains start and stop dates for many pieces of information. These
must be applied to get a correct answer! TMA applies the dates for M2
and removes values if expired.
DEERS does not always have the correct status at the time it provides its
extracts. TMA updates the data received from DEERS. (Think
newborns).
FOR OFFICIAL USE ONLY
36
DEERS Data
•
Strengths:
•
•
•
Vetting occurs when DEERS data are updated. Must provide official
documentation.
TMA-processed DEERS data is the cleanest source for beneficiary
status.
Weaknesses:
•
•
•
•
1st of the month snapshot. Not real-time or even near real-time.
Beneficiaries are not always diligent about keeping DEERS data up to
date. DEERS cannot force a beneficiary to update their information!
Deaths are not always reported in a timely manner, or at all!
Some types of errors can be difficult to fix.
FOR OFFICIAL USE ONLY
37
DEERS Files in M2
•
DEERS Eligibility:
•
•
All records in these file represent eligible beneficiaries. If person has
more than one reason for eligibility, only counted once.
DEERS Person Detail:
•
•
•
•
Monthly list of person’s eligible; FY06+
Contains significant demographic and service related data.
(Most robust of all files)
DEERS Population Summary and DEERS Longitudinal Eligibility
FOR OFFICIAL USE ONLY
38
Navy Eligible Population Profile
Navy
Sponsored
Marine
Sponsored
Navy Afloat
Sponsored
Total DoD
% Navy Marines
Affiliated
Active Duty Family (1)
286,963
229,616
162,991
2,409,277
28%
Retirees (2)
503,762
120,335
2,111,668
30%
Others (3)
788,966
202,261
3,460,503
29%
Active Duty (4)
215,639
213,112
129,292
1,709,807
33%
1,795,330
765,324
292,283
9,691,255
29%
Bencat
Total
•
•
All data are from M2 DEERS Population Summary and represent December 2011.
Navy/Marine Sponsored patients represent a third of the Active Duty Population
FOR OFFICIAL USE ONLY
39
Eligible Population – Trend
•All data are from M2 DEERS Population Summary
FOR OFFICIAL USE ONLY
40
Navy and Marine Population
Age Group
Active Duty
FM
Retirees
Others
Active Duty
Total
A: 00-04
158,858
23,211
182,069
B: 05-14
197,377
110,531
307,908
C: 15-17
34,548
64,720
134
99,402
D 18-24
89,204
1,377
111,651
242,532
444,764
E: 25-34
119,137
7,205
30,016
207,334
363,692
F: 35-44
61,879
40,126
63,915
89,143
255,063
G: 45-64
17,813
312,415
293,925
18,848
643,001
754
262,939
293,250
29
556,972
35
8
23
66
624,097
991,227
558,043
2,852,937
H: 65+
Z: UNK
Total
679,570
•All data are from M2 DEERS Population Summary and represent December 2011.
FOR OFFICIAL USE ONLY
41
DEERS Files in M2
•
DEERS Relationships
•
•
•
•
Is a subset of the DEERS Person Detail, but with fewer data fields.
All records in these file represent beneficiaries in enrollment programs,
or active duty service members.
Each member is only counted once.
DEERS Relationship Detail
•
•
•
•
Monthly list of persons enrolled or active duty; FY06+
Contains more limited detail than the DPD.
DPD also contains information about enrollment so that if you need data
about enrollees that’s not in the relationship data, you can use DPD.
DEERS Relationship Summary.
FOR OFFICIAL USE ONLY
42
Prime Enrollment Trend
by Service of Enrolling MTF
One of these lines doesn’t look like the others!
Source: M2 Relationship Summary
FOR OFFICIAL USE ONLY
43
Navy Enrollment MTFs
6 Parent MTFs represent half of Prime Enrollment at Navy MTFs
DMISID
MTF
Enrollees
% Total
0124
NMC Portsmouth
100,001
14%
0029
NMC San Diego
79,301
11%
0039
NH Jacksonville
55,653
8%
0024
NH Camp Pendleton
45,863
6%
0038
NH Pensacola
42,711
6%
0067
Walter Reed Nat'l Med Center
41,492
6%
Others
361,716
50%
Total: All Navy MTFs
726,737
Source: M2 Relationship Summary
FOR OFFICIAL USE ONLY
44
TRICARE Plus Enrollees
at Navy MTFs
84% of Navy MTF T-Plus Enrollees are also TFL
Age Group
Female
Male
Total
% Total
A: 00-04
81
85
166
0%
B: 05-14
421
465
886
2%
C: 15-17
203
188
391
1%
D: 18-24
231
255
486
1%
E: 25-34
116
37
153
0%
F: 35-44
366
173
539
1%
G: 45-64
1,800
1,848
3648
10%
H: 65+
15,956
16,008
31,964
84%
Total
19,174
19,059
38,233
100%
FOR OFFICIAL USE ONLY
Source: M2 Relationship Summary
45
DMDC Deployment Data
•
DMDC also provides a monthly file that describes
OCO deployments
•
•
•
•
•
Contingency Tracking System
This does not come from the DEERS Section of DMDC (which deals
with peacetime benefits).
Since 9/11/2001, list of all members who have deployed, along with
their deployment start and stop dates.
New data feed. Added to M2 recently.
Users cannot see the deployment roster, but can query other tables to get
deployment flags.
FOR OFFICIAL USE ONLY
46
Top DMISIDs with Navy/Marine
AD Enrollees Deployed
DMISID
6311
6301
NONE
6303
6320
6317
6304
1170
6312
6318
6307
Description
Op Forces – Lejeune
Op Forces – Pendleton
N/A
Op Forces - San Diego
Op Forces - Pearl Harbor
Op Forces – Portsmouth
Op Forces - 29 Palms
NBHC Bahrain
Op Forces - Cherry Pt
Op Forces – Bremerton
Op Forces – Jax
Source: M2 Relationship Summary
AD Enrolled to AD Not
OP Forces
Enrolled
10,676
6,923
5,822
2,997
2,902
2,532
2,120
Prime
2,030
1,635
1,607
1,236
FOR OFFICIAL USE ONLY
Grand
Total
10,676
6,923
5,822
2,997
2,902
2,532
2,120
2,030
1,635
1,607
1,236
47
Direct Care Health Care Data
FOR OFFICIAL USE ONLY
48
Direct Care Health Care Data
•
There are many sources of direct care health care
data
•
•
•
Most of the health data that analysts use in the MHS comes from each
local site’s Composite Health Care System (CHCS)
Some data also comes from the newer (partial) electronic health record
system (AHLTA)
MTFs also provide data to the Medical Expense and Performance
Reporting System (MEPRS).
FOR OFFICIAL USE ONLY
49
Composite Health Care System and AHLTA
FOR OFFICIAL USE ONLY
50
Composite Health Care System
•
The Composite Health Care System (CHCS):
•
•
•
•
•
Primary system used at each MTF to conduct operational
and many clinical activities.
Appointing, registration, scheduling, ordering, results
reviewing, etc…
Legacy system.
100+ CHCS Host Servers house local CHCS servers.
Local CHCS Hosts only have visibility of data collected
within the host itself.
FOR OFFICIAL USE ONLY
51
Data Collection Systems
•
Some limitations in CHCS:
•
•
•
•
•
No central access. Users who need global data must maintain
100+ separate accounts.
Demographic and enrollment update processes are not fail-safe.
Can only see care that is provided locally.
Cannot see any purchased care at all (more than half of the care
provided is purchased).
Quality issues are often not fixed locally.
FOR OFFICIAL USE ONLY
52
Example of Quality Issue in CHCS
•
•
•
•
DEERS updates CHCS whenever a “DEERS Check” is done or an
enrollment transaction affects an MTF.
• These are the only circumstances, generally, that demographic and
enrollment information is updated in CHCS.
• Means that information about patients who are not actively being treated
may be incorrect.
Patient Information Transfer (PIT) errors are common in this exchange
of data
MTFs that don’t properly managed PIT errors have unreliable
enrollment and demographic data.
Examples below drawn from CHCS last month:
Person
Enroll MTF Start Date
Stop Date
Person
Enroll
MTF
Start Date Stop Date
A
0417
7/1/2009
1/31/2025
B
0006
6/17/2011 9/6/2012
A
5197
1/13/2012 3/22/2023
B
0106
8/23/2011 9/6/2012
FOR OFFICIAL USE ONLY
53
CHCS
•
Real-time, raw nature of CHCS data is a significant
advantage.
•
•
Data are available here and now, when needed at MTF Level.
Access to CHCS:
•
•
•
•
•
Local users can gain access through their local IT departments.
Interface is not user friendly.
Since each CHCS machine (host) is separate, there is no method for
universal access to all CHCS.
TRICARE Operations Center used to provide extract support, but that
has not worked well for Navy Medicine.
Service information agencies sometimes maintain accounts to all CHCS
hosts.
FOR OFFICIAL USE ONLY
54
AHLTA
•
AHLTA:
•
•
•
•
•
Originally funded to replace CHCS; then called CHCS II.
Mission was scaled back to develop an electronic health record system.
(AHLTA)
Mission was scaled back again so that AHLTA is used to capture officebased electronic health information.
AHLTA data used to be visible centrally in Clinical Data Mart. But
CDM was shut down in 2011.
Users can access AHLTA type data:
•
Centrally through the MHS Data Repository or
•
Locally through AHLTA directly.
FOR OFFICIAL USE ONLY
55
AHLTA
•
AHLTA:
•
•
•
•
•
•
Fundamental flaw in design related to identification of a person.
Developers did not understand that many beneficiaries have more than
one reason for access to care.
Example:
•
Active Duty Service Member married to Guard Member
•
Active Duty Dependent who subsequently goes on active duty.
AHLTA created unique person identifiers (i.e. CDR Unit ID) based
solely on sponsor social security number.
Means that patients with more than reason for access to care may not be
uniquely identifiable in AHLTA.
This issue affects more than a million members!
FOR OFFICIAL USE ONLY
56
Remember Joe?
•
•
•
•
CDR assigned Joe Smith two different “unique” person identifiers.
This “unique” person identifier is the key to the CDR Architecture
Results in incorrect aggregations of a person’s data; incorrect application of
demographics
DEERS Person ID in CDR and AHLTA is also affected by this error.
Joe’s data between 2005/2006 and Oct 14, 2011
Name
Joe Smith
Joe Smith
Person ID Sponsor SSN
A
A
A
B
Relation to
Sponsor
Self
Spouse
Bencat
Reservist
AD Family
Elg Start Date
3/1/2005
6/2/2006
Elg Stop Date
6/1/2006
6/2/2026
Joe’s data beginning Oct 15, 2011
Name
Joe Smith
Joe Smith
Person ID
A
A
Sponsor SSN
A
B
Relation to
Sponsor
Self
Spouse
FOR OFFICIAL USE ONLY
Bencat
Reservist
AD Family
Elg Start Date Elg Stop Date
10/15/2011 11/15/2012
6/2/2006
10/14/2011
57
CHCS and AHLTA Data Flows
•
CHCS is the data capture • AHLTA is the data capture point
point for MTF:
for MTF:
•
•
•
•
•
•
•
Inpatient Admissions
Appointments
~20% of ambulatory
encounters
Laboratory
Radiology
Pharmacy
Appointment
•
•
•
•
•
•
~80% of ambulatory encounters
Vitals
Linkages of diagnosis/procedures
Historical Procedures
Immunizations
Other clinical data
FOR OFFICIAL USE ONLY
58
Encounters
•
Note that encounters are captured in two separate
systems
•
•
•
Depends on where care is provided
Whether AHLTA is operational when the provider needs to
use it.
AHLTA is not used for:
•
•
•
•
Inpatient Care
Same Day Surgeries
Most ER Visits
~10% of routine medical care
FOR OFFICIAL USE ONLY
59
Ambulatory Data Collection at MTFs
CDR/CDM
AHLTA
Coding
edits do not
flow to
CDR/CDM
APPT
CHCS Appt
Module
Coding
Editor
CHCS ADM
MDR
APPT
ADM + AHLTA
Records are in
CAPER file for MDR
CAPER
60
FOR OFFICIAL USE ONLY
Detailed CHCS Data Products in the MDR
Name
Description
Periodicity
Standard Inpatient Data
Record (SIDR)
Inpatient Hospital Records
Monthly
Appointment
Outpatient appointment records
Weekly
Referral
Referrals for specialty care or
services
Weekly
Comprehensive Professional
Outpatient visit, t-con or inpatient
Encounter Record (CAPER)
rounds records
(used to be SADR)
Weekly
Ancillary Lab, Rad and Rx
Procedure Records
Monthly
Medical Home Enrollment
CHCS-reported Medical Home
records
Monthly
Will discuss other feeds from CDR in a later session
FOR OFFICIAL USE ONLY
61
Standard Inpatient Data Record
•Records
•
•
•
•
•
•
about MTF hospital stays
One record per stay at an MTF.
200+ data elements in each record.
Each CHCS host sends monthly; data files combined; processed and
stored in MDR.
Cannot be accelerated unless Services agree to code more often.
Data mart extracts are then prepared (i.e. M2)
Navy has ~81K SIDRs per year (270K all Services total)
62
FOR OFFICIAL USE ONLY
Standard Inpatient Data Record
•Called
“Inpatient Admissions Detail (SIDR)” in M2.
•Information on the SIDR
•Person
identifying information
•MTF and department providing care
•Provider information
•Patient Demographics and Enrollment
•Diagnosis and Procedure Codes
•Admission & Disposition Dates, Length of Stay
•MS Diagnosis Related Group (DRG) (Raw and Derived)
•Preventable Admission Indicators (AHRQ, Derived)
•Estimated Costs and Relative Weighted Products (Derived)
•Admission Source and Discharge Status, etc….
•No associated laboratory or other clinical data (only available in CHCS)
63
FOR OFFICIAL USE ONLY
Top MS-DRGs
performed at Navy Hospitals
MS-DRG Description
NORMAL NEWBORN
VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
NEONATE, BIRTHWT >2499G, W/O SIGNIF O.R. PROC, W OTHER PROB
CESAREAN SECTION W/O CC/MCC
VAGINAL DELIVERY W COMPLICATING DIAGNOSES
CESAREAN SECTION W CC/MCC
CHEST PAIN
ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O MCC
NEONATE, BIRTHWT >2499G, W/O SIGNIF O.R. PROC, W MAJOR PROB
UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC
Count
10,911
10,337
5,163
2,818
2,464
1,992
1,569
1,250
1,110
1,065
These ten DRGs make up about half of Navy’s
inpatient production!
•Source: M2 Inpatient Admissions Detail (SIDR).
64
FOR OFFICIAL USE ONLY
Multiple Direct Care Admissions
for a Single Patient
Person is an unenrolled active duty family member
Person
MS
DRG
Description
Adm Date
Days
A
282
Acute Myocardial Infarction
11/27/10
2
A
236
Coronary Bypass w/o Cardiac Cath
12/05/10
4
A
246
Percutaneous Cardiovascular Proc
02/04/11
3
A
313
Chest Pain
02/21/11
1
A
287
Circulatory Disorders
03/08/11
2
•Source: M2 Inpatient Admissions Detail (SIDR).
65
FOR OFFICIAL USE ONLY
Case Mix at U.S.-based Navy
Inpatient MTFs
Tmt DMIS
ID
Tmt DMIS ID Name
0067
0029
0124
0104
0038
0126
0039
0091
0024
0030
0028
0127
WALTER REED NATL MED CENTER
NMC SAN DIEGO
NMC PORTSMOUTH
NH BEAUFORT
NH PENSACOLA
NH BREMERTON
NH JACKSONVILLE
NH CAMP LEJEUNE
NH CAMP PENDLETON
NH TWENTYNINE PALMS
NH LEMOORE
NH OAK HARBOR
RWPs
Disp
Case Mix
3,951
4,201
3,952
112
577
449
822
1,194
907
209
75
109
3,542
4,661
4,412
128
865
718
1,332
2,071
1,709
472
185
301
1.12
0.90
0.90
0.88
0.67
0.63
0.62
0.58
0.53
0.44
0.40
0.36
•Source: M2 Inpatient Admissions Detail (SIDR), FY 2011.
FOR OFFICIAL USE ONLY
66
Strengths and Weaknesses
•
Strengths:
•
•
•
Richest source of inpatient direct care available.
Usually coded by certified coders
Weaknesses:
•
•
Timeliness
Lack of clinical detail (i.e. associated labs, etc)
FOR OFFICIAL USE ONLY
67
Referral Records
•Some
appointments require referrals
•Referrals are issued by MTFs using CHCS
•Referral File is updated in CHCS when a referral is issued; or used.
•CHCS sends a referral extract weekly
•Combined in MDR, processed and data mart extracts prepared.
•Referrals done by Managed Care Support Contractor not currently
available.
68
FOR OFFICIAL USE ONLY
Referral Records
•Called
‘Referrals” in M2
•Information on the CHCS Referral Data
•Person
identifying information
•CHCS Host of issuing MTF
•Provider ID
•Patient Demographics and Enrollment
•Issue Date, Referral Begin and End Date
•# Visits Authorized
•Clinic Issuing the Referral
•Clinic that the referral is to be used in
•Linkers to information about MTF care that resulted from the referral if the care
occurred on the same CHCS host as the referral was made.
•Referrals that are unmet (no appointment booked) are removed from CHCS and
not present in this file)
69
FOR OFFICIAL USE ONLY
Navy-Wide Number of Referrals
ACV Group
ADFM
RET
OTH
AD
Desig Prov
152
195
50
17
16,198
18,578
29,924
Other
Overseas Remote
Plus
244
UNK
Total
414
22,212
86,912
11
981
1,236
1,409
47,408
44,247
10
93,074
Prime
385,839
141,037
186,879
605,106
1,318,861
Reliant
11
311
327,629
327,951
261,422
933,743
Grand Total
403,853
207,218
22,212
1,828,448
•Source: M2 Referral File; FY 2011.
70
FOR OFFICIAL USE ONLY
Example of Linked Referral and Outpatient Data
Referral Record
Person
Referral
Date
Referring
Provider
A
08/03/2010
Prov A
Begin
Date
End Date
08/03/2010 08/03/2011
Refer to
Clinic
Referral
Number
BAB
X
Associated Encounters
Person
Appt
Date
Clinic
Referral
Number
A
12/04/2010
BAB
X
A
01/03/2011
BAB
X
A
02/01/2011
BAB
X
71
FOR OFFICIAL USE ONLY
Strengths and Weaknesses
•
Strengths:
•
•
Only source for direct care referral information
Weaknesses:
•
•
•
Must back into ‘which MTF’ issued the referral
Only completed referrals are in the file
No standardized business rules for identifying MTF-issued
referrals intended for the network.
FOR OFFICIAL USE ONLY
72
Appointment Records
•Appointments
are made at MTFs using CHCS
•Patient Appointment File is updated in CHCS when:
• An appt is made or
• it’s status recorded.
•Appt File extract sent to MDR weekly
• One record per appt
•Extracts are combined and processed in the MDR.
•Processed appointment data is also incorporated into the
preparation of CAPER data (more later)
73
FOR OFFICIAL USE ONLY
Appointment Records
•Information
•
•
•
•
•
•
•
•
•
on the CHCS Appointment Data
Person identifying information
Appointment MTF
Provider ID
Patient Demographics and Enrollment
Appointment Date and Time
Clinic
Date Appointment Made
Appointment Status
Appointment ID Number
74
FOR OFFICIAL USE ONLY
Professional Services Records
•Providers
are required to capture records about:
• Outpatient encounters
• Documented telephone consults
• Inpatient rounds
•Providers are not required to capture records about inpatient procedures
• Some code them anyway, but not all do. Cannot rely upon having
complete inpatient professional records
• Improvements in collection of inpatient professional service records has
been significant!
• Consider the example in Navy obstetrics, to follow.
75
FOR OFFICIAL USE ONLY
Top DRGs performed at Navy Hospitals
Delivery DRGs from Navy Top 10 List
MS-DRG Description
VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
CESAREAN SECTION W/O CC/MCC
VAGINAL DELIVERY W COMPLICATING DIAGNOSES
CESAREAN SECTION W CC/MCC
Count
10,337
2,818
2,464
1,992
CAPERs recorded for professional services in MEPRS A Codes
CPT/HCPCS
59409: Vaginal Delivery and Postpartum Care
Count
10,229
59514:
59410:
59612:
59400:
Etc…
4,015
386
265
166
C/Section Only
Vaginal Delivery Only
VBAC Only
Complete Obstetrics Package (all-prenatals/PPM)
•Source: M2 Inpatient Admissions Detail (SIDR) and Professional
Encounters Detail (CAPER); FY 2011
FOR OFFICIAL USE ONLY
76
Professional Services Records
•Comprehensive
•
•
•
•
•
•
•
Used to be called the SADR; many still use the terms interchangeably.
One record for each documented encounter, telephone consult or
inpatient rounds data (and sometimes other items)
Contains ~200 data elements
Sent daily, processed weekly
Records are combined with appointment file, processed and data mart
extracts prepared
Enables easy tracking of incomplete records.
~40 million CAPERs worldwide, Navy share is ~ 11 million.
•Called
•
Professional Encounter Record (CAPER)
“Professional Encounters Detail (CAPER)” in M2.
Summary also available.
77
FOR OFFICIAL USE ONLY
CAPER
•Information
•
•
•
•
•
•
•
•
•
•
•
•
on the CAPER:
Patient Identifiers and Demographics
Enrollment Information
Sponsor Information
Clinic (MEPRS Code)
Encounter Date
Type of Appt
Appointment Provider and Specialty Code
Additional Providers / Specialties
Diagnosis & Procedure Info
Administrative Data
Relative Value Units and Estimated Costs
Linkable to associated ancillaries (lab, rad and rx) and referrals if done at a local
MTF.
78
FOR OFFICIAL USE ONLY
Professional Encounters
CAPERs
“Kept” Appt Records
Record ID
Service Date
A
06/01/10
B
06/08/10
C
06/05/10
D
06/18/10
Inferred CAPERs have
no Diagnosis or
Procedure codes
+
Record ID
Service Date
A
06/01/10
B
06/08/10
MDR and M2 Professional Encounter Records
Record ID
Service Date
Dx 1
Type
Full Cost
A
06/01/10
V202
Recorded
$544.49
B
06/08/10
30002
Recorded
$389.44
C
06/05/10
Inferred
$381.46
D
06/18/10
Inferred
$381.85
79
FOR OFFICIAL USE ONLY
Top 10 Clinics at Navy Hospitals and
Clinics for FY 2011, based on encounters
MEPRS
Code
Description
Prime or
Reliant
Other
Plus
Total
% Prime or
Reliant
BHA
Primary Care
1,775,836
58,850
17,179
1,851,865
96%
BGA
Family Practice
844,483
67,500
40,212
952,195
89%
BGZ
FP Med Home
782,059
26,740
37,474
846,273
92%
BLA
Physical Therapy
565,154
15,663
8,926
589,743
96%
BCB
Gynecology
466,185
21,632
2,902
490,719
95%
BDA
Pediatrics
384,816
41,311
2,498
428,625
90%
BIA
Emergency Room
335,349
49,396
17,975
402,720
83%
BHZ
PC Med Home
310,991
32,591
5,161
348,743
89%
BHC
Optometry
297,245
22,885
4,795
324,925
91%
BFD
Mental Health
311,155
8,290
2,114
321,559
97%
•Source: M2 Professional Encounters Summary (CAPER); FY 2011
FOR OFFICIAL USE ONLY
80
Example of MTF Encounter History
for One Patient
Person
MTF
Clinic
Encounter
Date
Procedure
Primary Dx
A
Portsmouth
ER
11/11/2011
ER Visit
Neck or Femur Fracture
A
Portsmouth
Internal
Med
11/14/2011
Subsequent Hospital
Care
Hyposmolarity
A
Portsmouth
Outpatient
Nutrition
11/16/2011
Nutrition Therapy
Dietary Surveillance
A
Portsmouth
Plastic
Surgery
11/18/2011
Non-sterile Gauze
Open Leg Wound
A
Portsmouth
Peripheral
Vascular
11/18/2011
Extremity Study
Pain in Limb
A
Portsmouth
Occupation
Therapy
11/18/2011
Self Care Management
Training
Occupational Therapy
A
Portsmouth
Internal
Med
12/01/2011
Office Visit
Hyposmolarity
A
Portsmouth
Orthopedic
12/02/2011
Office Visit
Orthopedic Aftercare
A
Portsmouth
Internal
Med
12/11/2011
Telcon
Issue of Repeat
Prescriptions
A
Portsmouth
Orthopedic
12/23/2011
Follow-up
Follow-up on Surgery
Taken from an M2 Canned Report
FOR OFFICIAL USE ONLY
81
Frequent Flier Report
Person
Estimated
Cost
Clinic
Enc Date
Diagnosis
A
BIA
11/05/09
MIGRAINE,UNSP,WO INTRAC WO MIG
A
BIA
11/07/09
OTHER MALAISE AND FATIGUE
$308.98
A
BIA
11/08/09
DYSURIA
$381.52
A
BIA
04/06/10
VOMITING WITHOUT NAUSEA
$485.77
A
BIA
04/14/10
TACHYCARDIA NOS
$999.84
$1,447.39
•
•
•
A
Totals
BIA
10/29/10
CHRONIC PAIN SYNDROME
28 Encounters
19 Diagnoses
Example taken from an M2 Canned Report
FOR OFFICIAL USE ONLY
$448.37
$15,297.30
82
Case Management
•
From CAPERs, a Case Management Episode
Table is developed in the MDR
•
•
•
•
And sent to M2
Linked to all other data files in M2.
Enables users to retrieve information about case managed patients.
Only works if the site is following UBU Coding Guidelines for CM.
FOR OFFICIAL USE ONLY
83
Case Management Episode
Person
Enc Date
Diagnosis 1
Procedure 1
1015XXXX
3/2/2010
CM Svcs - Initiation
CM Acuity 2
1015XXXX
4/1/2010
CM Svcs – Maintenance
CM Acuity 2
1015XXXX
5/1/2010
CM Svcs – Maintenance
CM Acuity 2
1015XXXX
5/17/2010
CM Svcs – Completion
CM Acuity 2
Person
Beg Date
End Date
Acuity
1015XXXX
3/2/2010
5/17/2010
2
FOR OFFICIAL USE ONLY
84
Example of Linked Case Management Records
From Case Management File
Patient
A
Acuity
2
Start
10/1/2011
Stop
2/5/2012
CM
#1
From Case Management Corporate Report
Patient
A
Data
TED-N
Type
ER
Beg
10/15/2011
End
10/15/2011
CM
#1
Acuity
2
A
A
A
A
TED-N
TED-I
TED-N
PDTS
ER
Admission
Doctor Bill
Script
10/20/2011
10/22/2011
10/22/2011
11/23/2011
10/20/2011
11/22/2011
10/22/2011
11/23/2011
#1
#1
#1
#1
2
2
2
2
FOR OFFICIAL USE ONLY
85
Strengths and Weaknesses
•
Strengths:
•
•
Professional encounters contain the most detailed
information about ambulatory healthcare at MTFs available
Weaknesses:
•
•
Data capture has not always been complete; now seems to be
too complete!
Coding is not the best quality
FOR OFFICIAL USE ONLY
86
Coding and CHCS/AHLTA
•
MTFs are notorious for coding problems.
•
•
•
•
Minimal edits are applied.
Ambulatory records are generally not coded by a coder.
Sometimes AHLTA gives unclear hints on how to code, also.
Many users enforce stricter edits when using data.
•
For example, for chronic conditions it is common for analysts
to require more than one occurrence of a diagnosis code
before considering a patient to have been diagnosed.
FOR OFFICIAL USE ONLY
87
Coding Creep Example
3.15
Average E&M Code Intensity
3.10
3.05
3.00
A
2.95
F
N
2.90
Total
2.85
2.80
2.75
2.70
MHS Worldwide Average (non ERs), October 2005 through January882011
FOR OFFICIAL USE ONLY
88
Coding Creep Example
5.00
One Medical Examination Clinic. . .
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
October 2005 through January 2011
FOR OFFICIAL USE ONLY
89
89
Examples of Bad Units of Service Coding
•
•
•
Each CAPER represents care provided to one patient on one day.
The first three CAPERs indicate that there were 80 patients were given
more than 900 vaccinations at one visit!
The last CAPER shows 159 encounters where the patients had up to 52
days of psych counseling in one day!
CPT
Description
UOS Raw
# CAPERs
90471
Administration of a Single
Vaccine
906
48
90471
Administration of a Single
Vaccine
907
15
90473
Administration of a Single
Vaccine - Oral
906
17
90801
Psychiatric Eval (covers
up to 24 hours)
52
159
FOR OFFICIAL USE ONLY
90
Laboratory and Radiology Data Records
•Records
•
•
•
•
•
•
•
about laboratory and radiology procedures
MTF care; only associated with outpatient care
Links to CAPER where ordered
Created from CHCS laboratory and radiology files
Limited number of data elements
Automatically sent (monthly) by CHCS
Combined, processed and stored in MDR
Results not included currently, but that is being addressed.
91
FOR OFFICIAL USE ONLY
MTF Lab and Rad Data Records
•Information
•
•
•
•
•
•
•
on lab and rad records:
Patient Identifier and Demographics
Enrollment Information
Sponsor Information
Relative Value Units and Estimated Costs
Ordering Information (Provider, Appt ID, Clinic)
Exam Date
Procedure Codes (indicates the test), Modifiers and Units of Service
92
FOR OFFICIAL USE ONLY
Lab and Rad Services at Navy MTFs
Ben Cat
Radiology
Laboratory
Active Duty Family
554,703
3,143,057
Retirees
275,516
2,456,631
Others
513,918
3,172,379
Active Duty
1,110,986
6,133,256
Total
2,455,123
14,905,323
Source: M2 Laboratory and Radiology Files
93
FOR OFFICIAL USE ONLY
Sample Records
Person
ID Service Date
Proc
Modifier
Svcs
Work RVU
PE RVU
Total RVU
A
10/1/2011
77057
26
1
0.7
0.29
0.99
A
10/1/2011
77057
TC
1
0
1.36
1.36
B
10/3/2011
77056
TC
1
0
1.98
1.98
B
10/14/2011
77056
26
1
0.87
0.36
1.23
•
•
•
•
These records represent mammograms
26: Professional reading the mammograms
TC: Technicians using the mammogram machines
Note: Work RVUs for radiologists
FOR OFFICIAL USE ONLY
94
Example of Lab History
Person
MTF
Clinic
Encounter
Date
A
0058
BGA
08/18/10
A
0058
BGA
08/29/10
A
0058
BGA
08/04/10
A
0058
BAA
09/18/10
A
0064
BHG
10/13/10
Procedure
Primary Dx
GLYCOSYLATED
HEMOGLOBIN TEST
GLYCOSYLATED
HEMOGLOBIN TEST
GLYCOSYLATED
HEMOGLOBIN TEST
GLYCOSYLATED
HEMOGLOBIN TEST
GLYCOSYLATED
HEMOGLOBIN TEST
Can usually be linked to visit where test was ordered
for information about what diagnoses may have led to
the test order.
95
FOR OFFICIAL USE ONLY
Example of Linked Outpatient and Lab/Rad Data
CAPER
Person
MTF
Appt Date
Referring Clinic
Diagnosis
Record ID
A
0110
07/01/2011
BAG
Abdominal Pain
22652870
Associated Lab/Rad data
Person
MTF
Related
Record ID
Ordering
Clinic
Service
Date
A
0110
22652870
BAG
07/01/2010
Comprehensive
Metabolic Panel
A
0110
22652870
BAG
07/01/2010
C-Reactive Protein
A
0110
22652870
BAG
07/02/2010
X-Ray Exam of
Abdomen
Procedure
96
FOR OFFICIAL USE ONLY
Strengths and Weaknesses
•
Strengths:
•
•
Lab and Rad data will allow you to see what types of services
were provided for outpatients.
Weaknesses:
•
•
Does not include results.
Does not include ancillaries for inpatients.
FOR OFFICIAL USE ONLY
97
MEPRS
•
MTF Accounting System
•
•
•
•
MEPRS Contains:
•
•
•
•
Medical Expense Performance and Reporting System
Each service has their own Service-unique accounting system
But all fixed MTFs are required to also submit MEPRS data.
Expense data from Service systems
Workload data from CHCS, primarily
Manpower data from DMHRS
Available only at MTF, Month, Year and MEPRS Code
level.
FOR OFFICIAL USE ONLY
98
Navy MEPRS Workload and FTE Summary - 2011
MEPRS
Code
Average
Available
Provider FTEs
Rx Wtd
Procs
Total
“Count”
Visits
A
253
253,588
81,040
2,921,768
0
B
2,806
0
0
7,677,508
8,270,099
C
580
0
0
165,642
0
D
780
0
0
258,428
0
E
543
0
0
0
0
F
385
0
0
4,210,375
268,755
G
357
0
0
0
0
Bed Days Dispositions
FOR OFFICIAL USE ONLY
99
Largest Navy MTFs (by FY 2011 MEPRS $)
Name
NMC SAN DIEGO
Total Exp
939,943,300
% of All
Navy
18%
WALTER REED NATL MIL MED CEN
NMC PORTSMOUTH
NH JACKSONVILLE
NH CAMP PENDLETON
NH CAMP LEJEUNE
NH PENSACOLA
NH BREMERTON
NH OKINAWA
NH YOKOSUKA
806,693,504
806,367,625
280,307,588
279,086,160
242,465,456
239,806,816
170,396,460
133,421,055
129,861,050
15%
15%
5%
5%
5%
5%
3%
3%
2%
FOR OFFICIAL USE ONLY
Cumulative
%
18%
33%
49%
54%
59%
64%
69%
72%
74%
77%
100
Strengths and Weaknesses of MEPRS data
•
Strengths:
•
•
•
•
MEPRS is the only source in M2 for FTE data
Expense data can be an advantage, depending on your
purpose.
Inpatient ancillaries (aggregate only) are available.
Weaknesses:
•
•
FTE data is only as good as the command cares
Data are too aggregated for most functional needs.
FOR OFFICIAL USE ONLY
101
Purchased Care Claims Data
102
FOR OFFICIAL USE ONLY
TRICARE Purchased Care Data
•Ever-growing
•
•
•
•
•
•
•
•
•
purchased health care (billions)
Physician Services
Hospital Stays
Ancillary Services
Emergency Room & Other Hospital Outpatient Dept
Durable Medical Equipment
Pharmacy
Home Health
Hospice
Other miscellaneous
•Claims
used for reimbursement
•Claims records should be thought of as bills
103
FOR OFFICIAL USE ONLY
TRICARE Encounter Data Records
•Claims
records are called TEDs
•Institutional TED records
• Inpatient hospital care and institutional-based home health
•Non-Institutional TED records
• All other types of services and supplies
•TED Provider Records
• List of authorized TRICARE providers
•Sent & processed monthly; stored in MHS Data Repository; data mart
extracts prepared
104
FOR OFFICIAL USE ONLY
TED Records
•Information
on the Institutional TED Records
•Claim
Number
•Provider Identifier & Type of Institution
•Patient Identifiers
•Demographic and Enrollment Information
•Diagnosis / Procedure Codes, MS-DRG
•Admission Date
•Begin Date and End Date
•Payment and Billing Data
•RWPs
•Linker available to link records associated with acute care stays
•Each
record represents a hospital bill
•Can
•Sent
cover partial stays, includes multiple diagnoses and procedures
and processed monthly in the MDR, data mart extracts prepared.
105
FOR OFFICIAL USE ONLY
Top DRGs for Navy MTF Enrollees
in the Private Sector – Acute Care Only (FY2011)
MS-DRG Description
Admissions
Hospital
Paid
Avg Hosp
Paid
775
Vaginal Delivery w/o CC/MCC
3,187
11,587,703
3,636
795
Normal Newborn
1,483
1,582,965
1,067
766
C-Section w/o CC/MCC
1,010
6,124,436
6,064
765
C-Section w CC/MCC
557
4,062,051
7,293
774
Vaginal Delivery w/ CC/MCC
453
1,846,598
4,076
792
Neonate >2499G w oth prob
430
765,115
1,779
Source: M2 Purchased Care Institutional Detail
Note impact of Region South enrollment policy
FOR OFFICIAL USE ONLY
106
Average Cost of Hospital Care
for Navy MTF Enrollees
Acute Care -- Purchased Care
Program
Admissions
Total Hosp Paid
Avg Hosp Paid
Plus
3,049
3,775,662
1,238
Prime
20,412
183,760,018
9,003
Hospital Costs in Direct Care
Program
Dispositions
Total Hosp Cost
Avg Hosp Cost
Plus
5,582
82,512,125
14,099
Prime
41,000
410,887,551
9,621
Source: M2 Inpatient Admissions Detail and TED Institutional Detail, FY11
FOR OFFICIAL USE ONLY
107
Multiple Related Admissions -- Private Sector
Person
Hosp
MSDRG
A
X
619
A
X
A
X
Description
Adm Date
Disp Date
LOS
O.R. PROCEDURES FOR OBESITY W MCC
03/18/11
03/20/11
2
862
POSTOPERATIVE & POST-TRAUMATIC
INFECTIONS W MCC
03/26/11
04/01/11
6
603
CELLULITIS AGE >17 W/O MCC
04/28/11
04/30/11
2
108
FOR OFFICIAL USE ONLY
Example of Linked Inpatient Data
Institutional TED
Person
Admitting
TED No.
Begin Date
End Date
MSDRG
Diagnosis
A
X
10/10/11
10/12/11
619
MORBID
OBESITY
Primary Procedure
LAPAROSCOPIC
GASTROENTEROSTOMY
Associated Non-Institutional TEDs
Person
Admitting
TED No.
Service Date
Place of Service
A
X
10/10/10
Inpatient
ANESTH, SURGERY FOR OBESITY
A
X
10/10/10
Inpatient
LAPARO,SX,GASTRIC RESTRCT PROC
A
X
10/11/10
Inpatient
EXTREMITY STUDY
A
X
10/11/10
Inpatient
CONTRAST X-RAY, ESOPHAGUS
A
X
10/12/10
Inpatient
RAD EXM,CHEST,2,FRONTAL & LAT;
Procedure
109
FOR OFFICIAL USE ONLY
Purchased Care Subtleties
•Treatment
of Records for Long Stay Patients
Direct care policy for completion of inpatient records is that they
must be completed within 30 days of discharge.
This doesn’t work in the private sector because sometimes
providers want to get paid before the patient is discharged.
•
•
Rec ID
Pers
ID
Adm Date
Begin Date
End Date
FY
FM
Disch
Stat
Adm
Bed
Days
#
Claims
1
A
2/10/2009
2/10/2009
2/18/2009
2010
5
Still pt
1
8
1
2
A
2/10/2009
2/19/2009
4/19/2009
2010
7
Still pt
0
59
1
3
A
2/10/2009
4/20/2009
5/22/2009
2010
8
Disch
0
32
1
1
99
3
Total for all three records
110
FOR OFFICIAL USE ONLY
TED Records
•Information
on the Non-Institutional TED Records
•Provider
Identifier & Specialty
•Patient Identifiers
•Demographic and Enrollment Information
•Diagnosis / Procedure Code, APC, NDC
•Place of Care / Nature of Care
•Begin Date and End Date
•Payment and Billing Data
•RVUs
•Linker available to link records associated with acute care stays
•Each
•Sent
record represents one provider and one procedure code
and processed monthly in the MDR, data mart extracts prepared.
111
FOR OFFICIAL USE ONLY
Navy Prime Enrollee Places of Care
95% of TED Non-Institutional Costs for Navy Prime enrollees were in these places of care.
Place
Description
RVUs
Amt Paid
11
Office
5,050,436
166,437,180
22
Hospital Outpat Dept
535,199
128,031,307
19
Pharmacy
23
Emergency Room
468,722
74,413,734
12
Home
36,833
74,118,707
21
Inpatient
944,377
35,491,182
24
Ambulatory Surg Ctr
188,302
11,442,515
113,454,048
Source: M2 Non-Institutional Detail, FY11.
FOR OFFICIAL USE ONLY
112
Example of Claims when Patient has Surgery
Person
Service Date
Place
Provider Specialty
Procedure
A
02/09/11
ASC
Anesthesiology
A
02/09/11
ASC
Clinic or other group practice ARTHROSCOP ROTATOR CUFF REPR
A
02/09/11
ASC
Orthopedic Surgery
ARTHROSCOP ROTATOR CUFF REPR
A
02/09/11
ASC
Physician’s Assistant
ARTHROSCOP ROTATOR CUFF REPR
A
02/09/11
ASC
Orthopedic Surgery
REPAIR BICEPS TENDON
A
02/09/11
ASC
Physician’s Assistant
REPAIR BICEPS TENDON
A
02/09/11
ASC
Clinic or other group practice
A
02/09/11
ASC
Orthopedic Surgery
A
02/09/11
ASC
Physician’s Assistant
A
02/10/11
Office
A
02/13/11
Pharmacy
ANESTH,SURG ARTHROSCP
SHOULDER
SHOULDER
ARTHROSCOPY/SURGERY
SHOULDER
ARTHROSCOPY/SURGERY
SHOULDER
ARTHROSCOPY/SURGERY
Clinic or other group practice THERAPEUTIC EXERCISES
Pharmacy
PRESCRIPTION DRUGS
These are not duplicate records; they are indications that both the facility
and the providers were paid. FOR OFFICIAL USE ONLY
113
Strengths and Weaknesses
•
Strengths:
•
•
•
TED data are auditable . There are powerful incentives for
getting the data right!
There is a clear indication of amount paid!
Weaknesses:
•
Data collection is governed by billing rules
FOR OFFICIAL USE ONLY
114
TED Records
•
•
With CAPER, there is one record for each encounter; not
so with TEDs.
TED records can be difficult to use because there are often
many records for a single event.
•
•
•
•
Must consider that TEDs are billing records
All providers are paid separately
Only one procedure code per record.
Claims billing rules sometimes obscure understanding of
what really happened.
•
•
Global bills
Special billing rules for administrative simplification.
115
FOR OFFICIAL USE ONLY
Direct and Purchased Care Provider Workload
Example CAPER
Rec ID
E&M
Proc1
Proc 2
A
99392
99173
90471
Proc3
Proc4
Prov1
Prov2
C*
D*
Prov3
Encounters
1
CAPER Prov to Proc Linkage says that C* did 99392 and D* did 99173 and 90471
TED-N records each have only one provider and one procedure
Record A, as it would
appear if the care had
been delivered in the
private sector
Rec
ID
Line
Item
Provider
Procedure
# Line
Items
# Visits
A
1
C*
99392
1
1
B
1
D*
99173
1
1
B
2
D*
90471
1
1
116
FOR OFFICIAL USE ONLY
Direct and Purchased Care Provider Workload
• With TED, the same claim can be used to represent multiple services,
as long as the procedure code is the same.
• With CAPER, each encounter must be separately reported.
Rec
ID
Line
Item
Number
Person
Beg Date
End Date
Procedure
#
Line
Items
#
Services
# Visits
1
1
A
11/6/2009
11/9/2009
97110
1
4
4
2
1
A
11/18/2009
11/20/2009
97110
1
4
4
3
1
A
11/23/2009
11/25/2009
97110
1
4
4
4
1
A
11/30/2009
11/30/2009
97110
1
4
4
•Procedure Code represents 15 minutes of PT
117
Differences in Direct & Purchased Care
Provider Workload
•Treatment
of Global Procedure Codes
•CAPERs
are required for each and every encounter. In TEDs, pre and post
operative care are not generally separately reported.
Example TED Records for Global Maternity Procedures
Rec
ID
Line Item
Number
Person
Beg Date
End Date
Procedure
Place
# Line
Items
#
Services
#
Visits
1
1
A
12/9/009
12/9/2009
59510
21
1
1
0
2
1
A
1/16/2010
1/16/2010
59400
21
1
1
0
3
1
A
1/9/2010
1/9/2010
59410
21
1
1
0
Each of these TEDs represents roughly 10-15 visits plus an inpatient procedure;
number of visits counted is 0 and place of service is listed as inpatient
118
FOR OFFICIAL USE ONLY
.
Pharmacy Data
119
FOR OFFICIAL USE ONLY
PDTS
•
•
•
•
•
Pharmacy Utilization Review
Contains direct care, retail, mail order, and some VA
prescriptions all in one file.
Outpatient prescriptions only
MTF records link to encounters where the prescription
was ordered.
Sent in weekly and processed in the MDR, data mart
extracts prepared.
120
FOR OFFICIAL USE ONLY
PDTS
•Called
“Pharmacy (PDTS)” in M2
•Information on the PDTS Record:
•
•
•
•
•
•
•
•
•
•
Patient Identifier and Demographics
Enrollment
Sponsor Information
Issue Date
Source (Direct, Retail, etc)
Pharmacy Information
Ordering Provider Information
National Drug Code, Generic Class and Therapeutic Class
Estimated Costs, Payment and Billing Data
MTF Fills are linkable to the encounter where the prescription was ordered.
121
FOR OFFICIAL USE ONLY
Navy MTF Share of Prescriptions for
Navy Enrollees (Prime and Plus)
Year
MTF
Retail
Mail
2002
7,598,878
412,550
2003
7,205,752
2004
VA
Total
MTF Share
36,914
8,048,342
94%
455,600
26,124
7,687,476
94%
8,444,779
630,625
32,986
9,108,390
93%
2005
8,214,707
813,797
39,634
9,068,138
91%
2006
7,926,540
921,459
42,179
356
8,890,534
89%
2007
7,656,153
991,813
48,248
5,171
8,701,385
88%
2008
7,387,124
1,073,450
51,603
11,327
8,523,504
87%
2009
7,430,660
1,150,555
50,674
16,902
8,648,791
86%
2010
7,437,309
1,156,181
51,206
21,510
8,666,206
86%
2011
7,507,661
1,217,905
59,391
86,966
8,871,923
85%
Source: M2 Pharmacy (PDTS); FY 2011
FOR OFFICIAL USE ONLY
122
Top Drug Classes for Navy MTF Enrollees
Code Therapeutic Class
280804
280808
281604
040800
280892
ADFM
NSAIDs
Opiate Agonists
Antidepressants
Antihistamines
Analgesics
RET
OTH
AD
Total
182,290 126,722 120,523 353,360 782,895
137,782 73,398 88,892 256,403 556,475
117,019 44,804 81,833 126,239 369,895
121,858 36,638 61,143 74,659 294,298
102,997 14,422 27,360 80,499 225,278
240608 HMG-COA Reductase Inhibs
562836 Proton Pump Inhibitors
9,967 103,102
34,351 62,619
Source: M2 Pharmacy (PDTS); FY 2011
FOR OFFICIAL USE ONLY
72,616
59,858
36,686 222,371
57,549 214,377
123
Drug History Example
Person
Issue Date
Product
Name
Days
Supply
QTY
Strength
Full Cost
Pharmacy ID
A
10/20/10
Oxycontin
14
28
20 MG
$59.24
0520862
A
10/20/10
Oxycontin
14
28
40 MG
$98.36
0520862
A
11/03/10
Oxycontin
14
28
20 MG
$59.24
0520862
•
•
•
A
03/25/10
Oxycontin
30
30
80 MG
$338.31
0576477
A
03/30/10
Oxycontin
7
14
80 MG
$157.76
0595047
Oxycontin
5
10
10 MG
$19.74
0504692
63 MG
(avg)
$13,783.83
15
pharmacies
•
•
•
A
10/07/11
Totals
1 year
737 days 1593
supply
pills
124
FOR OFFICIAL USE ONLY
CAPER and PDTS Link
PDTS Record
Treatment
DMIS ID
0089-Bragg
Prof Enc
Record ID
15513083
Ordering
Site
0089-Bragg
Ordering
MEPRS
Code
BAB – Allergy
Issue Date
10/04/2010
Therapeutic
Class
Ethanolamine
Derivatives
(e.g.
Benadryl)
CAPER/SADR ENCOUNTER
Treatment DMIS
ID
0089
Record ID
15513083
Procedure 1
95010-Percutaneous Tests, Imm
Reaction
Procedure 2
94760-Pulse Oximetry
Procedure 3
94010-Spirometry
E&M Code
99245-Office Consult
Diagnosis 1
99560-Anaphylacti Shock; Food
NOS
Diagnosis 2
9957-Adverse Reaction
Diagnosis 3
4779-Allergic Rhinitis
Diagnosis 4
9950-Anaphylactic Shock
MEPRS 3 Code
BAB-Allergy
125
Provider ID
FOR OFFICIAL USE ONLY
Prov #1
Strengths and Weaknesses
•
Strengths:
•
•
•
Only source for person level, detailed pharmacy data
Much better pharmacy cost data than other sources.
Weaknesses:
•
Limited to outpatient prescriptions
FOR OFFICIAL USE ONLY
126
Dental Data
•
•
Dental data was recently added to M2 also.
Purchased care dental:
•
•
•
•
Active Duty Dental Plan
TRICARE Dental Plan
TRDP N/A Yet.
Direct Care Dental:
•
•
Excludes Navy due to data limitations.
DWVs will be added to MEPRS, however.
FOR OFFICIAL USE ONLY
127
MHS Data Repository
•
•
•
MDR is the most complete source of healthcare information in
one place
As a subset of MDR, the M2 can be very helpful as well.
We will discuss many other MDR data files in a later session.
128
FOR OFFICIAL USE ONLY
FOR OFFICIAL USE ONLY
129